There's no shortage of statistics about the depth of America's opioid epidemic — there were 72,000 overdose deaths just last year — but numbers don't tell the whole story. Beth Macy takes a ground-level look at the crisis in Dopesick, a new book focusing on central Appalachia. Macy has spent three decades reporting on the region, focusing on social and economic trends and how they affect ordinary people — she says this area is the birthplace of the modern opioid epidemic.
Dopesick explores the lives of young heroin users and their long-suffering parents, and takes an intimate look at drug dealers and the cops, judges, doctors and health activists struggling to fight the epidemic. Macy also details the actions of executives of a pharmaceutical company that aggressively marketed opioids. Many users became addicted to drugs such as OxyContin when the medications were prescribed for pain, and moved to heroin when it became harder to get more pills.
Macy says she herself grew up with a father who was addicted to alcohol, which made addiction a particularly difficult subject to tackle.
"The only way I could stand to write this book was to write about the people fighting back — so the families and the first responders. ...," she says. "My goal was to mobilize people to care about this."
On how Ronnie Jones, a drug dealer in Woodstock, Va., smuggled heroin into the area
This is an area where there ... had been a lot of workplace injuries and the pill problem had been going on for quite some time. So Ronnie found a connection in Harlem and he started sending runners or mules up to New York on the Chinatown bus. The heroin was packaged in these hockey puck-shaped-like disks that fit inside a Pringles can.
So these young women — largely addicted women themselves — would go up. He would pay them extra — he would pay them "in heroin" as he called it — and they would sneak them back. They look like snacks on the bus — like typically tucked inside Pepperidge Farm cookie bags or Pringles cans inside of a Walmart bag. And so he would bring it back and he would sell it and make a lot of money, and he had a lot of people dealing for him. ...
By the time the feds came after him ... there were 84 people on a pyramid chart with his name at the top, him and another dealer. Some of the names at the bottom of the chart were crossed out because they had already overdosed. They were tree trimmers. They were high school wrestlers. They were young women who had grown up in foster care. They were people who had been addicted to pills and now they were addicted to heroin.
On how Purdue Pharma marketed OxyContin
The FDA let them make this squishy claim that because of OxyContin's brand new time-release mechanism — which was supposed to allow the pill to bleed out over 12 hours — the FDA allowed them to say that that mechanism was believed to reduce abuse and addiction. And then the marketing team at Purdue went into a full frenzy with that. ...
The sales reps went out ... bought data — physician prescribing information — and they went to the communities where competing opioids were already being prescribed in large quantities. So they went to these distressed communities ... where there were loggers, tree trimmers, coal miners, furniture factory workers, people who had legitimate pain — and had used Vicodin, Percocet, Lortab, immediate release opioids — and they sent their reps out to doctors with this notion that addiction with this drug is "exquisitely rare," or only happens in "less than 1 percent of all cases." ... Then they hired doctors, nurses and pharmacists — 5,000 of them — to go to seminars and to become paid speakers for OxyContin. ...
Opioids for a whole century had only been used for very severe pain — end of life pain. [And the company's goal] was to make it acceptable for moderate pain. ... The more milligrams [sales representatives] talked doctors into prescribing, the bigger their bonus was — bonuses as high as $100,000 a quarter, just in bonuses alone.
On a criminal case against OxyContin
The parent company, Purdue Frederick, pled guilty to felony misbranding charges. The executives, they got it negotiated down ... they would only plead guilty to a misdemeanor charge. All the parents [of people who overdosed on OxyContin] on the stand that day said they should go to jail. Even prosecutors in the office now — who are just deluged with heroin cases — say they should have gone to jail because, in a white collar crime, if nobody goes to jail the crime is just going to continue. ... Of course OxyContin continued being sold, the same formulation for three more years.
On how Purdue has continued since the suit
[Purdue] reformulated the drug in 2010. A lot of people believe that they only did it because their patent was about to expire. Opioid makers and distributors — they've spent almost a billion dollars on political lobbying and campaigns. They've continued deluging American communities with these drugs. I mean, if you look at Eric Eyre's reporting, which won a Pulitzer last year out of Charleston, he writes about a tiny town — Kermit, West Va. — that has 400-some people. They were sending 9 million pills to that town. And how do they not know that those drugs were being widely diverted and abused?
On many rehab centers not offering medication like buprenorphine to help addicts manage opioid dependence
Most rehab centers in America do not offer medication assisted therapy. ... Rehab centers historically came out of treating alcoholism and they are [Alcoholics Anonymous] and [Narcotics Anonymous]-based largely, which just isn't as effective with opioid use disorder — effective in 10 or 11 percent — as opposed to medication assisted therapies, which have shown to prevent overdose deaths in 40 to 60 percent. That's a tough thing to get better from.
John Kelly at Harvard [University] says it takes the typical opioid use disorder patient eight years and five to six treatment attempts to achieve just one year of sobriety.
On remembering each death is a tragedy
We lost 72,000 people last year — up 10 percent from the year before. And every one of those 72,000 people and their family members and their friends, that's a tragedy. This is an unprecedented level of a drug epidemic, and we really need a comprehensive model to mitigate it. ... I think we just have to have leadership at the state, at the local, at the federal level of a big scale and intensity.
