One of the tragedies of the opioid epidemic, according to Beth Macy, is that the whole thing has happened before, and that anyone familiar with the history of opioids in the U.S. could have predicted the new epidemic. Knowledge of the addictive properties of opioids has existed in some form since the Neolithic Period. Much more recently, there was a widespread opioid epidemic in the U.S. around the turn of the twentieth century, when the pharmaceutical company Bayer introduced heroin. During the current opioid crisis, history repeats itself on smaller scales, too, with families and communities often witnessing the same addiction stories again and again, rarely with happy endings. In Dopesick, Macy vividly portrays the dangers of forgetting the past and argues that a greater knowledge of history can help prevent future tragedies.
While the opioid epidemic may seem to be a very modern problem, Macy shows that actually it isn’t the first opioid epidemic in the United States, and that studying the past could have helped to prevent the present crisis. Humans have understood the effects of opioids since the beginning of history, when Neolithic humans first learned the effects of poppy. More recently, the Opium Wars between Britain and China showed that these drugs were so powerful that they could even lead to mass conflict. In the United States in particular, there were at least two clear warnings about the dangers of opioids. The first occurred in the aftermath of the Civil War. Many soldiers who were wounded in battle received morphine or other opioids from doctors in order to ease their pain. Shortly after, these soldiers became addicts. While the science of addiction was not as well understood back then, doctors knew to leave behind morphine and hypodermic needles for wounded patients, in order to spare them the pains of withdrawal. These wounded veterans continued to seek out morphine and opium, turning into haggard shells of their former selves.
The second instance of mass addiction is perhaps even more relevant to the current crisis. In the late 1800s, a researcher at the pharmaceutical company Bayer developed heroin. Initially, his goal was to create a nonaddictive substitute for morphine. This is how the drug was marketed, and it ended up being sold in 23 countries around the world, aimed at everyone from babies to the elderly. It didn’t take long for many doctors to realize the problem: that heroin was, in fact, highly addictive. Though doctors eventually stopped prescribing heroin, by then the damage had already been done. The story of heroin would end up being very similar to the story of OxyContin when it was introduced by Purdue Pharma just about one century later—but few at the time would draw the parallel.
The book doesn’t offer an easy explanation for why history is so often forgotten in the “United States of Amnesia” (as Macy titles one chapter), but Macy does suggest one important contributing factor: profit. On the one hand, the new opioid crisis can be attributed to Purdue Pharma’s reckless disregard for the addictive potential of OxyContin as they rushed it onto the market in order to make money. But there were also larger structural forces in the healthcare industry that caused many professionals to disregard the past. In the 1990s, patients were beginning to be treated more like customers, with many of them being given formal surveys to rate their healthcare experiences. Hospitals began to compete to get the best ratings, and bad ratings from patients could lead to serious financial difficulties. As a result, doctors were encouraged (either tacitly or directly) to be more liberal with painkillers, since being stingy ran the risk of bad reviews from patients. This move toward treating patients as customers came at right around the same time that pain was being recognized as “the fifth vital sign” in patient treatment (an idea that was boosted by millions of dollars’ worth of advertising by Purdue). All of these factors combined to put pressure on physicians to prescribe more opioids. While some doctors familiar with history may have had misgivings about prescribing OxyContin, they were either swayed by the hype that the new drug really was a history-defying breakthrough, or they felt that in order to keep their jobs, they had no choice but to prescribe the painkiller, since it was what patients wanted.
In hindsight, it seems obvious that an opioid like OxyContin would cause mass addiction just like heroin or morphine did. But to really understand why heroin and morphine became epidemics, Macy argues, it takes more than just a surface-level knowledge of history. Most doctors who prescribed heroin the late 19th and early 20th century were not ignorant about addiction—they simply bought into the hype that heroin was something new. In the 1990s, Purdue Pharma used similar techniques to convince physicians to prescribe OxyContin, preying on the natural human tendency to believe “this time is different.”
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Cycles of History Quotes in Dopesick
In the United States of Amnesia, as Gore Vidal once called it, there were people in history who might have expressed skepticism over Haddox’s claim, had anyone bothered reading up on them. Ever since the Neolithic humans figured out that the juice nestled inside the head of a poppy could be dried, dehydrated, and smoked for the purposes of getting high or getting well, depending on your point of view, opium had inspired all manner of commerce and conflict.
By the 1870s, injecting morphine was so popular among the upper classes in Europe and the United States that doctors used it for a variety of ailments, from menstrual pain to inflammation of the eyes. The almost total lack of regulatory oversight created a kind of Wild West for patent medicines, with morphine and opium pills available at the nearest drugstore counter, no prescription necessary. As long as a doctor initially OK’d the practice, even injected morphine was utterly accepted. Daily users were not socially stigmatized, because reliance on the drug was iatrogenic.
Awareness of the opioid crisis has typically come in waves, often celebrity-studded and well covered by the media: the death by overdose of Philip Seymour Hoffman, in 2014, then two years later the death of Prince. But for ordinary citizens, the news that opioids had crossed over from Not me and not anyone I know to mainstream traveled more slowly, in dribs and drabs, maybe when the Cincinnati Enquirer became the first newspaper in the country to dedicate a reporter solely to the heroin beat.
The skin-popping weathermen represented Roanoke’s first wake-up call. But it was wrongly viewed, by myself and other area journalists, as an anomaly. The story was so tawdry that the Roanoke Times assigned two beat reporters to track it, one from courts and the other from media and entertainment. It received much more attention, for instance, than the national story that broke in our backyard when Purdue Pharma settled with the feds a year later.
In rural counties decimated by globalization, automation, and the decline of coal, the invisible hand manifested in soaring crime, food insecurity, and disability claims. In Martinsville and surrounding Henry County, unemployment rates rose to above 20 percent, food stamp claims more than tripled, and disability rates went up 60.4 percent…
It was easy to understand the connection between joblessness and hunger, to get that hunger fueled some of the crime. It was growing clearer, too, that the federal disability program was becoming a de facto safety net for the formerly employed, a well-intentioned but ultimately disastrous way of incentivizing poor people to stay sick, with mental illness and chronic pain—conditions that are hard to prove and frequently associated with mental health and substance use disorders—prompting the majority of disability awards.
I hoped the stories of Ronnie Jones and his victims would illuminate the ruts in both a criminal justice system that pursues a punishment-fits-all plan when the truth is much more complicated and a strained medical system that overtreats people with painkillers until the moment addiction sets in—and health care scarcity becomes the rule.
I hoped, too, that my interview with Jones would help answer Kristi Fernandez’s questions about what led to her son Jesse’s premature death. Was Ronnie Jones really the monster that law enforcement officials made him out to be? Had the statewide corrections behemoth that returns two thousand ex-offenders a year to Virginia’s cities, counties, and towns played a role in his revolving door of failures?
The birthplace of the modern opioid epidemic—central Appalachia—deserves the final word in this story. It is, after all, the place where I witnessed the holiest jumble of unmet needs, where I shadowed yet more angels, in the form of worn-out EMTs and preachers, probation officers and nurse-practitioners. Whether they were attending fiery public hearings to advocate for more public spending, serving suppers to the addicted in church basements, or driving creaky RVs-turned-mobile-clinics around hairpin curves, they were acting in accordance with the scripture that nurse-practitioner Teresa Gardner Tyson had embroidered on the back of her white coat:
Verily I say unto you, inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me. (Matthew 25:40)
