by Beth Macy
It was almost three years since Jesse’s death. His grave was now decorated with red-white-and-blue pinwheels, an American flag, and a brand-new 55 metal sculpture painted in school colors. Over the next year, Kristi would hatch plans for a memorial five-kilometer race for opioid awareness that she envisioned meandering past Jesse’s old football field and the Shenandoah River. Photos of overdose victims, including another friend of Jesse’s who had recently died, would be placed along the runners’ path; the money raised would benefit the area’s substance abuse coalition.
In one week in October 2016, nineteen people in the northern Shenandoah Valley region would overdose, seventeen of them brought back with Narcan. Baltimore dealers continued to hot-pack their heroin with fentanyl, an area naloxone trainer told me, because when someone dies, customers flock to his or her dealer, chasing a better high. “It’s like, ‘I might lose three of my customers, but in the long run I’ll gain ten of yours,’” theorized the trainer, a mom who’d lost a son to fentanyl-laced heroin. The fentanyl-packing strategy is also sometimes employed with known snitches or suspected confidential informants, the goal being to kill them.
After a day passed, I tried to break the news gently to Kristi over the phone that Ronnie hadn’t even recognized Jesse’s name.
In that respect, Ronnie Jones was no different than the drug reps in their tailored suits and SUVs: He had failed to see the harm his drugs had caused.
And why should he be any different?
A few months before I sat down with Ronnie, Purdue Pharma executive J. David Haddox gave a speech urging members of the Richmond Academy of Medicine not to be swayed by the narrative taking shape around the opioid epidemic. His company was working to create new and “safer” painkillers, he said. The assembled doctors were unimpressed. What can we do, they wanted to know, when our patients need pain relief but we don’t want them to become addicts? Haddox could only suggest using local pain specialists—including the friend of his who’d invited him down to deliver the speech. But there weren’t enough pain specialists, and the doctors were increasingly aware of studies showing that long-term opioids in fact created more pain in many patients, a condition known as opioid-induced hyperalgesia.
Eight years after the 2007 sentencing of the company and three top executives for criminal misbranding, more lawsuits were being filed against Purdue and/or other opioid makers and distributors by the month, and they would grow to include such plaintiffs as the city of Everett, Washington; the state of Ohio; Cabell County, West Virginia; and Virginia’s tiny Dickenson County, not far from Lee. Purdue had followed Big Tobacco’s playbook when it downplayed the risks of its drug, and now some of America’s best legal minds were trying to make it and other pharmaceutical companies pay for the “public nuisance” burdening their communities. The states of West Virginia and Kentucky had already garnered modest settlement payments from Purdue, to the tune of $10 million and $24 million, respectively, victories that brought to mind the civil litigation brought by forty-six states and six other jurisdictions against the tobacco industry in 1998. Cigarette companies then agreed to pay billions to the states, in perpetuity, for the funding of prevention and public health programs.
But painkillers aren’t tobacco, and the cases differ partly because opioids have legitimate medical benefits when prescribed and used correctly, and the companies who make them use as fall guys the out-of-work coal miners and furniture makers and underchallenged youth who have illegally abused and diverted their drugs. “The cigarette companies finally caved, but only because the litigation costs were eating them alive,” said legal scholar Richard Ausness at the University of Kentucky. He foresaw the possibility of such a settlement being forged with opioid makers, but to a much smaller degree. “It’s a tough call because you want to punish them, but you may not want to put them out of business, because then you’re largely forgoing the right to any future claims,” he said. Tightening new opioid prescriptions through physician monitoring programs, then shifting the government’s focus to treatment and prevention, were more effective strategies than litigation, Ausness believed.
Haddox punctuated his talk with slides touting the work Purdue was undertaking to create new, “safer” painkillers. When his thirty-minute speech was over, the general practitioners in the audience grumbled a bit. Despite Haddox’s great slides and optimistic plans for new and improved opioids, the doctors were still slogging it out in the trenches. They knew they’d be the ones left holding the prescription pads when it came time to juggle their patients’ pleas for pain relief and addiction treatment with their patient satisfaction ratings, still used by many insurers to gauge reimbursements.
But Haddox remained firmly on point. “What’s getting lost here is the prevalence of chronic pain in this country,” he said. The optics of the opioid epidemic had clearly been bad for business. While Ronnie turned gray in prison and Kristi prepared the next seasonal decorations for Jesse’s grave, the Sacklers’ rank among “America’s Richest Families” slid from sixteenth to nineteenth on the Forbes list.
Powell Valley Overlook, Wise County, Virginia
Chapter Thirteen
Outcasts and Inroads
“If you want to treat an illness that has no easy cure, first of all treat it with hope.”
—Psychiatrist George Vaillant, Harvard Medical School
In 1925, the psychiatrist Lawrence Kolb Sr. published a set of groundbreaking articles arguing that addiction afflicted only people who were born with personality defects. He distinguished between “normal” users, who had been prescribed opiates by their doctors, and users who were “vicious” (a word deriving from “vice”), who had become addicted via illicit channels. The latter were much worse than the former, he initially believed, and this notion led him to categorize the addicted person as a criminal rather than a patient deserving of treatment and care.
