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Shooting up

James Fryer for the boston globe

One of the most insidious features of America’s opioid epidemic is its ability to slink just below the public’s radar, even while disquieting statistics make headlines daily. Its relative invisibility is especially surprising since nearly all of us have friends or relatives numbered among those statistics.

Here’s a staggering one, from Beth Macy’s new book: Drug overdose is the new leading cause of death for Americans under age 50. “[It kills] more people than guns or car accidents, at a rate higher than the HIV epidemic at its peak,” Macy writes.

So why aren’t we sounding the alarm more loudly? Macy attempts to answer that question, and to turn up the volume, in “Dopesick’’ — an impressive feat of journalism, monumental in scope and urgent in its implications.


Author of the lauded bestsellers “Truevine’’ and “Factory Man,’’ Macy takes a cinematic approach to an issue of epic proportions. She divides the book into three parts: The first documents the epidemic’s roots in the coalfields of Appalachia during the mid-1990s; the second traces its spread to the suburbs, as it transformed from a rural, working-class phenomenon to one affecting everyone from wealthy teens to TV meteorologists. The final section explores the systemic failures that have allowed the epidemic to flourish — and addresses ways to fight back.

First, though, Macy rewinds the tape to the historical origins of our recreational and medicinal use of Papaver somniferum, the opium poppy — and the havoc it has wreaked on humanity throughout the ages. America’s first opioid crisis, she notes, emerged after the Civil War, when soldiers given morphine for pain became addicted to the drug by the thousands.

A Bayer chemist developed what he heralded as the antidote to that crisis: a new compound he called “heroin” that was impossible to become addicted to. At the dawn of the 20th century, you could buy it at any American drugstore, where it was pumped into cough drops and dripped into syrups to soothe colicky babies. It took the US government another 26 years to ban heroin’s manufacture, after it had ruined enough lives to convincingly undermine the drug developer’s claims of harmlessness.


This historical anecdote is no detour. As Macy compellingly demonstrates, history tends to repeat itself: Roughly a century later, chemists from Purdue Pharma developed a new wonder drug and echoed the claim that it was near-impossible to get hooked on. The drug was called OxyContin. Company executives ultimately pleaded guilty to misbranding charges for downplaying the risks it carried. They also reformulated the drug to make it less prone to abuse: The new version, released in 2010, can’t be crushed, snorted, or injected intravenously. But that hasn’t stopped the epidemic: Addicts simply switched to heroin.

The modern opioid epidemic has a cast of thousands — drug developers, pharmacists, doctors, dealers, addiction specialists, and of course, users and their families — and Macy interviews so many of them that it can be hard to keep all the characters straight. But their stories drive the crisis home far more powerfully than statistics. Their narratives are gritty and heartbreaking, like that of the farmer in his 70s who was introduced to OxyContin and, within six months, had sold his land — worth $500,000 — and everything else he owned to feed his addiction. “It’s over,” he told his doctor. “The kids are gone. The wife’s gone. The farm’s gone.”


Even though the Trump administration declared the opioid epidemic a national public health emergency in October, little has been done to remedy the problem, and the statistics keep getting grimmer. Opioid addiction is now roughly as common in the United States as diabetes, but only about 10 percent of the addicted have access to treatment, and even fewer to what Macy calls “the gold standard for opioid treatment: medication-assisted therapies.”

She outlines the institutional problem, which she describes as twofold: “a criminal justice system that pursues a punishment-fits-all plan . . . [and] a medical system that overtreats people with painkillers until the moment addiction sets in — and health care scarcity becomes the rule.”

What’s the solution? It’s complicated, of course, just like addiction itself. Macy touches on a number of possibilities, including better treatment options, smarter drug laws, and increased regulation of Big Pharma.

But the most pervasive and crippling barriers to treatment, she maintains, are cultural. Part of the reason the stories she tells have gone unheard for so long is that the shame and stigma surrounding addiction remain as real today as they were in 1925, when the psychiatrist Lawrence Kolb argued that “addiction afflicted only people who were born with personality defects.”

“Until we understand how we reached this place,” Macy writes, “America will remain a country where getting addicted is far easier than securing treatment.”


Dealers, Doctors, and the Drug Company That Addicted America


By Beth Macy

Little, Brown, 384 pp., illustrated, $28

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Jennifer Latson is the author of “The Boy Who Loved Too Much,’’ a nonfiction book about a genetic disorder sometimes called the opposite of autism. Follow her on Twitter @JennieLatson.