Beth Macy

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On a hot day in 2016, Beth Macy goes to a federal prison in West Virginia to interview the former heroin dealer Ronnie Jones. Many have blamed Jones for bringing tragedy to the region, due to the deaths and crimes that came in the wake of the heroin he imported, but even after Jones’s imprisonment, opioids continue to decimate the region, particularly a new synthetic drug called fentanyl.

Seeking to understand the epidemic from another angle, Macy speaks to Kristi Fernandez, whose son, Jesse Bolstridge, was a high school football star who died of an overdose. Jesse was born right around the start of the epidemic, when OxyContin was first released. Unlike previous drug epidemics, this one didn’t start in the cities—it began in rural places like Appalachia and the Rust Belt before eventually moving into urban and suburban centers.

OxyContin is a product of Purdue Pharma, which used to be an obscure pharmaceutical company, but which gradually grew under the ownership of the Sackler family. The company used to produce a popular end-of-life painkiller drug, but when the patent on that drug was about to expire, they launched OxyContin to replace it, giving their new drug a massive publicity push. The company deliberately covers up how addictive OxyContin is, citing outdated data, but few in the medical community push back.

OxyContin does, however, have some early opponents: the small-town Virginia doctor Art Van Zee; his wife and accomplice, Sue Ella Kobak; and a fiery drug counselor and Catholic nun named Sister Beth Davies. As a doctor who is used to being an outsider, Van Zee is among the first to notice the harmful effects of OxyContin when it comes to his Lee County community. He, Sue Ella, and Sister Beth hold community meetings to organize resistance to the drug and to Purdue Pharma.

Progress against Purdue is slow, with the company refusing to yield to the demands of protesters. Early court cases against the company are unsuccessful, with judges ruling that there simply isn’t enough evidence to indict the company. Finally, however, in 2005 a federal grand jury investigates the company.

In 2007, Purdue Pharma accepts a plea deal. Though the occasion is a milestone for activists against OxyContin, it is also a bit of a letdown for them—the charges are significantly less than they could have been, and the Sackler family is still nowhere near the courtroom.

The book also looks at how the opioid epidemic has been directly affecting victims and their families. One tragic story is the story of former high school classmates Scott Roth and Spencer Mumford. Spencer sold Scott the heroin that led Scott to have a fatal overdose. As a result, Spencer gets sent to federal prison. Scott’s mother Robin Roth is devastated and wants nothing to do with Spencer (although later, she will begin to take a softer stance toward him, and Spencer will write an apology letter from jail). Spencer’s mother Ginger Mumford, a local community leader, remains there for her son the whole time, and she helps him begin to turn his life around after he hits rock bottom in jail. In Roanoke (the hometown of author Beth Macy), Scott’s death is a shocking turning point that helps many wake up to the seriousness of the opioid epidemic.

Meanwhile, in the western part of Virginia, before he ended up in federal prison, Ronnie Jones was the head dealer of a heroin ring that operated in Woodstock, Virginia. Law enforcement officials Brent Lutz and Bill Metcalf are obsessed with tracking Jones down, but at first all they know about him is his nickname: D.C. Eventually, however, arrests of subdealers in Jones’s ring give the officers enough evidence to arrest and charge Jones. The break-up of Jones’s heroin ring doesn’t stop the flow of heroin into Woodstock, however. Like Whack-a-mole, new sources of the drug just keep popping up, including a deadly new synthetic strain of heroin called fentanyl.

One of the addicts that Macy gets to know best over the course of her reporting is a young mother by the name of Tess Henry. Tess used to be a star high school athlete, but after she is prescribed opioids during a routine urgent care visit, she quickly becomes an addict. She turns to theft and ends up in prison, only learning there that she is in the second trimester of a pregnancy. After the birth of her son, Tess tries to get her life together so that she can be a better mother. Her own mother, Patricia, is eager to help.

As time goes by, however, Tess seems to be less interested in seeking treatment. She stops going to Narcotics Anonymous meetings (which Macy was driving her to) and soon it is clear she is using again. She starts losing touch with her family and turns to prostitution.

After a visit to a psych ward, however, Tess again gets serious about treatment. Her family sends her to a program in Nevada, and at first, she seems to be making progress. Eventually, however, she leaves the program for Las Vegas and is back to using. She contacts her mother with paranoid and disturbing messages. She talks about wanting to come home but procrastinates about getting the proper paperwork.

Finally, one day just after Christmas, Patricia gets the news that her daughter Tess has been murdered in Las Vegas. The body is shipped back to Virginia. At a viewing, on what would’ve been Tess’s 29th birthday, Patricia looks Tess’s body and sticks some mementos into Tess’s clothes, including a picture of her toddler son.