In the mid to late 1930s, Kolb oversaw the opening of two U.S. Narcotics Farms, in Lexington, Kentucky, and Fort Worth, Texas, part of the federal government’s so-called New Deal for the Drug Addict. In bucolic rural settings, the government provided treatment both to the addicted who had arrived by court mandate and those who had volunteered, along with job training and medical care. Meanwhile, the government scientists were allowed to conduct research on the farms’ captive populations.
Kolb changed his beliefs about addiction after his colleagues proved to him that “normal” people, including the 10 to 15 percent of patients who were health care professionals, could become addicted, too, if they were opioid-exposed.
The work at the Narcotics Farm labs led to the field of addiction medicine. Both farms closed in the mid-1970s—due to an ethics scandal over experimentation on the addicted who were improperly exploited as research subjects. But their legacy includes the establishment of the National Institute on Drug Abuse and the scientific notion that addiction is a chronic, relapse-ridden disease.
Today, courts largely continue to send the addicted to prisons when reliable treatment is difficult to secure, and many drug courts controlled by elected prosecutors still refuse to allow MAT, even though every significant scientific study supports its use.
Not every patient wants or needs maintenance drugs, because every human experiences addiction differently, and what works for one might not work for another. Still, it is crucial to preserve treatments for people with addiction and help them obtain the means needed to get off drugs, rather than simply treat them as criminals who have no right to health care.
If my own child were turning tricks on the streets, enslaved not only by the drug but also criminal dealers and pimps, I would want her to have the benefit of maintenance drugs, even if she sometimes misused them or otherwise figured out how to glean a subtle high from the experience. If my child’s fear of dopesickness was so outsized that she refused even MAT, I would want her to have access to clean needles that prevented her from getting HIV and/or hepatitis C and potentially spreading them to others.
&
nbsp; As the science historian Nancy D. Campbell, who documented Kolb’s work, has written: “Perhaps the day will come when more sensible views prevail—that relapse is the norm; that drug addiction should be treated as a chronic, relapsing problem that affects the public health; and that meeting people’s basic needs will dampen their enthusiasm for drugs.”
But there is so much more work to be done.
Why, in less than two decades, had the epidemic been allowed to fester and to gain such force? Why would it take until 2016 for the CDC to announce voluntary prescribing guidelines, strongly suggesting that doctors severely limit the use of opioids for chronic pain—recommendations that echoed, almost to the word, what Barbara Van Rooyan begged the FDA to enact a decade before? Why did the American Medical Association wait two decades before endorsing the removal of “pain as the fifth vital sign” from its standards of care? If three-fourths of all opioid prescriptions still go unused, becoming targets for medicine-chest thievery, why do surgeons still prescribe so many of the things?
While it is true that doctor junkets funded by Big Pharma are no longer the norm, and physicians no longer ask reps to sponsor their kids’ birthday parties, more than half of all patients taking OxyContin are still on dosages higher than the CDC suggests—and many patients in legitimate pain stabilized by the drugs believe the pendulum has swung too far the other way.
A journalist and former colleague of mine was so worried about the epidemic’s chilling effect on painkillers that she emailed me an X-ray of her back, showing a sixty-four-degree curve in her lumbar spine—from the front, it resembled a question mark—and slipped disks that caused severe arthritis pain. Painkillers had allowed her to work and actively pursue gardening, cooking, and beekeeping, and they precluded risky and potentially debilitating surgery.
And yet her scoliosis specialist had recently discontinued her pain management “without any notice and with no discussion during appointments to come up with a pain management strategy” because the new CDC guideline “frightened him into abandoning his patients,” she said. (For her arthritis, she takes the synthetic opioid Tramadol; for neuropathy, she takes the seizure medication gabapentin, which is increasingly sought on the black market for its sedative effects.) “My life is not less important than that of an addict,” my friend wrote, in bold letters, explaining that her new practitioner requires her to submit to pill counts, lower-dose prescriptions, and more frequent visits for refills, which increase her out-of-pocket expense.
“The system taking shape treats me like an addict, like a morally dubious person who must be treated with the utmost suspicion,” she said.
The CDC guideline had become so controversial among pain patients that the two employees charged with drafting it received death threats.
To follow the physician’s imperative of “Do no harm” in a landscape dominated by Big Pharma and its marketing priorities, the medical community only recently organized behind renewed efforts to limit opioid prescribing, teach new doctors about the nuances of managing pain, and treat the addicted left in the epidemic’s wake. The number of residency programs in the field of addiction medicine has grown in recent years from a dozen to eighteen.
“We live in an era where for a century now the pharmaceutical industry has invested enormous capital investments in new drugs, and there’s no turning back that clock,” said Caroline Jean Acker, an addiction historian. “So, 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.”
