Dopesick

by Beth Macy

  “The doctor didn’t force me to take them,” Honaker said. “But they’re like a high-standard person, someone you’re supposed to trust and believe in. My husband and I both understood that I was supposed to take the pills every two hours.”

  They have discussed that defining moment a lot in the intervening years. They’ve wondered aloud what might have happened had her gallbladder not given out at the same time the factories and mines were laying off and shutting down.

  She might not have visited a neighbor, a well-known pill abuser, for advice on what to do when the pain wouldn’t subside. “If you snort ’em up your nose, they hit you better,” her neighbor told her.

  She might not have found herself doubled over and dopesick the day her prescriptions ran out. “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,” she recalled.

  “And believe me, you’ll do anything to make that pain go away.”

  She might not have later turned, in the throes of withdrawal, to her sixty-year-old neighbor, Margie, one of the growing legions of laid-off workers in town. Or suggested that, given Margie’s bad hip from decades of standing on hard factory floors, she should go visit the town’s so-called pain doctor and ask him to “write you”—parlance for coaxing a prescription out of a doctor by making the pain seem more debilitating than it really is. She might not have driven Margie to the appointment, then coached her on what to say.

  “She didn’t want to do it,” Honaker recalled. “Margie would say, ‘God knows I wouldn’t be doing this if I didn’t have to choose between paying a bill or going to the doctor to get the medicines I really need,’” for diabetes and high blood pressure.

  Within the span of three months, Honaker had mastered the classic drug-seeking emergency-room trick, beginning with an impassioned complaint about kidney stone pain. “I’d say, ‘My back’s killing me,’ and [in the ER bathroom] I’d pierce my finger, then put a drop of blood into my urine sample,” she recalled.

  She’d leave with a prescription for Percocet. She was a full-blown opioid addict when she resorted to stealing the money her husband set aside for paying the electric bill and spending it at the office of a well-known Lebanon doctor who began most of her visits to him with the question “What do you want?”

  The Board of Medicine suspended Dr. Dwight Bailey’s license to practice medicine in 2014 for excessive prescribing and poor record keeping, noting that five patients had died from drug overdoses while under his care—but that was more than a decade after Honaker first came through his doors.

  Honaker went on to steal painkillers from her husband’s elderly grandmother. She bought pills from people who paid one dollar for their OxyContin prescriptions using their Medicaid cards. “They’ve got to choose to eat or pay their electric bill. But if they’re on Medicaid, they can sell their drugs to supplement their income,” she said.

  In an Appalachian culture that prides itself on self-reliance and a feisty dose of fatalism, peddling pills was now the modern-day moonshining. Some passed the trade secrets down to their kids because, after all, how else could they afford to eat and pay their bills?

  “It’s our culture now, taking pills,” said Crystal Street, whose father, an octogenarian, got hooked on morphine and Dilaudid in the wake of a coal-mining injury. By 2016, he was on house arrest for selling prescription pills from his nursing-home bed. “I come from a long line of distributors,” Street told me.

  We spoke at an addiction clinic in Lebanon, where she and Honaker were being treated with the medication-assisted treatment (MAT) drug Suboxone. Like its methadone predecessor, Suboxone staves off dopesickness, reduces cravings, and, if prescribed appropriately and used correctly, doesn’t get you high.

  Both middle-aged, Street and Honaker had each been jailed. They took turns telling twin near-death stories, one beginning where the other left off. They’d both lost their teeth. “You get sick and throw up. Or you leave pills in your mouth and it takes the enamel off,” Honaker said. Neither had ever had steady work. “You couldn’t keep a job because you’d steal if you worked at a restaurant,” Street added. “Or you just couldn’t get up and go—you were too sick.”

  Honaker put in: “At the end of your journey, you’re not going after drugs to get high; you’re going to keep from being sick.”

