In Dopesick, Beth Macy argues that the American healthcare system has been broken in a significant way since at least the mid-1990s. Around the turn of the millennium, the healthcare industry began promoting the notion that pain was “the fifth vital sign,” and that physicians should respond to this sign by prescribing powerful painkillers, such as the opioid OxyContin. Conventional wisdom at that time also held that drugs like OxyContin were safe, with all but negligible risk for abuse. As it turns out, this common wisdom was wrong: opioids like OxyContin turned out to be extremely addictive, and they quickly became the driving force behind an epidemic that led to a sharp uptick in crime and a shocking increase in drug-related deaths. Because powerful opioids were embraced so widely by the medical community (in part because of how much money can be made from them), the first people to raise the alarm about the danger of opioids were not necessarily the experts—they were often small-town activists who saw firsthand what was happening to their communities, people like Art Van Zee, Sue Ella Kobak, and Sister Beth Davies. In this way, the book deftly portrays how the medical establishment turned a blind eye to the brewing catastrophe, leaving it to everyday people to hold big corporations accountable and fight for their communities.
As Dopesick reveals, the medical establishment helped fuel the opioid epidemic—in large part because there was so much money to be made. The pharmaceutical industry is an obvious culprit. Purdue Pharma, the makers of OxyContin, knew early on that they had created a dangerous and addictive drug. But their profit motive outweighed any humanitarian concerns, so they covered up the addictive side of Oxy, promoted the notion that pain was “the fifth vital sign” to convince doctors that it was actually good to prescribe heavy painkillers, and lavished doctors with perks (free meals, free gas, and even free shrubberies) to coax them into prescribing more and more Oxy. As the epidemic grew, doctors also faced increasing incentives to prescribe addictive painkillers. Virginia physician Steve Huff, for example, faced strong resistance from his patients themselves when he cut back on prescribing opioids out of fear of their effects. By this time, the pharmaceutical companies had created a huge market for opiates by convincing doctors to prescribe addictive pills, and when their addicted patients demanded more painkillers, doctors had a strong incentive to keep prescribing them. This created the vicious cycle at the heart of the epidemic, one in which patients became casualties of the medical establishment’s desire for profit.
Due to this strong profit motive, it makes sense that people outside the medical establishment were often the first to sound the alarms. One of the people Dopesick profiles, Sister Beth Davies, is a Catholic nun with a history of advocating for coal miners. While she had no particular insight into the pharmaceutical industry nor medical expertise, her involvement in her community meant that, when the opioid crisis hit, she noticed it immediately. Her history of activism positioned her to fight back. Sister Beth worked closely with Art Van Zee, who actually is a doctor. But he, too, was outside the medical establishment—instead of choosing to get rich at a more prestigious practice, Van Zee decided to become a family doctor in a medically underserved community. Since Van Zee was always more interested in community than money, he too could immediately identify and push back against the culture of overprescribing opioids. A core idea of Dopesick, then, is that the medical establishment is not necessarily out to keep patients healthy and to help communities thrive—sometimes, if those priorities are in conflict with moneymaking, money wins out at great cost to everyday people. To fight that, everyday people must sound the alarms.
Fighting the Medical Establishment ThemeTracker
Fighting the Medical Establishment 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.
But what exactly was adequate pain relief? That point was unaddressed. Nor could anyone define it. No one questioned whether the notion of pain, invisible to the human eye, could actually be measured simply by asking the patient for his or her subjective opinion. Quantifying pain made it easy to standardize procedures, but experts would later concede that it was objective only in appearance—transition labor and a stubbed toe could both measure as a ten, depending on a person’s tolerance. And not only did reliance on pain scales not correlate with improved patient outcomes, it also had the effect of increasing opioid prescribing and opioid abuse.
Industrywide, pharmaceutical companies spent $4.04 billion in direct marketing to doctors in 2000, up 64 percent from 1996. To get in the doctor’s door, to get past the receptionist and head nurse, the reps came bearing gifts, from Valentine’s Day flowers to coupons for mani-pedis.
The average sales rep’s most basic tool was Dine ’n’ Dash, a play on the juvenile-delinquent prank of leaving a restaurant without paying the bill. For a chance to pitch their wonder drug, reps had long offered free dinners at fancy restaurants. But soon, to-go options abounded, too, for a busy doctor’s convenience. Reps began coming by before holidays to drop off a turkey or beef tenderloin that a doctor could take home to the family—even a Christmas tree. Driving home from the office, doctors were also invited to stop by the nearest gas station to get their tanks topped off—while listening to a drug rep’s pitch at the pump, a variation the reps nicknamed Gas’n’ Go. In the spring, the takeout menu featured flowers and shrubs, in a version some dubbed—you guessed it—Shrubbery ’n’ Dash.
Though it took nearly a decade before police, the press, and drug-abuse experts fully understood what was happening, Ed Bisch watched the urbanization of the pill epidemic play out on his front lawn in 2001, as paramedics carried his son’s body away.
He retreated to his computer, where he was shocked to learn that his son’s death had been the region’s thirtieth opioid overdose in the past three months.
How was that possible when he’d only just learned the word? “The internet was still new, and back then it was mostly message boards as opposed to websites,” he said.
In the fall of 2006, Purdue’s lawyers began to sense that this case against them was different; that a full-court press meant nothing when the opposing counsel was the United States of America. Was it really possible the small-town lawyers had compiled enough evidence to indict both the company and its top executives on a host of felony charges, not just for misbranding the drug but also for mail fraud, wire fraud, and money laundering? It seemed so, according to a memo written by the federal prosecutors to Brownlee at the time.
NIDA, the Institute of Medicine, the World Health Organization, and the White House drug czar’s office would all agree that indefinite (and maybe even lifelong) maintenance treatment is superior to abstinence-based rehab for opioid-use disorder. And even Hazelden, the Betty Ford-affiliated center that originated the concept of the twenty-eight-day rehab, changed its stance on medication-assisted treatment, or MAT, offering Suboxone to some patients in 2012.
But the rehab Jesse went to was aimed at abstinence, as most were, then and now.
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)
If the federal government wouldn’t step in to save Appalachia, if it steadfastly refused to elevate methods of treatment, research, and harm reduction over punishment and jail, Appalachia would have to save itself.