by Beth Macy
I covered Spencer Mumpower’s transition from private-school student to federal inmate at the same time I witnessed the rise in overdose deaths spread north along I-81 from Roanoke. It infected pristine farm pastures and small northern Shenandoah Valley towns, as more users, and increasingly vigilant medical and criminal justice systems, propelled the addicted onto the urban corridor from Baltimore to New York. If you live in a city, maybe you’ve seen the public restroom with a sharps container, or witnessed a librarian administer Narcan.
While more and more Americans die of drug overdose, it is impossible to not look back at the early days of what we now recognize as an epidemic and wonder what might have been done to slow or stop it. Kristi Fernandez’s questions are not hers alone. Until we understand how we reached this place, America will remain a country where getting addicted is far easier than securing treatment.
The worst drug epidemic in American history didn’t land in the bucolic northern Shenandoah Valley until 2012, when Ronnie Jones, a twice-convicted drug dealer from the Washington suburbs, arrived in the back of a Virginia Department of Corrections van and set about turning a handful of football players, tree trimmers, and farmers’ kids who used pills recreationally into hundreds of heroin addicts, as police officers told the story.
The transition here, in the quiet town of Woodstock, was driven by the same twisted math I’d witnessed elsewhere, as many users began with prescriptions, then resorted to buying heroin from dealers and selling portions of their supply to fuel their next purchase. Because the most important thing for the morphine-hijacked brain is, always, not to experience the crushing physical and psychological pain of withdrawal: to avoid dopesickness at any cost.
To feed their addictions, many users recruit new customers. Who eventually recruit new customers. And the exponential growth continues until the cycle too often ends in jail or prison or worse—in a premature grave like Jesse’s adorned with teddy bears, R2-D2 action figures, and the parting words of mothers like Kristi engraved in granite: UNTIL I TAKE MY FINAL BREATH, YOU WILL LIVE IN MY HEART.
To reach Ronnie Jones, I head north on the nearest “heroin highway,” I-81. I travel roughly the same path in my car, only in reverse, that Jones’s drugs did by bus, his heroin camouflaged inside Pringle’s cans and plastic Walmart bags on the floor beside him or his hired drug runners.
On the suburban outskirts of Roanoke, I drive near the upper-middle-class subdivision of Hidden Valley, where a young woman I’ve been following for a year named Tess Henry was once a straight-A student and basketball star. At the moment, she’s AWOL—her mother and I have no idea where she is—although sometimes we catch glimpses of her on our cellphones: a Facebook exchange between Tess and one of her heroin dealers, or a prostitution ad through which Tess will fund her next fix.
I pass Ginger’s Jewelry, the high-end store where parents of the addicted still drive from two hours away simply because they can think of nowhere else to turn. They’ve read about Ginger’s imprisoned son in the newspaper, and they want to ask her how to handle the pitfalls of raising an addicted child.
Up the Shenandoah Valley on the interstate, I pass New Market and think not of the men who fought in the famous 1864 Civil War battle but of the women who grew poppies for the benefit of wounded soldiers, harvesting morphine from the dried juice inside the seed pods. Three decades later, the German elixir peddlers at Bayer Laboratories would stock America’s drugstores with a brand-new version of that same molecule, a pill marketed as both a cough remedy and a cure for the nation’s soaring morphine epidemic, known as “morphinism,” or soldier’s disease. Its label looked like an amusement advertisement you might have seen on a circus poster, a word derived from the German for “heroic” and bracketed by a swirling ribbon frame: heroin. It was sold widely from drugstore counters, no prescription necessary, not only for veterans but also for women with menstrual cramps and babies with hiccups.
Outside Woodstock, I pass George’s Chicken, the poultry-processing plant where Ronnie Jones first arrived to work in a Department of Corrections work-release program, clad in prison-issue khakis. I pass the house nearby where a cop I know spent days, nights, and weekends crouched under a bedroom window, surveilling Jones and his co-workers from behind binoculars—a fraction of the man-hours the government invested in putting members of Jones’s heroin ring behind bars.