Phyllis Myers and Mooj Zadie produced and edited this interview for broadcast. Molly Seavy-Nesper and Beth Novey adapted it for Shots.
TERRY GROSS, HOST:
This is FRESH AIR. I'm Terry Gross. The depth of America's opioid epidemic can be measured in appalling statistics - 2.6 million addicts in the U.S., 72,000 overdose deaths last year - a rate of nearly 200 per day. Our guest Beth Macy takes a ground-level look at the crisis in a new book focusing on central Appalachia, which she calls the birthplace of the modern opioid epidemic.
Macy has spent three decades reporting on the region, focusing on social and economic trends and how they affect ordinary people. Her book is an intimate look at cops, judges, drug dealers, young heroin users and their long-suffering parents, doctors and health activists struggling to fight the epidemic and executives of a pharmaceutical company that aggressively marketed opioids.
Many users became addicted to drugs such as OxyContin when they were prescribed for pain after minor surgery or other treatment and then moved to heroin when it became harder to get more pills. Beth Macy's previous books include "Factory Man" and "Truevine." FRESH AIR's Dave Davies spoke to her about her new book "Dopesick: Dealers, Doctors And The Drug Company That Addicted America."
DAVE DAVIES, BYLINE: Well, Beth Macy, welcome back to FRESH AIR. You begin the book with a visit to a prison inmate named Ronnie Jones. And you spent a long time trying to arrange this visit. Why were you so interested in talking to him?
BETH MACY: I had been asked by a mother in Strasburg, Va., which is in the northern Shenandoah Valley, full of little, idyllic, small farm towns, Civil War monuments. And this mother first met me at her son's grave. His name was Jesse Bolstridge, and he had been the high-school football star in the town. She had his grave situated right next to the high school. The cemetery was right next door. And she had his grave on the edge, so she could visit him and overlook the football field, where he had once been able to move the audience to roars simply by pumping his fists.
And he had died of a heroin overdose. And she wanted me to find out, why was her beautiful, burly son, who never missed a day of work - why did he end up dead on somebody else's bathroom floor? So I just started pulling the strings, as we do in journalism. And I found out that he was - one of the ways that he became further enmeshed in his addiction was that a twice-convicted drug dealer had landed in this region a year earlier and had set about, according to the prosecutors, turning a handful of heroin users into hundreds almost overnight. But, of course, it was more complicated than that. So she said, I want you to find out why, so I can understand because I don't understand. I thought it was just pills.
DAVIES: Now, this was a stable, middle-class community. And Ronnie Jones, this dealer, I mean, it seems, as you describe it, kind of just took this place by storm, and havoc followed. What was distinct about his business model, his way of distributing the drug?
MACY: Ronnie had landed in Woodstock, Va., near Strasburg. He was serving the final part of a sentence for an earlier drug-related charge. And it was a re-entry program designed to help felons get jobs skills. And when he ended that job, he tried to, as he told me, go legit in town. He tried to set up a business in computer repair. And he said nobody would rent space to him. Nobody would hire him.
He ended up losing the chicken plant job when he got sick. And he remembered - he had been in the breakroom of the chicken plant. And he had previously had charges on dealing crack and marijuana. And somebody pointed out that everybody was already hooked on pills here. And they said, if you really want to make money, you're not going to go back to dealing marijuana and crack. You need to bring heroin in.
DAVIES: They were addicted...
DAVIES: ...To prescription opioid pills.
MACY: They were - yes.
MACY: Yes. Yes. This is an area where there were - had been a lot of workplace injuries. And the pill problem had been going on for quite some time. And so Ronnie found a connection in Harlem. And he started sending runners - or mules - up to New York on the Chinatown bus. And the heroin was packaged in these hockey-puck-shaped-like discs that fit inside a Pringles can.
And so these young women, largely addicted women themselves, would go up. He would pay them extra. He would pay them in heron (ph), as he called it. And they would sneak them back. They looked like snacks on the bus, like, typically tucked inside Pepperidge Farm cookie bags or Pringles cans and inside of a Walmart bag. And so he would bring it back. And he would sell it and make a lot of money. And he had a lot of people dealing for him.
DAVIES: These were who? I mean, who does he get to do this?
MACY: These were largely addicted women that he found. By the time the feds came after him, investigated him, there were 84 people on a pyramid chart with his name at the top - him and another dealer. And some of the names at the bottom of the chart were crossed out because they had already overdosed. They were tree trimmers. They were high-school wrestlers. They were young women who had grown up in foster care. And they were people who had been addicted to pills. And now they were addicted to heroin.
DAVIES: You describe this as an evangelical model.
MACY: Yeah, so in order to fund your own supply, many people in my book end up selling heroin for people above them. It's called middle-manning. And in order to keep their own supply steady - because they don't want to be dopesick - that is they don't want to be in this excruciating withdrawal - some recruit new users. And so that's why it's such a hard thing to put a stop to.
