The Washington PostDemocracy Dies in Darkness

Heartbreaking stories of lives lost and families crushed in the opioid epidemic

Susan Okie is a doctor and a former medical reporter and science editor for The Washington Post. Her debut poetry collection, “Let You Fly,” was published this year.

Drug overdoses killed a record 72,000 Americans last year — more than the peak annual totals from HIV, guns or automobile crashes. Compared with those long-familiar plagues, the explosion in drug addiction and overdose deaths in the United States still feels new enough to startle us: After all, it was belatedly declared a national emergency only last year. As a journalist, I recall writing a commentary almost a decade ago about the rapid increase in overdose deaths from prescription pain pills, including in rural states like West Virginia and New Mexico. As a physician, I’ve been the recipient of conflicting messages about the optimal use of opioids. I remember a national campaign in the 1990s aimed at persuading doctors to prescribe them more readily to people suffering from chronic pain, followed in recent years by strict new guidelines, black-box warnings, prescription-monitoring databases and other measures aimed at stemming the overprescribing of those same drugs.

But until I read “Dopesick” by journalist Beth Macy, I didn’t grasp all of the factors that have produced the present crisis. They include unscrupulous prescription drug promoters, greedy or gullible physicians, the addictive potential and high resale value of the pain pills themselves, inadequate action by the Food and Drug Administration, the shortage and high cost of effective treatment programs for addiction, and prescription opioids’ role in opening up new geographic markets for heroin, a cheaper but more dangerous alternative for the addicted. The big picture is overwhelming and demands a vigorous national response.

A Roanoke-based reporter, Macy had a front-row seat for the pain pill epidemic’s march through rural and small-town western Virginia, moving south to north on a path roughly parallel to U.S. Highway 81. In the late 1990s, soon after Purdue Pharma began an aggressive national marketing campaign for its new, long-acting painkiller, OxyContin, patients hooked on that drug began showing up in clinics and emergency rooms in rural America — in farming and coal-mining counties, in economically depressed Midwestern factory towns, in logging and fishing communities in Maine. Overdose deaths began to rise. A few alert doctors, pharmacists, clinic workers and local health officials tried to sound an alarm. Among them was Art Van Zee, a dedicated Virginia country doctor who launched a petition drive in 2001 asking the FDA to remove OxyContin from the market. Van Zee’s efforts were chronicled in “Pain Killer,” a 2003 book by New York Times reporter Barry Meier, one of the first journalists to aggressively cover the OxyContin story.

Purdue sales representatives were urging physicians to prescribe OxyContin for patients with arthritis, low-back injuries and other common causes of chronic pain, not just for those suffering from intractable cancer. The company wooed doctors with free meals and gifts, assuring them that the risk of addiction with OxyContin was one-half of 1 percent — a misleading claim, based on a study of its short-term, supervised use in hospitalized patients. In people receiving opioids for long periods to treat chronic pain, the actual risk may be as high as 56 percent, according to a 2007 medical review article cited by Macy.

Users seeking a high quickly figured out how to remove the pill’s outer coating and crush the inner pearl of opioid into a powder that could be snorted or injected. “Oxy” also commanded a high street price: In a household strapped for cash, it could pay the rent, while an addict could use some of the proceeds from resale of the pills to buy heroin to stave off “dopesickness,” the jitters, body aches, nausea, diarrhea and other symptoms of withdrawal. “At the end of your journey, you’re not going after drugs to get high; you’re going to keep from getting sick,” Debbie Honaker, a housewife undergoing addiction treatment, told Macy. In areas where many people were unemployed or on disability, OxyContin and other opioids initially prescribed for chronic pain offered a tempting income source — “the new moonshine,” Macy calls it. And selling the pills helped recruit new users.

Often prescribed in too-large quantities, leftover pain pills in bathroom cabinets became targets for thieves or bounty that a teenager could swipe to pass around at a pill party. Within a few years, high school football stars and college-bound students from upscale neighborhoods were joining the ranks of the addicted.