I head northwest toward West Virginia, the crumbling landscape like so many of the distressed towns I’ve already traversed in Virginia some four hundred miles south, down to the same HILLARY FOR PRISON signs and the same Confederate flags waving presciently from their posts.
At the prison, I park my car and walk through the heavy front door. A handler named Rachel ushers me through security, making cheerful small talk as we head deeper inside the concrete maze and through three different sets of locked doors, her massive cluster of keys reverberating like chimes at each checkpoint.
We pass through a recreation area, where several men—all but one of the prisoners black and brown, I can’t help noticing—push mops and brooms around the cavernous room, looking up and nodding as we pass. The manufactured air inside is cold, and it smells of Clorox.
Ronnie Jones is already waiting for me on the other side of the last locked door, seated at a table. He looks thinner and older than he did in his mug shot, his prison khakis baggy, his trim Afro and beard flecked with gray. He looks tired, and the whites of his eyes are tinged with red.
He rises from the chair to shake my hand, then sits back down, his hands folded into a steeple, his elbows resting on the table between us. His mood is unreadable.
The glassed-in room is beige, the floors are beige, and so is Rachel, in her beige-and-blue uniform and no-nonsense shoes, the kind you could run in if you had to. She tells us to knock on the window if we need her, then leaves for her perch in the rec room, on the other side of the window, the door lock clicking decisively behind her.
I open my notebook, situate the questions I’ve prepared off to the side, next to my spare pens. I’m thinking of Kristi and Ginger and of Tess’s mom, and what Jones might say that will explain the fate of these mothers’ kids.
Jones leans forward, expectant and unsmiling, and rubs his hands together, as if we’re business associates sitting down to hammer out a deal.
Then he takes a deep breath and, relaxing back into his chair, he waits for me to start.
Part One
The People v. Purdue
Pennington Gap, Lee County, Virginia
Former coal-mining facility, Lee County, Virginia
Chapter One
The United States of Amnesia
Though the opioid epidemic would go on to spare no segment of America, nowhere has it settled in and extracted as steep a toll as in the depressed former mill and mining communities of central Appalachia, where the desperate and jobless rip copper wire out of abandoned factories to resell on the black market and jimmy large-screen TVs through a Walmart garden-center fence crack to keep from “fiending for dope.”
In a region where few businesses dare to set up shop because it’s hard to find workers who can pass a drug test, young parents can die of heroin overdose one day, leaving their untended baby to succumb to dehydration and starvation three days later.
Appalachia was among the first places where the malaise of opioid pills hit the nation in the mid-1990s, ensnaring coal miners, loggers, furniture makers, and their kids. Two decades after the epidemic erupted, Princeton researchers Anne Case and Angus Deaton were the first economists to sound the alarm. Their bombshell analysis in December 2015 showed that mortality rates among white Americans had quietly risen a half-percent annually between the years 1999 and 2013 while midlife mortality continued to fall in other affluent countries. “Half a million people are dead who should not be dead,” Deaton told the Washington Post, blaming the surge on suicides, alcohol-related liver disease, and drug poisonings—predominantly opioids—which the economists later referred to as “dise
ases of despair.” While the data from which Case and Deaton draw is not restricted to deaths by drug overdose, their central finding of “a marked increase in the all-cause mortality of middle-aged white non-Hispanic men and women” demonstrates that the opioid epidemic rests inside a host of other diseases of despair statistically significant enough to reverse “decades of progress in mortality.”
At roughly the same time the Case and Deaton study was published, a Kaiser Family Foundation poll showed that 56 percent of Americans now knew someone who abused, was addicted to, or died from an overdose of opioids. Nationwide, the difference in life expectancy between the poorest fifth of Americans by income and the richest fifth widened from 1980 to 2010 by thirteen years. For a long time, it was assumed that the core driver of this differential was access to health care and other protective benefits of relative wealth. But in Appalachia, those disparities are even starker, with overdose mortality rates 65 percent higher than in the rest of the nation. Clearly, the problem wasn’t just of some people dying sooner; it was of white Americans dying in their prime.
