An hour south of Roanoke, Virginia, is Martinsville, which in 2012 has the highest unemployment rate in the state. It has held that record for the past 12 years, ever since globalization reduced the number of factory jobs in the area. Macy began reporting on areas like Martinsville in 2008 for the Roanoke Times and later for her first book, Factory Man (2014). Because of the recession and because of the disappearing factory jobs, disability checks become a major source of income, which incentivizes people to stay sick. Children are frequently given Ritalin because the ADHD diagnosis will help them draw disability checks in adulthood.
The Great Recession was a period of economic decline that officially lasted in the United States from December 2007 through June 2009, although arguably its effects on the economy have lasted long beyond then. It was likely a contributing factor to the high unemployment rate in Martinsville in 2012 (although the declining coal industry is another major factor behind unemployment in many parts of Virginia). Macy brings up the importance of disability checks not to shame people who draw them but to emphasize how limited the options are for people in the region to make a living wage.
Macy learns about the connections between poverty, disability, and opioid addiction when the Basset Furniture store (in Basset, Virginia) is burned down by an accidental arsonist who was trying to steal copper (to sell for money for opioids). The man who started the fire looks like a poor junkie who is desperate to avoid being dopesick. His circumstances are very different from Spencer Mumpower, who went to private school and several rehabs, but their desperation is the same.
Macy once again returns to the theme that the opioid crisis isn’t happening in a vacuum. Race, class, unemployment, and poverty are all related to each other in complicated ways, and the opioid crisis only makes these connections more complicated.
In rural America in the 2000s, the opioid epidemic enters its “wily adolescence.” It spreads like an infectious disease, jumping in particular between family members. The main hub is Interstate 81, where OxyContin spreads up and down the Appalachians.
While the opioid crisis is usually called an “epidemic” in the metaphorical sense (because it spreads like a disease), Macy shows that in some ways it may be a literal disease. The family spread of the opioid epidemic mimics the way that a contagious disease would spread through a community.
In 2010, police begin to notice that the opioid epidemic is not just a rural phenomenon but also a suburban one, spread more among peer groups than families. The spread is stealthier in the suburbs because many users have more money and are able to better disguise their spending. Teenagers, for example, pretend to lose electronic devices when in fact they are selling them for drug money.
Macy looks at how money and class change the impact of the opioid epidemic on a community. While wealthier people have more options for treatment, Macy shows that wealth also has a dark underside: it allows the epidemic to hide, spreading through a community in secret.
The death of Scott Roth helps wake Roanoke up to the seriousness of the epidemic. He was well-liked and remembered for his life-of-the-party personality, which makes his death particularly shocking.
Scott’s upbeat personality contrasts with the mercilessness of the opioid epidemic, suggesting that even youth and good health are not enough to make a difference.
Drug prevention coordinators have a hard time catching up—they don’t realize the connection between heroin and pills until at least 2014. Flashier drug stories like warnings about bath salts distract from the quieter problem with opioids.
Macy once again criticizes the media’s tendency to focus on sensational stories, like bath salts, instead of focusing on more important stories that don’t quite generate the same easy headlines.
Teenagers in the Hidden Valley region of Virginia become experts at finding pills, usually from other people who have been overprescribed. The 2010 reformulation of OxyContin, which makes the pills harder to crush up for an instant high, causes many to turn to heroin to fulfill their addictions. For most teenagers that develop addictions, the first drugs they took were Ritalin or Adderall (prescribed for attention deficit disorders but also abused as a study drug on campuses).
Ritalin and Adderall are controversial because, arguably to a greater extent than OxyContin, they have legitimate medical uses (as a treatment for hyperactivity disorders), but they still do present the opportunity for abuse and may lead to future drug use. Macy seems to suggest that these drugs are overprescribed, but she makes a more nuanced argument because these drugs are not, on their own, anywhere near are dangerous as OxyContin.
Between 1991 and 2010, prescription of stimulants like Adderall and Ritalin increases tenfold among all age groups, with some going to children as young as two years old. Although not all studies show that behavior meds lead to opioid abuse, some addiction researchers have suggested a connection. While the drugs can be helpful in the short term, there is also no evidence that these medications lead children to perform better in school over the long term—particularly if the stimulants become a gateway to harder drugs.
