On a very hot day in 2016, at a federal prison just outside of Bruceton Mills, West Virginia, the imprisoned former drug dealer Ronnie Jones has his first visitor: the author of Dopesick, Beth Macy. Jones is in the second year of his 23-year prison sentence for being involved with a heroin ring. This particular area of West Virginia used to be a coal mining hotspot, but shortly after the turn of the millennium, most of the mines shut down—leaving prisons as the state’s biggest employer.
Although Dopesick is about the opioid epidemic and the pharmaceutical industry, the story begins at a federal prison, establishing how healthcare and criminal justice are interconnected. Coal is an important symbol in the book that represents the old way of life in Appalachia (the region of the United States near the Appalachian Mountains, where mining was once the biggest industry). As an investigative journalist, Beth Macy has firsthand experience conducting interviews with the people she profiles in the book and she sometimes describes the process, as she does here with Ronnie Jones.
During their early communication, which takes place over Jones’s prison-monitored email, Jones is skeptical about talking to Macy. Eventually, he agrees to communicate with her because he wants his young daughters to see a different side of him. As one prosecuting lawyer put it, Jones has a reputation for bringing a “tsunami of misery” to western Virginia: between 2012 and 2013, he ran vast quantities of heroin into the region. Macy wonders how many of Jones’s former users ended up dopesick after he was arrested or how many of them drove over to big cities where they took their chances with new heroin dealers.
As a prisoner, Jones has his freedom restricted in many ways: his communications are all monitored by prison guards, and he doesn’t get to see his young daughters. Some people, like the prosecuting lawyer here, believe that Jones’s punishment is fitting, given all the misery that came as a result of the heroin that Jones imported. Macy, however, questions such easy narratives. She asks whether the users who bought Jones’s heroin are really better off with Jones in prison or if they will just seek heroin from other sources.
Within a week of Macy’s interview with Jones, a batch of heroin comes to Huntington, West Virginia (four hours away from Jones’s cell), and it kills 26 people in a single day. A new synthetic opioid from China called fentanyl has proven to be particularly deadly. And the issue isn’t limited to Virginia or West Virginia: it’s nationwide. In the past 15 years, 300,000 Americans have died of opioids, and some experts predict it will only take five years for another 300,000 to die.
The figures cited here are from 2018, but they nevertheless show the staggering human toll of the opioid epidemic. This is the first of many scenes where Macy uses statistics to back up her argument, appealing to the value of science to convince her audience. This passage also broadens the scope of the book, showing that, while much of Dopesick focuses on regions of Virginia, the opioid crisis is larger than any one place, impacting the whole of the United States.
Seeking to understand the opioid epidemic from another angle, Macy visits Kristi Fernandez in Strasburg, Virginia, in the spring of 2016. Kristi’s son, Jesse, has died of an overdose and was buried with a headstone that carries the number of his varsity high school football jersey: 55.
In addition to looking at the science behind the opioid epidemic, Macy also seeks to show the human side of individuals who have been affected by opioids. The fact that Jesse’s gravestone is emblazoned with his high school football number emphasizes that when he died, he was young and healthy. Jesse was a unique individual, whose story Macy will explore in greater detail, but he also represents the many other healthy young people who died as a result of opioids.
Jesse was a popular, energetic boy in a small town where football is everything. Kristi and her family maintain Jesse’s grave, keeping it clean and even bringing decorations. Kristi also remains obsessed with figuring out what happened to her son: how he went from high-school football star to construction worker to overdosing. Macy agrees that the questions of mourners like Kristi are a central part of the story of the opioid epidemic.
Kristi’s dedication to maintaining her son’s grave represents her dedication to his memory, even long after his death. While Jesse’s gravestone represented the immediate consequences of the opioid epidemic, Kristi’s grieving represents the longer scars of the epidemic and how it did long-term damage to families across the country.
Most new drugs start in urban centers and move out to rural areas, as was the case with cocaine and crack. But the opioid epidemic went in reverse, starting in places like Appalachia, the Rust Belt, and rural Maine—places where families traditionally depend on high-risk industries, like steel, coal, and logging. Jesse was born right around when the epidemic started, in the mid-1990s.
This passage sets up the link between rural and urban America during the opioid epidemic, an important recurring theme. Coal—and other industries with dangerous, blue-collar jobs—represent the old way of life in Appalachia. While they offered stability to families in the region and are sometimes remembered fondly, they were also dangerous and helped create conditions that would allow the opioid epidemic to thrive.
Opioids made an impact in a diverse variety of communities. First were the coalfields, in places like St. Charles, Virginia (where OxyContin was introduced in 1996). Then there were the suburbs, like the ones around Roanoke, Virginia, (Macy’s hometown and a place where heroin arrived by the mid-2000s). The epidemic first got attention in Roanoke when Spencer Mumpower (son of local civic leader Ginger Mumpower) went to federal prison for the overdose death of a former classmate. Finally, the epidemic made it to big cities like Baltimore and New York, where needle drops in public restrooms became evidence of the spread.
Macy establishes a timeline for the opioid epidemic, showing when it reached different parts of the country. This timeline once again emphasizes how in the modern United States, the fates of rural towns and major urban centers are connected. By bringing her hometown of Roanoke, Virginia, into the story, Macy shows that she isn’t simply a disinterested observer in the story, but someone who has a stake in the outcome. By emphasizing how widespread the epidemic is, Macy argues to readers that they may have a stake in the outcome too.
The epidemic didn’t reach the Shenandoah Valley (where the dealer Ronnie Jones lived) until 2012. There, the epidemic followed the same pattern as elsewhere: users began with prescription opioids, then increasingly turned to heroin and to dealing themselves in order to avoid the pain of dopesickness.
Throughout the book, there are many examples of seemingly unbreakable cycles. One of the most important is the cycle of opioid addiction, where even users who want to quit often struggle with overcoming dopesickness (the painful withdrawal symptoms for people who go off opioids). The book is called Dopesick partly because dopesickness is one of the main drivers behind addiction, but also because the title suggests that the whole United States is metaphorically “sick” with the opioid crisis.
To get to Ronnie Jones, Macy takes Interstate 81, dubbed a “heroin highway” by some, and she goes in the opposite direction that Jones went for his drug runs. She passes through the suburbs of Roanoke where she sees the toll of the epidemic, particularly in parents who are dealing with addicted children or grieving their deaths. When she finally meets Jones in prison, he looks older and thinner than his mugshot, with more gray hair. Macy thinks of all the victims of the epidemic and what Jones might say to their mothers. The two sit down, and Jones waits for Macy to start.
This passage introduces Interstate 81, the physical embodiment of all the connections between rural and urban life that Macy explores in the book. Macy’s physical journey in this passage represents the metaphorical journey that the opioid crisis took across the country, leaving destruction in its wake. Macy ends the prologue on a cliffhanger, partly to build suspense about an eventual conversation with Jones, but also to suggest the sprawling, open-ended nature of the opioid crisis. The prologue ends in the same place where it begins, with Jones in prison—this cyclical structure resembles cycles of addiction as well as the cyclical nature of history (particularly when it comes to opioid epidemics).