The story of how the opioid epidemic came to change this country begins in the mid to late 1990s, in Virginia’s westernmost point, in the pie-shaped county sandwiched between Tennessee and Kentucky, a place closer to eight other state capitals than its own, in Richmond. Head north as the crow flies from the county seat of Jonesville and you’ll end up west of Detroit.
Geopolitically, Lee County was the ultimate flyover region, hard to access by car, full of curvy, two-lane roads, and dotted with rusted-out coal tipples. It was the precise point in America where politicians were least likely to hold campaign rallies or pretend to give a shit—until the unchecked epidemic finally landed on their couches, too.
Four hundred miles away, at the northern end of the Shenandoah Valley, a stressed-out preschool teacher would tell Kristi Fernandez around this time that her four-year-old son, Jesse, was too rambunctious for his own good. He was causing mayhem in the classroom, so Kristi took him to his pediatrician, who urged her to put him on Ritalin. She acquiesced two years later, the drug seemed to quell his jitters and anxiety, and the teacher complaints stopped.
But he was still her high-energy Jesse. You could tell he was hyper even by the way he signed his name, blocking the letters out joyfully and haphazardly, adding a stick-figure drawing of the sun with a smiley face below the first E. The sun’s rays stuck out helter-skelter, like a country boy’s cowlick, as if it were running and winking at you all at once.
Lieutenant Richard Stallard was making his usual rounds, patrolling through Bullitt Park in Big Stone Gap in Wise County near the Lee County line. This was the same iconic small town romanticized in Adriana Trigiani’s novel and film Big Stone Gap, the one based on her idyllic upbringing in the 1970s, when a self-described town spinster with the good looks of Ashley Judd could spend her days wandering western Virginia’s hills and hollows, delivering prescriptions for her family-run pharmacy without a thought of danger.
The year was 1997, a pivotal moment in the history of opioid addiction, and Stallard was about to sound the first muffled alarm. Across central Appalachia’s coal country, people hadn’t yet begun locking their toolsheds and barn doors as a guard against those addicted to OxyContin, looking for anything to steal to fund their next fix.
The region was still referred to as the coalfields, even though coal-mining jobs had long been in steep decline. It had been three decades since President Lyndon Johnson squatted on the porch of a ramshackle house just a few counties west, having a chat with an unemployed sawmiller that led him to launch his War on Poverty, which resulted in bedrock social programs like food stamps, Medicaid, Medicare, and Head Start. But poverty remained very much with the coalfields the day Stallard had his first brush with a new and powerful painkiller. Whereas half the region lived in poverty in 1964 and hunger abounded, it now held national records for obesity, disability rates, and drug diversion, the practice of using and/or selling prescriptions for nonmedical purposes.
If fat was the new skinny, pills were becoming the new coal.
Stallard was sitting in his patrol car in the middle of the day when a familiar face appeared. An informant he’d been working with for years had some fresh intel. At the time, the area’s most commonly diverted opioids were Lortab and Percocet, both of which sold on the streets for $10 a pill. Up until now, the most expensive painkiller of the bunch had been Dilaudid, the brand name for hydromorphone, a morphine derivative that sold on the black market for $40.
The informant leaned into Stallard’s cruiser. “This feller up here’s got this new stuff he’s selling. It’s called Oxy, and he says it’s great,” he said.
“What is it again?” Stallard asked.
“It’s Oxy-compton…something like that.”
Pill users were already misusing it to intensify their high, the informant explained, as well as selling it on the black market. Oxy came in much higher dosages than standard painkillers, and an 80-milligram tablet sold for $80, making its potential for black-market sales much higher than that of Dilaudid and Lortab. The increased potency made the drug a cash cow for the company that manufactured it, too.
The informant had more specifics: Users had already figured out an end run around the pill’s time-release mechanism, a coating stamped with OC and the milligram dosage. They simply popped a tablet in their mouths for a minute or two, until the rubberized coating melted away, then rubbed it off on their shirts. Forty-milligram Oxys left an orange sheen on their shirtsleeves, the 80-milligrams a tinge of green. The remaining tiny pearl of pure oxycodone could be crushed, then snorted or mixed with water and injected.