  Art Van Zee saw it unfolding, and he was terrified. Within two years of the drug’s release, 24 percent of Lee High School juniors reported trying OxyContin, and so had 9 percent of the county’s seventh-graders. And Van Zee not only met with worried parents; he’d been called out to the hospital late at night about the overdose of a teenage girl he’d immunized as a baby. He remembered the exact position at the St. Charles clinic where he’d first held her. He was standing by the counter, made of materials recycled from a long-gone coal company’s commissary where coal miners once gathered to collect their pay in scrip.

  The miners had portions of their pay deducted from their salary to build the clinic in 1973. They’d also organized bake sales and talent shows, and spent years soliciting donations, many of the efforts shepherded by a trio of plucky nuns who’d migrated to the region a decade earlier, heeding LBJ’s and Robert Kennedy’s call to help Appalachia fight the War on Poverty. Nicknamed the Nickel and Dime Clinic, it was literally built by coal miners and community activists, people who chipped in every penny of their spare change.

  These weren’t simply Van Zee’s patients who were showing up in the ER; they were also dear friends, many of them descendants of the coal miners whose pictures lined his exam-room walls. They hailed from nearby coal camps with names like Monarch, Virginia Lee, and Bonnie Blue. When patients recognized a relative in the old black-and-white photos, Van Zee took the time to write their names down on the back of the pictures.

  In the spring of 2000, small-town newspaper stories weren’t yet available online, and rural news typically didn’t travel far. Van Zee had no idea that the force he was now wrestling with already had a hold elsewhere until a young doctor working in the clinic went home to visit relatives in the Northeast and hand carried a Boston Globe story back to the clinic in St. Charles. The story was headlined A PRESCRIPTION FOR CRIME.

  Machias, Maine, was a remote town known for its juxtapositions—of coastal beauty and blueberries, of poverty and population decline. Its parallels to Lee County were stunning: In a region of just thirty-six thousand residents, the Washington County jail population had doubled in two years. It was overcrowded with young adults and middle-aged women and men, drug users and diverters who were facing charges of break-ins and robberies. A level of violent crime that was wholly unprecedented in the region had begun, including the firebombing of a police cruiser. The plainspoken sheriff blamed the new criminal landscape on OxyContin, and the DEA agreed, noting that Purdue’s drug was being prescribed more than twice as often as in other parts of the state.

  And though OxyContin’s initial converts in Maine were fishermen and loggers, not coal miners, the results were the same:

  People were “walking” prescriptions, or stealing prescriptions pads the moment a doctor turned his or her back. They were “shopping,” too—quietly soliciting concurrent prescriptions from multiple doctors. Selling prescribed pills, available for a pittance with an insurance or Medicaid card, was now seen as a viable way of paying your bills in a county where the unemployment rate hovered around 22 percent.

  In a place where people had once left keys in cars and didn’t bother locking their homes, a forty-one-year-old resident told the Globe reporter, he now kept a loaded gun inside the house. A quarter of his former high school classmates had developed addictions to Oxy.

  Van Zee’s co-worker distributed copies of the Boston Globe story to others in the clinic, marveling: “That’s us!”

  Near the other end of the Appalachians, some eighteen hundred miles from Maine, it dawned o
n Van Zee and his wife that they were not alone. And they needed to get organized.

  Within weeks, Van Zee had put on several public meetings under the auspices of the Lee Coalition for Health, a grassroots group of ministers, social workers, and other community-minded people. Edited and coached by his lawyer wife, a plucky former VISTA volunteer, he wrote letters of complaint to Purdue, noting injecting patterns, frequent overdoses, abscesses, and a higher incidence of hepatitis C.

