Dopesick

Dopesick: Dealers, Doctors, and the Drug Company That Addicted America

By Beth Macy

In this extraordinary work, Beth Macy takes us into the epicenter of a national drama that has unfolded over two decades. From the labs and marketing departments of big pharma to local doctor's offices; wealthy suburbs to distressed small communities in Central Appalachia; from distant cities to once-idyllic farm towns; the spread of opioid addiction follows a tortuous trajectory that illustrates how this crisis has persisted for so long and become so firmly entrenched. 

Beginning with a single dealer who lands in a small Virginia town and sets about turning high school football stars into heroin overdose statistics, Macy sets out to answer a grieving mother's question-why her only son died-and comes away with a gripping, unputdownable story of greed and need. From the introduction of OxyContin in 1996, Macy investigates the powerful forces that led America's doctors and patients to embrace a medical culture where overtreatment with painkillers became the norm. The unemployed use painkillers both to numb the pain of joblessness and pay their bills, while privileged teens trade pills in cul-de-sacs, and even high school standouts fall prey to prostitution, jail, and death. 

Through unsparing, compelling, and unforgettably humane portraits of families and first responders determined to ameliorate this epidemic, each facet of the crisis comes into focus. In these politically fragmented times, Beth Macy shows that one thing uniting Americans across geographic, partisan, and class lines is opioid drug abuse. But even in the midst of twin crises in drug abuse and healthcare, Macy finds reason to hope and ample signs of the spirit and tenacity that are helping the countless ordinary people ensnared by addiction build a better future for themselves, their families, and their communities.

I think that description is balderdash.  It's a much bleaker book than the blurb appears.  The "once idyllic" farm communities are actually coal mining areas, beset first by the terrible working conditions of the mines, and now by the even worse specter of no working conditions at all. Maybe they're scenic, but they were never idyllic.  There's also very little hope in the book.  Although there is greater recognition of opioids and laymen are more familiar with the dangers of Oxycontin, Macy doesn't seem to think the epidemic is slowing at all. I suppose it will burn itself out eventually, as fewer people get on the opioid track to begin with, but there's nothing promising real diversion from that track once began. 

I was wrapped up in the book; although it's fairly dense Macy manages to keep it pretty zippy and move things along.  The first section focuses on the pushed over-prescription of opioids for low-level issues, the incentives behind the American medical system for companies and individual doctors to upsell drugs and the gaps in oversight which let it happen (and the financial incentives to keep doing it this way). The second section is more about individuals who, once hooked for whatever reason, are now sliding deeper into addiction, and the third section was more about what options there are for diversion, rehab, prison, getting clean, etc. The third section felt the weakest, less focused and more self-insertion, as to what is or is not an appropriate way to treat people.  The whole fentanyl thing was also confusing - fentanyl is another opioid drug, but also, any amount included in heroin will kill you? Or is it just fake fentanyl? It felt like the topic was so big another book could have been written on it, so including just a little bit was like getting only one or two pieces of a jigsaw puzzle. 

One criticism I will level is Macy's habit of introducing a character, diverting almost immediately onto another topic or segue, and then come back to the character.  It was annoying for several reasons: (a)  I couldn't keep everyone straight and that made it harder to connect who I'd already been reading about versus who was newly introduced (b) it felt like she was doing an injustice to their personal stories by leaving us on these sort of "cliffhanger" notes, like they weren't real people with heartbreaking problems, and (c) she'd sometime bring us in in the middle of an event, like an overdose, and I struggled to figure out if we'd read any background on these people or not.  Was I supposed to remember that they had been in fifth grade together? Whose mother was it that this person was relying on? Although honestly, it wasn't all that relevant, since basically anytime a mother was mentioned, they had an adult child who was addicted, and they were all helping out other parents and children.  No explanation was given as to why fathers were never involved.  Were these all single parent households? Did the fathers just not care about their children? Is any of that relevant to these kids' addiction stories? Who knows?

For all that I criticize, it is a good, engrossing, important read.  There needs to be more attention paid to the systemic problems pointed out in the book - the incentives to push drugs for profit instead of health, the bias towards jail instead of rehabilitation, the reluctance to commit resources or medicines to combat the problem, the idea that the addicted are somehow deficient, rather than victims. Although I certainly don't feel as sympathetic for teens who just took random medication at pill parties as those who were over-prescribed opiates by trusted physicians, I also don't think that anyone deserves to be reviled for a single bad decision, especially one when made at the height of peer pressure and immaturity. Like I said, it's a depressing read, but a worthwhile one. Hopefully it will help change minds and allow doors to open that create better results for the addicted than what we currently see.

31: A Book Featuring A Man-Made Disaster