American Pain

by John Temple

  So Stacy had felt fine even as the carbon dioxide thickened in his bloodstream. His breathing reflex drowsed, and so did he, kneeling over the barrel behind the barn. His inhalations and exhalations slowed to four a minute . . . then two . . . then one. His heart continued to push blood throughout the body, but his lungs didn’t do their part. Millions of air sacs in the lungs began to flood, drowning him in his own blood serum. The few slack breaths he did take forced bloody foam up into his mouth and nose. His brain swelled with fluid. His heart, starved for oxygen, pittered into wild arrhythmia.

  The postmortem over, Billy Dowell zipped the corpse into a body bag, loaded it into the coroner’s van, and headed back toward Rockcastle County.

  Alice, Lisa, and Shelby. The three women who loved Stacy. They had questions. Of course, what had killed him? But also, where had he been the last couple of days? Why was he so weak and exhausted? Why hadn’t he gotten Lisa’s voicemail messages?

  Shelby talked to Stacy’s friend, the one who’d dropped him off at the farm. Stacy’s friend said he’d picked up Stacy at Peg’s, the little grocery off the interstate. Then Stacy’s friend said something crazy. He said when he picked him up, Stacy said he’d just got back from Florida.

  Florida? This made no sense to Shelby. Stacy had never been on an airplane. Never seen the ocean. He’d barely been out of Kentucky. No way he’d been to Florida.

  Stacy’s friend said Stacy had started the argument with Lisa so he could leave and go to a pain clinic in Florida. To get pills. Stacy had gone with a group of people he didn’t know well, the friend said.They’d driven all night and just gotten back on New Year’s morning.

  It was outlandish, but Lisa now believed the story. After she calmed down some, Lisa told her mother how the argument had started. Stacy had said he might go to a pain clinic to try to get some pills. His doctor in Mount Vernon had cut him off, he told Lisa. Cold turkey. He needed the painkillers if he was ever going to get back to work. They argued, and he said he was leaving, going to the farm.

  Alice was all torn up and people spoke carefully around her, but Lisa told her about the Florida rumor.

  Alice couldn’t imagine it, Stacy going all the way to Florida, where he didn’t know a soul. But then, a couple days after Stacy died, Alice remembered the pill bottles she’d taken out of his jacket pocket.

  Alice told her husband to get the bottles so she could look at them. And sure enough, the name of Stacy’s doctor in Mount Vernon wasn’t the name printed on the labels. Instead, there was a name she’d never seen before, a name she didn’t know how to pronounce: Dr. Cynthia Cadet.

  There were three bottles. One contained alprazolam, and two contained oxycodone, two different dosages, 15 milligrams and 30 milligrams.

  Oxycodone. Alice had heard of oxycodone. She believed it was some kind of cancer drug.

  The alprazolam and the 15-milligram oxycodone had been filled at a place called America’s Pharmacy. The 30-milligram oxycodone was from a place called Speedy Scripts II. The addresses were Fort Lauderdale. Florida.

  They went through the garbage bag Stacy had brought home. Mostly clothes, but also some papers. A photocopied sheet with drawings of people doing stretching exercises. A pharmacy receipt with the Speedy Scripts II logo at the top, the words tilted slightly to call attention to the speediness, like they were about to zip off the page. Stacy’s name and the farm’s address. The doctor again: Dr. Cynthia Cadet. Oxycodone HCL 30-milligram tablet. Quantity: 240. Stacy had paid $247.30, cash.

  The receipt contained a long set of printed-out instructions.

  “. . . used to treat moderate to severe pain . . .”

  “. . . acts on certain centers of the brain . . .”

  “. . . Follow your doctor’s instructions exactly as prescribed . . .”

  “. . . take this medication only ‘as needed’ for acute pain (e.g., pain after surgery) or on a regular schedule for chronic pain (e.g., cancer pain) . . .”

  “. . . withdrawal symptoms . . . anxiety, irritability, sweating, trouble sleeping, diarrhea . . .”

  “. . . SIDE EFFECTS: Nausea, vomiting, constipation, mild itching, drowsiness, dry mouth, lightheadedness, loss of appetite . . .”

