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Dopesick; Dealers, Doctors and the Drug Company That Addicted America by Beth Macy (Little Brown, 311 pages)

By Paul Markowitz

In the past few weeks the New York Times has published full-page ads by companies boasting of their benevolent deeds in the larger community. One ad was from Wells Fargo, which we all know was involved in an outrageous scheme regarding illegal sales practices that ultimately led to the firing of many top executives and a fine of $2.09 billion. The other three full-page ads were from Purdue Pharmaceutical's recitation of its activities helping with the opioid crisis. The company's self-congratulatory description could become the standard account of the company's role in the crisis if more accurate narratives do not emerge.

Luckily we have Beth Macy’s Dopesick: Dealers, Doctors and the Drug Company That Addicted America to tell us the in-depth story of the opioid crisis in modern America. And yes, the "Drug Company" referred to in the book's title is the self-same Purdue Pharmaceutical.

The first section of Macy’s book is a detailed history of the opioid crisis in America, which is now the leading cause of death of Americans under 50 years of age. It represents more than guns, cars and HIV at its peak. What is different about this epidemic is that new drugs normally start in the cities, as with cocaine and crack. But the opioid epidemic started in rural areas like Appalachia and spread from there. Because it was felt in rural areas and small towns first, the crisis did not receive the initial publicity it might have if it had started as an urban or suburban problem.

Macy describes in excruciating detail how Oxycontin crept into poorer communities in Appalachia as early as 1999, when mortality rates began to spike, with overdoses ranging 65% higher than the rest of the country. These rates would continue until 2013, the whole time with a 0.5 percent annual mortality rate attributed to overdoses and a shocking increase in Neonatal Abstinence Syndrome, a common malady of babies whose mothers were addicted when they gave birth.

Macy sketches how this abomination occurred with the willing participation of Purdue Pharmaceutical, a family-owned business. The company had developed Oxycontin, a powerful but time-released pain relieving breakthrough. Its doctors assured the public and the government that its addiction rate was less than 1 percent, well within the range of acceptable medicines. It could be prescribed for moderate back injuries, tooth surgery, bronchitis, or just treating pain liberally.

Purdue did not let natural circumstances increase its sales. Instead, it hired armies of salesmen to hand out freebies to doctors, did data-mining to locate high-prescribing doctors, and gave out large bonuses to top-performing representatives. Sales rep bonuses, which had been $1 million in 1996, rose to $40 million in 2000.

By 2005 Purdue faced legal troubles. The company hired the then-very-popular ex-Mayor of New York, Rudy Giuliani, to represent it. In 2007, Purdue settled for $34.5 million, with its executives pleading guilty to misdemeanor mislabeling. The executives -- legal, financial, and pharmaceutical -- received probation with community service. They never took responsibility for their behavior. To add injury to insult, it was a Purdue shell company that pleaded guilty, not Purdue Pharmaceutical, thus avoiding federal penalties. Purdue would ultimately make billions off of it exploits. The sad conclusion is that “the corporation felt no pain.” There might have been some ultimate cost to Purdue's owners, the Sackler family. In the list of America’s richest families, they dropped from 16th to the 19th.

Macy’s book is not the first look at the opioid crisis; Painkiller by Barry Meier and Dreamland by Sam Quinones covered similar ground. But what makes Dopesick different and ultimately more intimate and compelling is that the bulk of it is comprised of the author’s first-hand accounts of her involvement and relationships with people intimately involved in the crisis. Macy lives in her adopted hometown of Roanoke, Virginia which borders on Appalachia, making it ground zero, or at least one of the ground zeros, of the crisis, allowing her to easily observe it first-hand. Roanoke also lies on highways to Baltimore and Washington, D.C., pipelines for many of the drugs coming into Appalachia.

Just as she did with her last book, Truevine, Macy is able to develop an intimacy with key individuals that allows her to understand and explain the heartfelt feelings of her characters. She befriends opioid addicts, recovering addicts, parents of addicts, mothers who have lost children to overdoses, health professionals who strove to deal with the epidemic, and federal prisoners serving time for selling opioids. The end result is an on-the-ground survey of the crisis that explores it from both the head and the heart.

What one comes away with from reading the book is, ultimately, a feeling of tragedy and helplessness. There is the “whack-a–mole” system of arresting dope dealers only to have new ones pop up almost immediately, whether they are purveyors from out of town or local consumers selling to afford their next fix. A sad detail is that the Republican majority in the Virginia state legislature refused to expand Medicaid to Virginians, thus limiting options for many addicts, even though Virginia's governor strongly urged expansion. Another one is the Trump Administration’s “war on opioids,” which Macy presents as little more than a cruel joke. The "war" was a one-day headline followed by Jeff Sessions echoing Nancy Reagan in her oft-quoted injunction to “just say no”. Macy’s analysis of the government’s response since 1996 is that it has been “molasses slow, mired in bureaucracy, funding woes and slow to close treatment gaps.”

Macy leaves the reader with the anxiety that parents of addicts must feel just waiting to receive a phone call with the latest installment of bad news about their children. It could be about their newest arrest for shoplifting , selling of drugs or prostitution; or their acceptance yet again into a rehab program; or, most tragically, their death by overdose.

Paul Markowitz is a California-based writer.