  “The extent and prevalence of the problem [are] hard to overemphasize,” he wrote on August 20, 2000, in his first letter to Dr. David Haddox, then the company’s medical director, beseeching him to investigate Purdue’s prescribing patterns in the region. In another, he wrote, “My fear is that these are sentinel areas, just as San Francisco and New York were in the early years of HIV.” The company replied by sending Van Zee and his medical partner some paperwork called Adverse Event Report Forms. At a forum for area doctors and families, Van Zee brought in Yale University substance abuse experts to describe the sudden physical and psychological stress caused by dopesickness, outlining a hard truth that many Americans still fail to grasp: Opioid addiction is a lifelong and typically relapse-filled disease. Forty to 60 percent of addicted opioid users can achieve remission with medication-assisted treatment, according to 2017 statistics, but sustained remission can take as long as ten or more years. Meanwhile, about 4 percent of the opioid-addicted die annually of overdose.

  When the researchers recommended that area doctors prescribe other, less abuse-prone drugs to patients with severe pain, a Purdue Pharma rep who’d been sitting incognito in the crowd rose to sharply challenge him. The problem was inadequate pain treatment, he insisted, not OxyContin’s abuse.

  Sue Ella, Van Zee’s wife, worried that the patient load was getting her husband down. But, instead, she witnessed a burst of energy and something she’d never seen in her mild-mannered husband: righteous anger. By November, his letters took on a sharper tone as he described patients who drove the five-hour round-trip to Knoxville, Tennessee, for maintenance methadone—including a twenty-three-year-old woman who woke at 4 a.m. and made the drive to the clinic with her four-year-old daughter in the car.

  Van Zee attended a nearby meeting of the Appalachian Pain Foundation, a Purdue-funded professional association whose job was to capitalize on the growing pain-management movement of the 1990s and to amplify its organizing principle—that pain remained vastly undertreated. The invitation to the meeting featured a quote from a seventeenth-century English apothecary: “Among the remedies which it has pleased Almighty God to give man to relieve his suffering, none is so universal or efficacious as opium.”

  Van Zee presented the company with two major requests: stop the aggressive marketing of OxyContin for the treatment of noncancer pain, and reformulate the drug to make it less prone to abuse. As an example, he touted the makers of the painkiller Talwin, who in a 1982 reformulation had added a narcotic blocker, or antagonist, called naloxone, to the mix—and immediately reduced the drug’s diversion and misuse.

  In the fall of 2000, a newspaper story had run in nearby Tazewell County, Virginia, about an uptick in crime—between August 1999 and August 2000, 150 people had been charged with OxyContin-related felonies. In a county of just 44,000 people, there had been ten armed robberies of drugstores in the past eighteen months. Unemployed Tazewell miners like Doug Clark, who’d once made thirty-five dollars an hour, were now in legal trouble for ripping copper from an abandoned mining-equipment shop—to resell on the black market and fund his next OxyContin buy. Clark had gotten hooked after surgery to repair an injured neck and broken jaw; a rock had fallen on him inside a nearby Russell County mine, since closed.

  Purdue’s medical director, Haddox, called the reporter, Theresa M. Clemons, to complain about her crime coverage, and he seemed intimidating.

  Now, at the meeting that followed Clemons’s reporting, Haddox met with Van Zee, the county prosecutor, and other county officials, who told him about Oxy-related property crimes and check forgeries, and addicts who were doctor-shopping multiple physicians to feed their habit and to make a buck. Hypodermic needles were turning up at routine traffic stops.

  While Purdue was concerned about the problem in the coalfields, Haddox said, he believed the worries were overblown. At the meeting, when Haddox and his colleagues steered the conversation toward the underprescribing of narcotics, prosecutor Dennis Lee was gobsmacked.

  “We have never seen anything like this before,” Lee interrupted. “There’s just no comparison. Not just pill counting, but the human [tragedies].”

  On the way out of the meeting, Van Zee pulled Haddox aside to reiterate his concerns about the promotional gimmicks the company was lavishing on doctors. The physician freebies needed to stop, Van Zee said.

  “How is that any different from what every other drug company does?” Haddox fired back.

  “People aren’t stealing from their families or breaking into their neighbors’ homes over blood-pressure pills,” Van Zee said.