The euphoria was immediate and intense, with a purity similar to that of heroin. Stallard wondered what was coming next. In the early nineties, Colombian cartels had increased the potency of the heroin they were selling in urban markets to increase their market share—the goal being to attract needle-phobic users who preferred snorting over injecting. But as tolerance to the stronger heroin increased, the snorters overcame their aversion to needles and soon became IV heroin users.
As soon as Stallard got back to the station, he picked up the phone.
The town pharmacist on the other line was incredulous: “Man, we only just got it a month or two ago. And you’re telling me it’s already on the street?”
The pharmacist had read the FDA-approved package insert for OxyContin. Most pain pills lasted only four hours, but OxyContin was supposed to provide steady relief three times as long, giving people in serious pain the miracle of uninterrupted sleep. In an early concession to the potential for its abuse, the makers of OxyContin claimed the slow-release delivery mechanism would frustrate drug abusers chasing a euphoric rush.
Based on Stallard’s news, the pharmacist already doubted the company’s claims: “Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.” If the town’s most experienced drug detective was calling him about it just a couple of months after the drug’s release, and if his neighbors were already walking around with their shirts stained orange and green, it was definitely being abused.
Approved by the Food and Drug Administration in late 1995, OxyContin was the brainchild of a little-known, family-owned pharmaceutical company called Purdue Frederick, based in Stamford, Connecticut. The company was virtually unheard of when a trio of research psychiatrists and brothers—Mortimer, Raymond, and Arthur Sackler—bought it from its original Manhattan-based owners in 1952, with only a few employees and annual sales of just $20,000. The new owners made their initial fortunes specializing in such over-the-counter products as laxatives, earwax remover, and the antiseptic Betadine, used to wash down the Apollo 11 spacecraft after its historic mission to the moon. Expanding internationally in the 1970s, the Sacklers acquired Scottish and British drug companies and paved the way for their entry into the pain-relief business with the development of an end-of-life painkiller derived from morphine, MS Contin, i
n 1984. (Contin was an abbreviation of “continuous.”) With annual sales of $170 million, MS Contin had run its profit-making course by the mid-1990s.
As its patent was set to expire, the company launched OxyContin to fill the void, with the intention of marketing the new drug, a reformulation of the painkiller oxycodone, beyond hospice and end-of-life care. It was a tweak of a compound first developed in 1917, a form of oxycodone synthesized from thebaine, an ingredient in the Persian poppy.
Famously private, the brothers were better known for their philanthropy than for their drug-developing prowess, counting among their friends British royalty, Nobel Prize winners, and executives of the many Sackler-named art wings from the Smithsonian to the Metropolitan Museum of Art.
Promotion and sales were managed by the company’s marketing arm, Purdue Pharma, launched in the nation’s best-known corporate tax haven—Delaware.
Purdue Pharma touted the safety of its new opioid-delivery system everywhere its merchants went. “If you take the medicine like it is prescribed, the risk of addiction when taking an opioid is one-half of 1 percent,” said Dr. J. David Haddox, a pain specialist who became the company’s point man for the drug. Iatrogenic (or doctor-caused) addiction, in the words of a 1996 company training session for doctors, was not just unusual; it was “exquisitely rare.”
In the United States of Amnesia, as Gore Vidal once called it, there were people in history who might have expressed some skepticism about Haddox’s claim, had anyone bothered reading up on them. Ever since Neolithic humans figured out that the juice nestled inside the head of a poppy could be dried, dehydrated, and smoked for the purposes of getting high or getting well, depending on your point of view, opium had inspired all manner of commerce and conflict. The British and Chinese fought two nineteenth-century wars over it. And opium was a chief ingredient in laudanum, the alcohol-laced tincture used to treat everything from yellow fever and cholera to headaches and general pain. In 1804, at the end of Alexander Hamilton’s ill-fated duel, doctors gave him laudanum to numb the agony caused by the bullet that pierced his liver, then lodged in his vertebrae.