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Chapter 1
Themes
and Colors
Key
LitCharts assigns a color and icon to each theme in Dopesick, which you can use to track the themes throughout the work.
Poverty as an Obstacle to Recovery
Cycles of History
Race, Healthcare, and Criminal Justice
Fighting the Medical Establishment
The Value of Science
Summary
Analysis
Around the same time that Stallard is meeting with his informant, the FDA changes the rules for drug ads, giving pharmaceutical companies more leeway. The industry more than triples in size in just three years, with drug companies aggressively trying to win influence with doctors.
While Macy hinted in the previous chapter at how Purdue Pharma made OxyContin a best-selling drug, this chapter goes into greater detail, showing how the company overcame safeguards that should have theoretically prevented a dangerous opioid like OxyContin from entering mainstream medicine. One of Macy’s biggest targets of criticism is the FDA, which approved OxyContin’s use and allowed it to be widely advertised.
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OxyContin becomes a huge marketing success in rural America, where disability claims are already high. Purdue targets doctors who already prescribe lots of rival painkillers, hoping to convert them to OxyContin by handing out OxyContin-branded freebies. The campaign is wildly successful, and by 2000, family doctors are the largest group of OxyContin prescribers. In that same year, pharma companies spend over four billion dollars directly marketing to doctors, often providing additional freebies to receptionists, nurses, and anyone else who might stand between them and the doctor.
While there was a genuine need for pain medications in rural parts of the United States (as evidenced by all the disability claims), Macy shows that the spread of OxyContin was only possible due to the massive amounts of money that Purdue spent on advertising (which itself was only allowed because of loosened FDA regulations). The fact that Purdue Pharma spent over four billion dollars on advertising suggests that profits from OxyContin must have been even greater. Macy presents these shockingly high figures to explore how money influences the pharmaceutical industry (and not in a good way).
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The main technique these sales reps use is called the “Dine ‘n’ Dash.” Reps start by taking doctors to fancy restaurants but soon progress to just giving the doctors food to take home, then progress to giving the doctors other things, like gas or even shrubberies.
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Steve Huff first encounters pharmaceutical swag as a medical resident in the mid-1990s. It’s not just stickers and branded merch, but even golfing outings and free lunch most days of the week. Later, as a family doctor, Huff decides that the ethical thing to do is turn down these free meals, and he tries to convince the others at his practice to do the same.
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"My students can't get enough of your charts and their results have gone through the roof." -Graham S.
When in 2003, Huff moves to a new practice in Laurel Fork, Virginia, he finds himself overwhelmed by the volume of patients who had been prescribed large amounts of opioids by his predecessors. He cuts back severely on narcotics prescriptions and finds the whole experience very stressful—two patients even threaten his life.
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Dr. Sue Cantrell, a former pharmacist who has been a longtime health-department director in Virginia, sees the arrival of OxyContin as particularly ill-timed. The decent-paying mining jobs and lower-paying production jobs have all been steadily drying up, due to factory closings and increased automation. Cantrell gets her first call about OxyContin from a doctor based out of one of the smallest, poorest areas in the state: Dr. Art Van Zee.
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Van Zee is a Vanderbilt-educated doctor originally from Nevada who moved to tiny St. Charles, in Lee County, Virginia, at age 29 in order to help out a medically underserved community. There, at an NAACP rally to stop a planned KKK event, he met his wife, Sue Ella Kobak, who is a lawyer and an activist. When they got married, the flower girl was a three-legged goat, and Sue Ella didn’t change her name. Some locals compare Van Zee to Abe Lincoln, because he is lanky and bearded.
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Macy first learns about Van Zee from a 2003 book by Barry Meier called Pain Killer, which was one of the first books to explore the harmful effects of OxyContin. Van Zee was ahead of his time in recognizing the dangers of OxyContin, and he ends up spending much of his career dealing with the fallout of the opioid crisis.