The stunned, grieving parents of some of the teenagers who died of OxyContin overdoses became impassioned activists. Their voices are among the most powerful in Macy’s book. Ed Bisch and Lee Nuss, who each lost a son, founded a nonprofit organization, Relatives Against Purdue Pharma, whose members lobbied legislators, sponsored school workshops and demonstrated with posters of their dead children outside the company’s corporate headquarters. In 2007, John L. Brownlee, a young U.S. attorney, settled a landmark federal case against Purdue in a plea agreement under which the company admitted to fraudulently marketing OxyContin for six years, claiming that it was less prone to abuse than quick-release versions of the drug. It had even falsified scientific charts to buttress that claim. Three top executives pleaded guilty to misdemeanors, and Purdue paid $600 million in fines. At a rally before the sentencing, bereaved family members read from a 50-page list of the names of the dead.

But by then, the multi-year promotion and supplying of OxyContin and other prescription opiates to pharmacies all over America had ignited the pain pill epidemic, and there was no stopping it. “In the early 1990s, probably ninety percent of the heroin market was still in cities like New York, Chicago and Detroit,” historian David Courtright told Macy. But by the first decade of the new century, “any doctor in any small town, under the dispensation of a new FDA-approved prescription, could suddenly provide opioids to people with low back issues” or other types of chronic pain. The symptoms and consequences of both addictions are much the same, although heroin is more dangerous because of its potential for contamination or adulteration, including the recent lacing of heroin with a much more potent narcotic, fentanyl.

In Roanoke and other Virginia towns, as Macy learned, pain pill addicts readily switched to heroin as a cheaper alternative, and teenagers who’d used the pills were easily persuaded to try it. “I did my first bag of heroin before I drank my first bottle of beer,” recalled Spencer Mumpower, who, as a young addict and heroin dealer, went to jail after selling a friend the drug that caused his overdose death. Local “mules” would make day trips to Baltimore or Hagerstown, Md., to bring back a supply of heroin to sell. Eventually, scenting an untapped market, more-experienced dealers moved into rural Virginia from big cities in the Northeast, set up sales networks and began underselling the competition.

This exhaustively reported book includes many heartbreaking examples of young lives lost to drugs, sometimes so suddenly that parents had been unaware of the problem, sometimes after repeated efforts to help a child get clean in rehabilitation facilities or treatment programs. Although Macy’s stories are set in Virginia, they could happen anywhere in the United States. Most compelling are the characters she was able to follow over time, like Mumpower, who recovered from addiction in prison and a halfway house, trained himself in mixed martial arts, and was clean at the time of the book’s publication. Another of her subjects, high school athlete and honor student Tess Henry, became addicted to pills and then heroin, was jailed for dealing, and took heroin or Suboxone (a synthetic opioid used to treat addiction) throughout a pregnancy. Born healthy, her son was taken from her, and Tess’s struggles to stay off drugs and become a fit mother provide a moving counterpoint to Macy’s discussion of the controversies that roil our national debate over addiction treatment.

Macy argues persuasively that medication-assisted treatment, in which an addict receives a daily maintenance dose of Suboxone (which combines an opiate, buprenorphine and another drug, naloxone), offers a better chance of lasting recovery from drug addiction than regimens that require addicts to quit drugs cold turkey. “All studies — every single one of them — show superior outcomes when patients are treated” with maintenance medications, said Nora Volkow, director of the National Institute on Drug Abuse.

Sadly, OxyContin was not the first painkiller to launch a wave of addiction in the United States. After the Civil War, doctors handed out morphine (the active ingredient in opium, discovered in 1820) to injured soldiers, along with a supply of the newly invented hypodermic needles. An estimated 100,000 veterans became addicted, and morphine injection also grew popular among the wealthy. In 1874, Bayer chemist Heinrich Dreser discovered heroin, an even more powerful opioid and cough suppressant that the company touted as nonaddictive and safe even for babies. By 1900, more than 250,000 Americans were addicted to heroin or other opium-derived painkillers. Not until 1914 did Congress pass a law regulating the sale and possession of narcotics. The current epidemic proves that, a century later, doctors can still be seduced by the claim that a new opoid will kill the pain without danger of addicting the patient.

By Beth Macy

Little, Brown. 376 pp. $28