Beth Macy
New York
Little, Brown and Company
2018
376 pages
According to the Art:
This book is a journalistic account of causes and consequences of the opioid crisis in the U.S. during the first two decades of the twenty-first century. The analysis considers social factors, opioid supply chains, and responses of health care professions, criminal justice systems, advocates, regulators, and legislators.
Synopsis:
Beth Macy has been a newspaper reporter in the Roanoke, Virginia area for three decades. In this book, she provides extensive reporting on the opioid crisis, how it developed and wreaked havoc in Appalachia, and how it grew into a national crisis across the United States.
“Dopesick” is the colloquial term addicts and addiction medicine specialists use to describe the constellation of wrenching and violent symptoms opioid withdrawal causes. As one of Macy’s subjects describes it:
You’re throwing up. You have diarrhea. You ache so bad and you’re so irritable that you can’t stand to be touched. Your legs shake so bad you can’t sleep. You’re as ill as one hornet could ever be. And believe me, you’ll do anything to make the pain go away.
p. 41
As a result, not long after a person is addicted to opioids, drug seeking behaviors are not motivated by the urge for the next and best high, but instead are driven “to avoid dopesickness at any cost.” (p. 9)
Macy divides her reporting into three major parts: 1) the ways Purdue Pharma fueled the explosion of opioid addiction beginning with the introduction of its product Oxycontin in 1996; 2) the ways in which people get addicted to opioids and how they get their supplies; and 3) the ways the U.S. health care system, criminal justice system, Congress, state legislatures, and regulatory agencies have failed in preventing and fixing the addiction crisis.
As a journalist, Macy weaves the stories of individuals into the larger story of the opioid addiction crisis: people who became addicted to opioids and the effect it had on their families, and the stories of health care professionals who pulled alarms about the rapidly rising rate of opioid addiction and tried as best they could to treat addicted patients and protect the public. We read about the Purdue Pharma executives who were blamed and prosecuted for the marketing campaigns that turned localized opioid addiction patterns into a national opioid addiction epidemic. And we read about individual sheriffs, investigators, prosecutors, judges, and community activists who were trying to stem the tide of addition and death. These stories intersect throughout the book.
Embedded among the individual story lines are digressions Macy uses to elaborate on certain aspects of the opioid addiction crisis. She provides historical perspectives on drug addiction, and how this crisis differs from those of the past. She puts an emphasis on how trends in medical practice to liberalize the use of opioids in the management of all types of pain—minor and major, acute and chronic—converged with Purdue Pharma marketing campaigns for its proprietary opioid products. She cites statistics to show how fast the epidemic worsened, how widely it was spreading across the United States, and how deadly it had become with mortality rates exceeding those of AIDs mortality at its peak. Other digressions cover how illicit opioid supply chains are created and maintained, and how different levels of governments reacted to the crisis.
Analysis:
The stories Macy tells will be familiar to many readers. Stories of drug trafficking and criminalization of nonmedical use of drugs have been the subject of news coverage and cultural attention for a long time. In her book, Macy adds to what is known about opioid addiction and the epidemic by building a case for a better appreciation of the vulnerabilities involved, specifically the vulnerability of individuals to opioid addiction and the vulnerability of populations to aggressive marketing of dangerous pharmaceuticals. Though the book is directed at the general public, it could help health care professionals and students discover how they can put patients at risk for opioid addiction, apprehend the opioid addiction experience, and expand their knowledge of opioid addiction treatment options.
A common perception about people who are addicted to opioids is that they seek opioids to get high. Macy debunks this by telling the stories of people who went to physicians with workplace or sports injuries and were prescribed quantities of opioids that got them hooked. These physicians were often operating under the misconception that opioid addiction does not occur when the drugs are used for pain. Perhaps the people who became addicted to opioids when first receiving them for pain relief were in some way susceptible to addiction. Whether or not such a susceptibility was a factor, the excessive amounts of opioids physicians prescribed flooded entire regions making people that much more vulnerable—in effect, the drugs seek them.
But, Macy (along with many other journalists) may be inferring that if people receiving opioids for pain can become addicted to them, then anyone receiving opioids for any reason can become addicted to them. That may not be the case, however. Many clinicians have observed that those patients who receive continuous opioids for their cardiorespiratory, sedative, and amnesic effects during long-but-finite periods of mechanical ventilation (i.e., weeks, months), do not experience opioid withdrawal (dopesickness) when they are discontinued after mechanical ventilation is no longer necessary. Who is susceptible to opioid addiction is probably more complicated than it is conveyed in mainstream accounts, like Macy’s.
The story of Purdue Pharma promoting its drug OxyContin for use in ways that are not consistent with its regulatory approval is not unique. Indeed, many pharmaceutical manufacturers have settled with the U.S. government for hundreds of millions and sometimes billions of dollars for such offenses in just the first 18 years of this century. Macy’s detailing of the Purdue Pharma actions shows how populations are vulnerable to these types of activities even when the drugs involved can lead to addictions and deaths. After all, she says, “For centuries, dealers of opium, morphine, and heroin understood that an addicted person’s fear of running out—becoming dopesick—portended one hell of a business model.” (p. 60) Indeed, at least until all the customers are dead.
We should not count on the pharmaceutical industry to keep risk/benefit ratios balanced when there is money to be made. Macy advises, “as a society, we’re going to have to learn to live with possibly dangerous or at least risky new drugs—because Big Pharma’s going to keep churning them out.” (p. 272) We’re on our own.
Also:
An eight-part miniseries drama inspired by Macy’s book was released in October, 2021. The series covers a much narrower view of the opioid crisis than the book.
Macy has stayed on the trail since her book and the miniseries. She has completed a follow up book, Raising Lazarus, which was published in October, 2022. Based on an interview with Macy published in the November 4, 2021 Richmond Magazine, Macy says, “Dopesick was about the problems, this one is about the solutions.”
A personalized account of dopesickness is available from Alphonse Daudet’s autobiographical book, In the Land of Pain, which is reviewed here, and parallels between Thomas De Quincey’s opioid addiction in his memoir, Confessions of an English Opium-Eater, and Dopesick are reviewed here.
Barbara Kingsolver brings a fuller picture of the opioid crisis in Appalachia in her 2022 novel Demon Copperhead, which is reviewed here. The story recasts Dickens’ David Copperfield and it contains many through lines to Macy’s book Dopesick.
A discussion of how Dopesick the book, Dopesick the miniseries, The Empire of Pain, and Demon Copperhead compare with one another and how one may be preferred over the others or the order in which they should be approached is the subject of the episode, Getting Dopesick: Four Angles on the Opioid Crisis, on the podcast, The Clinic & The Person.
A version of this review is posted here on the NYU Literature, Medicine and Arts Database.