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In the 1990s when OxyContin first arrives in Virginia, however, Van Zee is still confused about what’s happening. He calls Sue Cantrell with some concerns about what he’s seen experienced users do with the new pill, OxyContin. He hears horror stories about how the drug is causing people to spend vast amounts of money and basically stop functioning as normal humans.
Cantrell, as the region’s top public health official, begins in the late 1990s to call other officials to look into the burgeoning opioid crisis. They don’t listen and mostly pass the blame elsewhere.
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In the early 2000s, Debbie Honaker is a 27-year-old woman who lives a couple counties east of Van Zee. She is prescribed OxyContin and Percocet after routine gall bladder surgery that continues to leave her in pain. When this isn’t enough for the pain, a neighbor advises her to snort the pills instead. Within three months, Honaker has become a regular user, learning how to fake kidney injuries to get more pills. Honaker begins stealing money from her husband and pills from her husband’s grandmother.
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Crystal Street is a patient in the same addiction clinic where Honaker is currently being treated. Street’s father got addicted to morphine and Dilaudid in his 80s and was arrested for selling prescription pills from his nursing home bed. Honaker and Street have both themselves spent time in jail after going through near-death experiences to get more pills.
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In the early days of the opioid epidemic, Van Zee watches as 24 percent of juniors at a local high school report having tried OxyContin, as well as nine percent of seventh graders. Many of his friends from the community begin showing up at the ER.
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In the spring of 2000, before small-town newspapers were widely online, Van Zee doesn’t yet know that the opioid epidemic is also affecting other communities. He first gets the news from a copy of the Boston Globe that a young doctor from his clinic brings back. The article details a remote area of Maine where addiction is on the rise, and as a result, crime is, too. Van Zee realizes that he and his community aren’t alone and that it’s time to organize.
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Van Zee begins holding public meetings. At one, an undercover Purdue Pharma rep raises sharp objections. Sue Ella begins to worry that her husband’s heavy caseload is getting the better of him. He begins contacting Purdue directly, writing increasingly pointed letters. Purdue remains resistant. At one point, Purdue's medical director, Haddox, calls a local Virginia reporter to complain about her crime coverage (which mentions connections to OxyContin).
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At a meeting about crimes related to the opioid epidemic, Van Zee has a chance to speak with Haddox. Despite Van Zee’s concerns and accusations, Haddox defends Purdue’s behavior and says it’s no different from what other pharma companies do.
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By late 2000, Purdue is giving doctors a promotional video about how OxyContin is helping patients with pain get their lives back. They push back against claims that OxyContin is addictive, citing a one-paragraph letter to the editor from a 1980 edition of the New England Journal of Medicine.
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By March 2001, Van Zee is frustrated that his letters are doing nothing while the harmful effects of OxyContin in his community only get worse, with people resorting to increasingly bold crimes to get more pills. Van Zee and the Lee County Coalition for Health launch a petition asking the FDA to recall OxyContin, receiving over 10,000 signatures.
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The next month, the DEA begins a “national action plan” to observe Purdue’s distribution and marketing. In response to the pressure, Purdue puts out its own plan to reduce abuse. The FDA announces in July 2001 that it will add a black-box warning (the highest kind for prescription drugs) to the label for OxyContin. Purdue tries to downplay the black box, suggesting that “legitimate patients” are being hurt by the decision. They maintain that the issue is abuse, not the drug, and that Purdue shouldn’t be blamed for any of the crimes committed by OxyContin users.
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One of Purdue’s other tactics to silence opponents is a $100,000 “grant” that they offer to community leaders in Appalachia like Stallard, with the money to be put toward drug treatment and law enforcement. During a meeting where several locals discuss the issue as a coalition, many—including Van Zee and Sue Ella—are initially leaning toward accepting the money. But a five-foot-tall nun named Sister Beth is adamantly opposed to the idea.
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Sister Beth is a Staten Island native with a masters from Columbia. She has a history of activism in the coal industry, helping miners demand reparations. She threatens to quit the coalition if they accept the grant, calling it “blood money.” Eventually, the whole group agrees with her.
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