  Van Zee didn’t yet grasp what was truly driving the furious rate of overprescription. Sales-rep bonuses were growing exponentially, from $1 million in 1996, the year OxyContin hit the market, to $40 million in 2001. New patients were given OxyContin “starter coupons” for free prescriptions—redeemable for a thirty-day supply—and Purdue conducted more than forty national pain management and speaker-training conferences, luring doctors to resorts from Boca Raton, Florida, to Scottsdale, Arizona. The trips were free, including beach hats with the royal-blue OxyContin logo. More than five thousand doctors, nurses, and pharmacists attended the conferences during the drug’s first five years—all expenses paid.

  “The doctors started prostituting themselves for a few free trips to Florida,” recalled lawyer Emmitt Yeary from nearby Abingdon, Virginia. As Van Zee delivered his message in meetings and letters, some desperate families hired Yeary to represent their loved ones for Oxy-related crimes. “The irony of it was, the victims were getting jail time instead of the people who caused it,” Yeary recalled.

  He remembered a dislocated coal miner from Grundy, Virginia, confessing that OxyContin had become more important to him than his family, his church, and his children. “It became my god,” the man said.

  By the end of 2000, Purdue had passed out fifteen thousand copies of an OxyContin video called “I Got My Life Back: Patients in Pain Tell Their Story,” without submitting it to the FDA for review, as required by the agency.

  The video, available for checkout from doctors’ offices, lauded OxyContin’s effect on patients’ quality of life and minimized its risks. The doctor-narrator heralded the new term “pseudo addiction,” wherein opioid-seeking patients “look like a drug addict because they’re pursuing pain relief…[when in reality] it’s relief-seeking behavior mistaken as drug addiction.” He then repeated Haddox’s favorite sound bite: that opioid analgesics caused addiction in less than 1 percent of patients.

  The source of this claim was a one-paragraph letter to the editor of the New England Journal of Medicine written in 1980. The letter was never intended as a conclusion on the risks of long-term opiate use, one of the authors would much later explain, yet it was trotted out repeatedly during OxyContin’s first decade.

  At Dine ’n’ Dash gatherings and in doctors’ offices from the coalfields to the California coast, this letter about an unrelated initiative was repeated and tweaked until its contents no longer resembled anything close to the authors’ intention, like an old-fashioned game of telephone gone terribly awry.

  A year after starring in the Purdue Pharma video, that same doctor, South Carolina pain specialist Dr. Alan Spanos, gave a lecture insisting that patients with chronic noncancer pain should be trusted to decide for themselves how many painkillers they could take without overdosing—just as the morphine-dispensing doctors had said of wounded Civil War veterans a century before. He reasoned that the patients would simply “go to sleep” before they stopped breathi
ng.

  By March 2001, Van Zee was as fed up with letter writing as the alarmed Richmond doctor had been in 1884, precisely two decades before his peers took up the cause and three decades before the government began regulating the drugs: I have heard them, with tears in their eyes, say that they wished it had never been prescribed for them.

  Van Zee’s neighbors were dying. The region had now buried forty-three people, dead of oxycodone overdose, since Purdue launched its drug. Addicted users had gone from snorting to routinely injecting the liquefied crushed-up powder with livestock syringes they bought (or stole) from local feed stores. At the Lee County jail, seventy-nine people were crammed into cells designed to hold thirty-four. “We were so overwhelmed, we were just stacking ’em on the floor,” the sheriff, Gary Parsons, told me; one of the prisoners had bought four OxyContin tablets by trading away his family’s mule.

  While attempting to make a night deposit at the bank next door, the manager of Payless Supermarket in nearby Coeburn was gunned down by a masked robber trying to fund his next Oxy fix.

  A half hour away in Clintwood, a man made the bold move of throwing a cement block through the front door of a pharmacy, even though it was across the street from the courthouse and the sheriff’s department. “A deputy heard the alarm go off, and here’s this guy running away and dropping pill bottles along the way, he’s so high,” Richard Stallard, the lieutenant, recalled.