  Then two more sets of receipts from America’s Pharmacy. The logo: a druggist’s mortar and pestle on top of an American flag. And some advertising in bold letters: “GENERICS STARTING AT $2.99. BUY 1, GET 1, FREE.” Stacy had paid $20 for the alprazolam and $100 for the oxycodone.

  Alice also found a card, the kind the doctor’s office gives patients to remind them of their next appointment. Stacy already had another appointment with Dr. Cynthia Cadet set for January 28 at 1:00 p.m., three and a half weeks away, at a place called American Pain.

  They also found Stacy’s MRI reports, the ones Stacy’s doctor had ordered back in August after the accident. There were two of them, one for the cervical spine and one for the thoracic spine. Lots of words like “reactive osteophytes at C5-C6” and “diffuse bulging disc” and “small left paracentral disc protrusion at T8-T9.”

  One other thing they found with Stacy’s things: a green plastic bottle, probably Mountain Dew, the label ripped away, heavy with coarse-grained sand.

  They reckoned Stacy had seen the ocean after all.

  Alice knew about the Internet, of course, but she didn’t mess with computers. She didn’t even know how to turn one on. But young Kevin was a wonder with electronic things, excited that something he called DSL was finally making its way out to Hummingbird Lane.

  Kevin was glad to have a way to help. He’d known more than Alice about Stacy and the pills. He knew Stacy had begun crushing and snorting the Lortabs the doctor had prescribed him. He knew that Stacy had started going to the pharmacy a couple days before he was supposed to, trying to get refills early. He’d seen his brother high on the pills. But Stacy high wasn’t too different than Stacy sober. He was the same mellow, friendly guy, maybe a little more so.

  So Kevin hadn’t worried much about the pills. A doctor had prescribed them. How bad could they be? And anyway, Kevin was busy with college and work. Kevin was going to have his own computer shop someday, be his own boss. College and computers were things Stacy and the rest of the family didn’t know much about. Stacy would have been happy to work masonry and live on the farm the rest of his life. But Stacy encouraged Kevin’s ambitions. He wanted the best for Kevin.

  Kevin began searching for information about pain clinics in Florida. He wanted to know what his brother had seen and done on his trip.

  Kevin looked up American Pain. On Topix and other websites, folks from Kentucky were talking about the clinic like it was somewhere in Somerset or Lexington instead of seventeen hours away. Apparently, Kevin told his mother, lots of people from Kentucky were going down to Florida to get pills. You just took them an MRI or a CAT scan and that’s pretty much all you needed.

  Kevin looked up oxycodone. He read that a usual starting dose for an adult was maybe two 10-milligram pills a day. Dr. Cadet had prescribed Stacy a twenty-eight-day supply of 240 30-milligram pills. More than eight 30-milligram pills every day.

  And that didn’t include the 15-milligram oxycodone pills. Or the alprazolam.

  Kevin was no doctor, but this didn’t sound right. Not for a patient’s first visit.

  Alice got the prescription bottles and flushed the pills down the toilet.

  Eugene always wanted to be buried on his land, so he and Alice decided to start a family plot on the pretty sloping meadow where the horses grazed, not far from the main house. Stacy’s tombstone would be the first.

  But they decided it just seemed too lonely to put Stacy out there by himself, so they ordered their own stones at the same time, leaving the final dates to be engraved later.

  Lisa, always organized, helped Alice plan Stacy’s funeral and burial. Lisa helped design the tombstone, adding a guitar and music notes. The mother and the girlfriend made arrangements, Lisa paying for things whenever Alice let her. And they talke
d and talked about Stacy, the trip to Florida, the pain pills. And as the initial shock dulled, what took its place was anger.

  Why in the world, Alice wondered, had that Dr. Cynthia Cadet prescribed Stacy so much medication? She couldn’t get her head around it. That lady doctor giving him not one, but two bottles of the exact same kind of medication. The question was never far from her mind: Why in the world would a doctor do that?

  Lisa came out to the farm, bringing news stories she’d found on the Internet about people dying of overdoses after receiving drugs from Florida pain clinics. She showed the articles to Alice and Kevin. People were dying in Florida too. Even if the police in Kentucky couldn’t do anything, maybe someone down there in Florida could.