The birthplace of the modern opioid epidemic—central Appalachia—deserves the final word in this story. It is, after all, the place where I witnessed the holiest jumble of unmet needs, where I shadowed yet more angels, in the form of worn-out EMTs and preachers, probation officers and nurse-practitioners. Whether they were attending fiery public hearings to advocate for more public spending, serving suppers to the addicted in church basements, or driving creaky RVs-turned-mobile-clinics around hairpin curves, they were acting in accordance with the scripture that nurse-practitioner Teresa Gardner Tyson had embroidered on the back of her white coat:
Verily I say unto you, inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me. (Matthew 25:40)
One three-day weekend every summer in far southwest Virginia, Tyson plays host to the nation’s largest free medical outreach event. Held at the Wise County Fairgrounds, Remote Area Medical serves the uninsured, from children with undiagnosed diabetes to adults on walkers with infected teeth, some caused by lack of dental coverage and others by years of meth use. It’s where I crossed paths with people like Craig Adams, a construction worker and recovering opioid addict, who brought his wife, Crystal, to RAM so they could both get their teeth fixed: They’d used so many tubes of temporary dental repair glue, he told me, they’d lost count. Craig had spent eight years in the state prison system for breaking into Randy’s Gateway Pharmacy in nearby Richlands, trying to steal OxyContin. But he was taking Suboxone now—“responsibly,” he told me, “because my wife wouldn’t have it any other way.” Having lost scores of people to opioid overdose, including his mom and grandmother, he hadn’t used illicit drugs in more than three years. “I had put off going to RAM for years because I figured they’d make you feel like shit about yourself, like ninety percent of the social service people do,” he said. “But everyone was just…so…kind.”
If there’s an argument to be made for a single-payer health care system with mental health and substance abuse coverage, this is the lumpy ground on which to make it, a gravel lot in which upward of three thousand Appalachians camp out for days in 100-degree heat to be treated in exam rooms cobbled together from bedsheets and clothespins. Behind a banner for the VIRGINIA-KENTUCKY DISTRICT FAIR & HORSE SHOW, patients wait in bleachers while volunteers pass out bottles of water as they triage them to pop-up clinics for medical, dental, and eye care.
I interviewed Tyson several times in the spring and summer of 2017, before and after the July RAM event that her organization helps plan and host. In the weeks leading up to it, she liaised with media from as far away as Holland and made frantic phone calls, once when her assistant struck out trying to secure enough bottled water for the RAM crowds. A nonprofit they usually counted on said this year’s pallets were already reserved for natural-disaster relief. “If this isn’t a disaster, I don’t know what is!” Tyson said, managing to sound both desperate and upbeat.
In rural America, where overdose rates are still 50 percent higher than in urban areas, the Third World disaster imagery is apt, although the state of health of RAM patients was actually far worse. “In Central America, they’re eating beans and rice and walking everywhere,” a volunteer doctor told the New York Times reporter sent to cover the event. “They’re not drinking Mountain Dew and eating candy. They’re not having an epidemic of obesity and diabetes and lung cancer.”
I had made a similar comparison two years before, when Art Van Zee drove me through the coal camps on my first visit to Lee County, just west of Wise. Though I’d covered immigration in rural Mexico and the cholera epidemic in northern Haiti, I told him, never before had I witnessed desolation at this scale, less than four hours from my house. Most of America would be shocked by the caved-in structures, with their cracked windows and Confederate flags, and burned-out houses that nobody bothered to board up or tear down. It felt completely out of scale with the rest of the nation I knew. But these conditions were hardly limited to St. Charles or Wise County, Van Zee pointed out. “On the other side of the cities [many Americans] live in, there’s poverty and poor health probably just as bad,” he said.
In Appalachia, he conceded, poverty and poor health were not only harder to camouflage; they were increasingly harder to recover from. For decades, black poverty had been concentrated in urban zones, a by-product of earlier inner-city deindustrialization, racial segregation, and urban renewal projects of the 1950s and 1960s th
at decimated black neighborhoods and made them natural markets for heroin and cocaine.
Whites had historically been more likely to live in spread-out settings that were less marred by social problems, but in much of rural America that was clearly no longer the case. These were the same counties where Donald Trump performed best in the 2016 election—the places with the most economic distress and the highest rates of drug, alcohol, and suicide mortality.
The national media’s collective jaw-dropping at the enormity of needs displayed at the RAM event underscored the fact that the outside world had zero clue. As the Appalachian writer and health care administrator Wendy Welch noted: “We’re not victims here, except for when it comes to Purdue Pharma. But when one of us makes a mistake, it tends to be a fatal one.”
I found hope in the stories of Tyson’s staff and patients as I set out, in multiple visits, to discern what happened after the volunteer doctors departed for their urban enclaves, and the politicians and pundits went home. I felt hope as I witnessed Tyson, a bubbly, every-curl-in-place blonde, manage her workaday free clinic as she seamlessly steered her rattling 2001 Winnebago through southwest Virginia’s serpentine roads, juggling phone calls from nurses, patients, and the media alike—in high-heeled, rhinestone-studded sandals. With her sorghum-thick accent, Tyson was camera-ready and thoroughly put together each time we met, except once, when mascara smudged her doctor’s coat.
I would find out soon enough why she’d been crying for days, and it wasn’t because the battery on her Winnebago had just conked out. (The nonprofit’s marketing manager was dispatched with the battery booster to give us a jump, while Tyson’s husband offered real-time jump-starting counsel via FaceTime.)