There is not specific evidence to link Adderall and Ritalin to opioid abuse, so rather than making the argument that the drugs are dangerous, Macy simply argues that not enough is known about them, given how widely they are prescribed. Her claim that Adderall and Ritalin don’t lead to long-term improvements for children in school is perhaps one of Macy’s more controversial arguments, which is why Macy appeals to the expertise of scientific studies to support it.
Brian is another member of the same Hidden Valley opioid-using group as Spencer. He becomes dependent on pills by the time he’s 17 years old. In six months, he blows $8,000 on pills. Finally, Brian’s counselor stages an intervention with his parents, and he admits to them that he’s addicted to heroin. They send him to detox. In 2012, at age 23, Brian is being weaned off Suboxone (a treatment for narcotic dependence) when he is interviewed by Macy and tells his story.
Brian’s story emphasizes how Spencer Roth’s addiction story wasn’t occurring in a vacuum—there were others in the same community like Brian who were going through the exact same thing (even if stigmas about discussing addiction prevented them from realizing it). The fact that Brian survived while Spencer didn’t may not suggest any meaningful difference in their personalities or circumstances—it could simply show that when it comes to opioids, sometimes who lives and who dies all comes down to luck.
Two mothers of opioid users meet and bond at a Families Anonymous meeting: Jamie Waldrop and Drenna Banks. Jamie and her family end up paying more than $300,000 while attempting to treat her son Christopher. Jamie begins isolating herself so that her friends don’t ask her how her kids are doing.
Macy mentions the detail that Jamie Waldrop spent over $300,000 on treatment to criticize the U.S. healthcare system. When treatment costs that much (and isn’t even guaranteed to work), it means that even many people who want treatment aren’t able to afford it.
After two weeks into his first stay at a residential treatment center, Christopher learns that his good friend Colton Banks (son of Drenna Banks) has fatally overdosed. Colton died during what was supposed to be his “last hurrah” before going in for treatment.
Colton isn’t the only opioid user profiled in the book who will die right when he’s on the cusp of receiving treatment. Macy shows just how precarious life can be for those struggling with addiction and how a simple matter of timing could mean the difference between life and death.
Drenna remembers how two years before Colton’s death, a family friend lost his son to heroin. At the time, she thought, “Why can’t you control your kid?” but she soon realized that it’s not so easy when she learned her own son had a hidden habit.
Drenna’s judgement toward her family friend isn’t meant to portray her as an overly critical person; rather it shows how easy it is to judge when you don’t have the full information about a situation. Drenna painfully learns this lesson when heroin comes to her own family.
At Colton’s funeral, Drenna presents him in an open casket. She begs during the service for Colton’s death to be the last and for the stigmas about addiction to be lifted. Later, she speaks to Christopher about how Colton wouldn’t want him to start using again.
Many of the most committed activists against opioids are motivated by the deaths of people in their family or in their community. While these deaths can sometimes bring about positive change, it remains hard for people struggling with addiction (like Christopher) to change their habits overnight, particularly when quitting often means having to deal with the pain of dopesickness.
Christopher, however, does relapse. Jamie refuses to bail him out financially again. Instead, she takes him to a hotel for a week for him to detox. At the time, he’s still only 20 years old. This time, however, it works, and as of the publication of Dopesick, he has been sober for four years. He tries to give back to his community, mentoring other young people who are newly sober. Christopher is a rare case: less than a quarter of patients who receive abstinence-only counseling for heroin like he did are able to stay clean for over two years. (The recovery rate climbs to 40 to 60 percent for those who also get medical treatment, such as with methadone or naltrexone.) When Colton dies in 2012, there are still 130 opioid-addicted Americans out there for every one death.
While Christopher seems to kick his addiction using an abstinence-only method, Macy questions whether his story really shows the benefits of abstinence-only treatment or whether it instead shows the benefits of having a dedicated support network (in this case, his mother, Jamie). Macy doesn’t blame the parents of children who die of opioids—in many cases, the situation is out of their control—but she does show how, with luck, some dedicated families are able to help loved ones through the treatment process. Macy emphasizes how treating addiction isn’t just about personal responsibility but in fact something that needs a whole community.