  The funeral home brought Stacy’s body to Sand Hill Baptist Church the evening before the funeral. The small white frame church stood at the crossroads of two wooded lanes cut into the mountainside. Alice spent the night there with him.

  The next day, the sanctuary was overflowing with hundreds of people.

  Rev. Tommy Miller, an auto mechanic during the week, preached a sermon of peace and forgiveness, but inside he was angry. If you asked him to speak his mind, he’d tell you he was hearing more and more about the pills, to the point where it seemed every family had a tragic story to tell. And the government was doing little that he could see. Oh, they had money to bust hardworking coal truck drivers for speeding, an easy form of local revenue, but they didn’t bust drug dealers unless they had $200,000 in the bank, an amount of money worth the trouble of seizing.

  Shelby, Lisa’s mother, came to the funeral. While Lisa and Stacy had been living together all these years, more or less common-law married, Shelby had been out to the farm on Hummingbird Lane only once before. The property contained a scattering of dwellings: the clean-swept and simple main house, two trailer homes for various Mason kin, a row of rooster hutches fashioned from barrels, the rust-streaked tin barn. A milk cow, three skinny mares, and a gelding. The Masons were hill-country people, meaning they took their time getting to know you. You were lucky to hear two words out of Eugene. On that single visit, Shelby had seen but not really met Alice. Stacy’s mother was maybe not quite five feet tall, shaped like a beanbag, face reddened by sun and wind, some teeth gone, the rest stained brown by the chaw of tobacco usually lodged in her gums. During warm months, she preferred to get around her farm on grubby bare feet, an oversized stars-and-stripes baseball cap perched backward over her chopped-off white hair.

  At the funeral, Shelby met a different Alice. Grief had demolished her barriers. The little woman grabbed Shelby and hugged her close, wanting Lisa’s mother to feel at home even on this day. Alice had Stacy’s pale eyes, eyes like a girl’s, showing exactly what she was feeling. One minute, they were all mischief. The next, a hard look of wrath. Then, over and over on this day, crumpling into deep wells of sorrow.

  Shelby saw Lisa and Alice fueling each other’s fire, and she worried about it. Lisa was so stubborn once she set her mind on something.

  And Lisa was the one who said it first.

  Lisa told Alice: We have to find out what happened. We have to go to Florida.

  Sheriff Mike Peters had been called out to Hummingbird Lane on the day Stacy died. He didn’t know the Mason family, who kept to themselves out in the woods and presumably obeyed the law. Alice Mason was completely torn up, as was to be expected. She seemed like a nice lady to Sheriff Peters, about as simple and country as you could find these days, pinning up her laundry on the clotheslines behind her house.

  Sheriff Peters had talked to Alice and Eugene Mason, taken some notes, and written up a report. Stacy’s toxicology report came back a few weeks after his death. The medical examiner found that Stacy had died from “acute oxycodone and alprazolam intoxication.” Trace amounts of hydrocodone and marijuana were also detected in his system.

  Sheriff Peters didn’t take it any further than that. What was he going to do? He’d been elected to his first term as sheriff two years earlier. He had a simple redbrick office and a tan Ford Explorer and three deputies to cover 17,056 residents spread out over 314 square miles of terrain. Their job already included transporting prisoners, collecting taxes, providing court security, and serving court papers. What could he do about doctors in Florida?

  When Sheriff Peters was a boy, which wasn’t yesterday, the biggest drug problem in Rockcastle County was the town drunk. A sheriff could do something about that problem, throw the drunk in the tank now and again. And then came marijuana. Don’t get him wrong, weed was illegal, but if people smoking pot was the worst problem in the Rock, things would be pretty good. Sheriff Peters knew plenty of folks he would call alcoholics or potheads. Friends, neighbors, family. Most could hold down a steady job, and he didn’t know any who stole to support their habits.

  Pills were different. At their worst, pillheads needed two or three hundred bucks a day to get by and would steal from family members to get a fix. And painkillers weren’t like crystal meth, which was something that tended to be restricted to a certain lowlife element. Pills truly changed the county, turning normally law-abiding folks into junkies and thieves and bad parents.

