1996 was the year Purdue Pharma rolled out its latest chemical solution to the ills of living: Oxycontin.
Purdue were riding the zeitgeist at the time: pain was the “fifth vital sign”. Elevated to the standing of blood pressure, heart rate, respiratory rate and temperature, pain was essential for understanding the situation of a “healthcare consumer”. With patients leaving treatment ratings, and pain being decried as the great untreated scourge on Americans, doctors were pressured to relieve even the most nondescript and non-threatening pains to avoid poor scores and litigation.
Luckily for them, here was Purdue’s new wonder drug – practically guaranteed not to cause addiction! So, at least, swore the army of sales reps now badgering clinics and emergency centers across the land. A non-addictive opioid, so safe the FDA even had a special label for it.
Of course, this was not the full story. As with many social health disasters, it was those outside the mainstream medical profession who saw the fallout first. As crime waves spiked across rural Appalachia, the first warnings came from an angry Catholic nun and a mild-mannered family doctor. They would go from outsider Cassandras to two of the most powerful national voices of the campaign to have Purdue pay for the devastation their drug and their lies caused to the communities of America.
Eventually, Purdue, and three of its top executives, would be convicted in court of misbranding, for their claims that Oxy was non-addictive. Even this was a surprise to the company and the Sackler family who own it. They had assumed that the backwoods government law office case would roll over when they deployed go-to influencer Rudy Giuliani to solve it for them. Instead, a deeply committed US attorney, John L. Brownlee, his fraud investigator Gregg Wood, and his assistant attorneys Randy Ramseyer and Rick Mountcastle, put together a case that threatened multiple felony charges (though Purdue would beat it down to misdemeanours). In an emotional court hearing, everyone who had been part of the opposition to Oxy had their say before sentencing was handed down. This case lead to a rescheduling of Oxycontin that checked the tide of pill-mill dispensaries.
This is not the end of the book, however.
Sister Beth Davies and Dr Art van Zee are two of the best-known voices for the crisis victims, but the twisting story of the US opioid crisis covers many more people. From the opening of the disaster (when it was damaged miners and mothers stealing and cheating to get their fix) to the rush of heroin that plunged into the gap that Oxy left after it was rescheduled, the book covers the high and low ends of addiction.
Whilst the Appalachian Mountains loom high over the early chapters, the regimented pleasantness of Roanoke suburbs, bastions of wealthy whiteness, take over. Rich white kids OD’ing and stealing parental prescriptions for pill parties became the norm. Many of the stories are theirs, or their friends and family, trying to escape William Burrough’s eternal “algebra of need”. The desperate, all-consuming need to escape dopesickness. The dope drive that hijacks the brain and leads previously decent people to increasingly terrible acts.
This is an angry book. The wreckage of human lives; the hopelessness of the “lock ‘em up” response; the big health desire to solve everything with a pill; the lack of Medication Assisted Treatment in the US; the crushing rural poverty that fed the epidemic; the greed of Purdue; and the government policies that allowed it all to happen burn through the personal stories and barrage of meticulously researched information. Macy was a local reporter in Roanoke when she started covering the story in 2012 and her local knowledge, and close access to the families about whom she writes, help show the most personal and brutal details of the degradation of addiction.
The book raises many issues those of us outside the US health system should watch for: the incredible sums involved in pharmaceutical products and the risks of weakened regulation and oversight; the moralistic colouring of the addict as personally responsible that can prevent effective treatment policies; the role poverty plays in fostering addiction; the stigma of drug use that can prevent meaningful conversation; the need for a health literate patient, who understands the risks of treatment and medication; and the need for a better understanding of pain management, that finds alternative methods of pain relief as a first-line response. There is no easy answer to drug addiction, but this crisis challenges us to be aware and to discuss all the options.
This is ultimately a human book, a response to a very human crisis – both in causes and victims. This is not the impartial omnipresence of Covid or Ebola. This was a human-created crisis, and it is the human stories that anchor the book, that give concrete reality to the streams of drug death statistics that cascade through the chapters. It is also, strangely, a hopeful book, one that sees people struggling to make a difference, the kids trying to put their lives back together, the little victories that individuals and organisations can make. It recognises it is likely impossible to end drug addiction in US life, but finds some solace in the people who try anyway.