How the American opioid crisis got so big

In 1995, I attended a regional conference of community health centers in Lexington, Kentucky. While reviewing the data on premature death rates, one presenter described how some local residents of Kentucky’s mountainous eastern counties used prescriptions for pain medicine as commodities for sale or exchange. In the discussion that followed, a health professional in the audience accused the doctor of anti-Appalachian bias for suggesting such a thing. Taken aback, the doctor explained that misuse of mind-altering substances was hardly unique to Appa­lachia, a region whose history of despoilment at the hands of outsiders he knew too well, but his accuser would have none of it. The session ended with their disagreement unresolved.

That was a year before Purdue Pharma tossed napalm on the smoldering opioid epidemic by aggressively marketing its newly approved, potent, and—according to Purdue—all but impossible to abuse painkiller, OxyContin. Now, more than 20 years later, that testy exchange in Kentucky seems from another, shockingly naive, world. But it encapsulates essential features of this ongoing public health disaster: failure to learn from the past, slowness to recognize the nature and scope of the problem, and misplaced efforts to assign blame.

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What the American past has to teach is recounted early in Beth Macy’s Dopesick. Following the Civil War, many injured veterans were given generous supplies of morphine and hypodermic needles to be used as needed for pain relief. Though the resulting epidemic of morphine addiction hit hardest in small towns of the former Confederacy, all regions and classes were eventually affected, making the problem difficult for newspapers and politicians to ignore. Nevertheless, attempts to impose even minimal regulations on morphine use were denounced as “class legislation” and “government overreach.”

At the end of the 19th century, an apparent solution emerged: a new drug marketed by the German manufacturer Bayer as a safe alternative to morphine, with little potential for addiction. That new medication was heroin. After a decade of skyrocketing hospital admissions and deaths from heroin overdose, the federal government finally imposed significant restrictions on the sale and possession of narcotics, eventually outlawing heroin altogether. By the 1930s, narcotic addiction, now mostly from heroin, was a mostly lower- and working-class phenomenon. Social elites were now free to regard the problem, if they saw it at all, as a vice rather than a physician-caused disease.

The remainder of Macy’s book documents the reprise of that sad history in the opioid catastrophe. Purdue Pharma knowingly misrepresented OxyContin, its slow-release narcotic, as posing a low risk of addiction or abuse. Purdue’s marketing campaign targeted primary care physicians, warning them of an epidemic of untreated pain and encouraging them —with gifts, highly selective “educational materials,” and mischaracterized medical data—to prescribe more OxyContin even to patients already exhibiting signs of drug dependency. Sales representatives received lucrative bonuses for increasing prescription rates in their territories. Burgeoning demand for Oxy came not only from newly hooked patients but from experienced abusers and traffickers, who learned that the time-release coating was easily rubbed away, resulting in a ball of oxycodone that could be crushed into powder for injection or snorting.

Soon, for-profit pill mills, staffed by unscrupulous providers who signed scores of blank prescriptions for others to dispense, could be identified by long lines of people awaiting refills to avert the agonies of withdrawal or to sell as a source of income. That this explosion of opioid addiction struck rural Appalachia first and most forcefully contributed to the delayed recognition and response by medical and regulatory organizations. By 2004, OxyContin was the most prevalent prescription opioid abused in the United States. When the number of OxyContin prescriptions finally began to decline, the now-addicted population turned to whatever was available, primarily heroin, often fortified with fentanyl, a highly potent opioid that’s become the leading cause of overdose deaths in the United States.

Journalists must impose narrative coherence on mountains of information. Macy, who has reported on the epidemic from her hometown of Roanoke, Virginia, since 2012, focuses on individual stories—like the blindsided father who first hears of Oxy when he asks a team of paramedics why their best efforts couldn’t resuscitate his teenage son, found blue and lifeless from an overdose in the bathroom of his suburban home. Through interwoven tales of grieving parents turned activists, increasingly alarmed local health professionals, and beleaguered first responders, Macy makes palpable the scale and intensity of suffering, shame, and institutional denial.

She also unravels the tangled knot of corporate greed, political conflict of interest, and regulatory neglect that delayed recognition of the epidemic, blamed the victims, and allowed some members of the Sackler family, principal owners of Purdue Pharma, to make billions in profit with near impunity. For the most part, Macy’s approach successfully blends the personal and political, though there are moments when the names and stories dissolve into a mass of nearly indistinguishable misery like characters in a 19th-century Russian novel. The photos, index, and copious endnotes are helpful, but I found myself wishing for a list of dramatis personae. That quibble aside, Dopesick is a compelling narrative.

Chris McGreal’s American Overdose, styled as a three-act national tragedy, covers much of the same ground with fewer individual stories and greater attention to the failures of regulatory and law enforcement systems. He documents how the pharmaceutical industry influenced government entities to make corporate-friendly decisions and policies.

During the Food and Drug Admin­istration’s approval process for Oxy­Contin, Purdue used selective data and specious claims to overcome a host of legitimate concerns about the drug’s ad­dictive potential. The FDA official who oversaw the approval soon left government and eventually worked for Purdue. The American Pain Society, an organization funded in part by drug companies, persuaded the Veterans Admin­istration to promote the society’s designation of pain—and pain control—as “the fifth vital sign” and convinced the Joint Com­mission on Accreditation of Healthcare Organizations to include corporate-friendly language in its “best practices” standards for medical facilities. In 2004, a year after government agencies and medical journals finally began to question opioid marketing claims and prescribing patterns, OxyContin annual sales passed the $2 billion mark.

Pharmaceutical companies spent a combined $2.5 billion in the last decade on lobbying and campaign contributions to members of Congress. McGreal identifies a handful elected officials willing to challenge “Big Pharma,” including Congressman Hal Rogers from opioid-devastated eastern Kentucky and Cal­ifornia representative Mary Bono, whose son, Chesare, became addicted to OxyContin.

Drug company cash may have less direct influence on law enforcement and justice systems, but the War on Drugs, with its emphasis on punishing drug users rather than providing them treatment and its slowness to investigate and prosecute corporate officials, prolonged the misplacement of blame. In 2007, Purdue at last admitted to a single felony charge of “misbranding with the intent to defraud or mislead.” Three of its executives accepted lesser convictions in a plea deal. The resultant penalties—$634 million for Purdue and a combined $34 million for the executives—were relatively modest in comparison to cumulative profits from sales, not to mention the toll in deaths and ruined lives.

Perhaps because McGreal’s narrative leans toward the big picture, it feels tidier than Macy’s while sacrificing some of Dopesick’s rich personal detail. Ameri­can Overdose includes a helpful timeline of events and endnotes for readers wanting to track down McGreal’s sources. Though the definitive history of the ongoing American opioid epidemic may not be written for decades, these two offerings by seasoned journalists prove accessible interim reports, helping the reader understand how we arrived in this pit of misery and perhaps how long it may take to find a way out.

A version of this article appears in the print edition under the title “Roots of the opioid crisis.”