  The organized gangs and cartels that supply the United States with illegal drugs had always avoided eastern Kentucky, for pretty much the same reasons major businesses stay away: too many hills, too few people. So folks who wanted to get high made do with what they had, which for a long time meant cooking moonshine. Certain families made a good living from making and running shine. Other folks in the community may have disapproved of liquor, but they also tended to distrust the government and outsiders. Local resources like timber and coal seemed mainly to enrich folks from other places. At least moonshine revenue stayed in the mountains.

  As vets came back from Vietnam with a taste for new highs, moonshine gave way to marijuana. Turned out the rugged mountains and humid climate of eastern Kentucky were excellent for growing weed. By the 1980s marijuana was believed to be the state’s number one cash crop. Most pot farmers grew high-grade plants in clusters no bigger than the John Deere Model Ds they once used to bring in forty acres of burley tobacco. A sixty-square-foot plot could yield about $60,000. Pot was harvested three times a year, and buyers came in to evaluate and bid on it just as tobacco buyers had for generations. In some areas, 40 percent of the community was involved in the trade, which meant basically everybody was dependent on its cash, from the feed-and-seed to the filling station.

  Most Appalachian marijuana rings were organized within families. Life in eastern Kentucky revolves around extended families. People figured out who they were by looking at their clan—more than the church, the job, the club, the school. Certain families controlled the majority of the marijuana trade. They also ran the other black-market establishments and trades, the illegal roadhouses and prostitution rings. Through interstate marijuana contacts, they eventually branched into transshipment of harder drugs. A light plane full of cocaine would fly in from Louisiana or Florida and land on an abandoned airstrip in the mountains, where it would be off-loaded and transported via pickup truck along an old bootlegger route to Pittsburgh or Chicago.

  Twenty years ago, there was no widespread black-market trade in painkillers. But pills were always part of life in the coalfields. Mining camp doctors prescribed painkillers liberally. They were overwhelmed by torn bodies and black lung and backs damaged by hunching over for hours in narrow shafts. Miners took to trading pills, deciding themselves when they needed medication. The other primary jobs—timber and farming and construction—also involved manual labor, which meant injuries . . . and pills. It didn’t help that the state had one of the highest cancer rates in the country and that doctors were scarce. Painkillers got folks back on their feet and back to work faster than physical therapy or other intensive treatments.

  OxyContin appeared in 1996, and its purity and strength was like nothing eastern Kentucky had ever witnessed. Stocking pharmacy shelves with pure oxycodone pills in the mounta
ins was like throwing dry timber on a smoldering ground fire—the whole forest blew up. OxyContin didn’t spread like weed or cocaine, because there was no pipeline needed. Pills were already everywhere, systematically and legally funneled through a national distribution system. OxyContin abuse didn’t spread like a product. It spread like an idea: in conversations, over the Internet and the phone, and face-to-face.

  Between 1998 and 2001, a cluster of nine counties on both sides of the Kentucky/West Virginia border received more prescription narcotics per capita than anywhere else in the country. The pills were everywhere, and it was a casual thing. In the early days, say 1999 or 2000, the dealer tended to be the old lady down the street who was prescribed twice as many pills as she used. Often as not, a drug deal went like this—you dropped by the old lady’s house, maybe had a cup of coffee at the kitchen table, asked after the family, traded a few stories, then cash for an old bottle of pills.

  Casual . . . until the user tried to stop using. Young people trying the pills were familiar with smoking weed and drinking beer. They’d had no exposure to hardcore opiates. They weren’t ready for the withdrawal, the fever and sweats and throbbing pain as every cell in the body ached for a fix. They went back for more.

  Supply and demand kicked in, and the street price bumped up to about $1 per milligram. Theft and petty crime reports rose. Pharmacies were robbed. Emergency room doctors saw more and more people complaining of pain. In a matter of months, police departments went from receiving an OxyContin-related call every couple of months to three or four phone calls a day. Perry County Park, a wooded roadside recreation area with a walking track and a mini-golf course, turned into an open-air pill market. They nicknamed it “Pillville.”