DAVIES: Right. So unlike the kind of drug network that we think of where there's a dealer that gets big quantities and has a network of people working corners, what he has are users who bring the stuff, recruit their friends, so they can feed their own habit. It's almost like a pyramid scheme, like - right? - like, a, you know - a network of sales people that are really users.
MACY: Right. And before he was doing that, some people in town were driving up to Baltimore. And they were buying it. And when I asked Ronnie about it in prison that day, he said, I actually was giving it to them at a better price. And they weren't having to go to Baltimore, where it was much more dangerous. So, you know, he made a lot of justifications for his actions.
DAVIES: OK. So he ends up getting lots of kids in this community on heroin. Some of them eventually overdose, particularly when the additive fentanyl comes. But let's back up a little bit. Where do most of these kids get started on opioids?
MACY: Well, Jesse Bolstridge, who was the football player I told you about - he had snowboarding injuries, football injuries. His mother doesn't know exactly which injury led him to - his pill of choice was Roxicodone - roxies, they called them. And sometime around age 15 or 16. But she didn't really become aware of it until he was 17 or 18.
Now, one other thing that I just happened to notice anecdotally as I was reporting this - because I was reporting, you know, kind of running up and down I-81, interviewing all kinds of families. But I noticed that many of the parents of the overdose dead would say, as they were telling me the history, that their child started out with Ritalin as a young kid. They had been diagnosed with ADHD.
And the science isn't really clear on that, but we do know that it's largely overdiagnosed. And one of the things kids like Jesse do when they hit that age, and especially when they start experimenting with pills, is they will trade their ADHD medication for stronger drugs, such as opioids. And that's what happened in Jesse's case and with numerous of the family members that I interviewed for this book.
DAVIES: A lot of your book deals with the pharmaceutical industry, particularly Purdue Pharma, which marketed OxyContin. They did this at around the time when, you know, the American medical establishment was taking a new interest in treating pain more aggressively. And so lots and lots of these opioid-based pills were being prescribed for people with all kinds of minor surgeries or problems. What were some of the ways that Purdue marketed this drug so aggressively?
MACY: Right. So the FDA let them make this squishy claim that, because of OxyContin's brand-new time-release mechanism, which was supposed to allow the pill to bleed out over 12 hours, the FDA allowed them to say that that mechanism was believed to reduce abuse and addiction. And then the marketing team at Purdue went into a full frenzy with that. And then that claim was buttressed by old, out-of-date data. And that claim became a certainty.
The sales reps went out, especially to distressed communities. They bought data, physician-prescribing information. And they went to the communities where competing opioids were already being prescribed in large quantities. So they went to these distressed communities, like Lee County, like Machias, Maine, where there were loggers, tree trimmers, coal miners, furniture factory workers, people who had legitimate pain and had used Vicodin, Percocet, Lortab, immediate-release opioids. And they sent their reps out to doctors with this notion that addiction with this drug is, quote, "exquisitely rare" or only happens in, quote, "less than 1 percent of all cases." And they made that squishy claim a certainty. And then they hired doctors, nurses and pharmacists - 5,000 of them - to go to seminars and to become paid speakers for OxyContin. And their whole goal at the beginning - you can read it right there in their budget plans, which I cite in the book - is to make OxyContin, which - opioids for a whole century had only been used for very severe pain, end-of-life pain - was to make it acceptable for moderate pain.
DAVIES: Beth Macy's new book is "Dopesick." We'll continue our conversation after a short break. This is FRESH AIR.
(SOUNDBITE OF STEFANO BOLLANI, ET AL.'S "ALOBAR E KUDRA")
DAVIES: This is FRESH AIR. And our guest is journalist Beth Macy. She spent many years reporting in Roanoke, Va., about social and economic trends affecting the Appalachian region of the country. Her new book is a ground-level look at the opioid crisis. It's called "Dopesick: Dealers, Doctors And The Drug Company That Addicted America." One of the things that makes this book such a great read is that you really introduce us to a lot of the people who are involved in this - parents and kids in pain, cops and doctors and activists who dealt with this. And you write about a guy named Art Van Zee. He was a physician who wanted to go work in a needy community. And he ends up in - was it Lee County in the coalfields?
MACY: Yeah, in St. Charles, a very tiny, little town.
DAVIES: What did he observe after Oxycontin's released there?
MACY: So before OxyContin, he told me he had one to two patients a year that he treated for substance use disorder. After OxyContin was introduced, he was being called out to the hospital at night on overdoses of young people whom he had immunized as babies. He was treating farmers and coal miners. One man said, I lost my farm. I lost my wife. I've lost everything. That drug became my god.
There was one miner that I write about in particular named Arnold Fayne McCauley. He had been injured numerous times in the coal mines and had been prescribed immediate-release opioids and had always been able to get off of them before. I mean, he took them as prescribed. But when Oxycontin came out, that pill was so strong, so much stronger than those other opioids that he had taken that he just couldn't do it. And his, you know, family sent him to rehab numerous times. He ends up murdered in a field after he had lost his family, after he had lost everything.
DAVIES: So as this problem increased in the area, there were civil suits filed by some people who felt that Purdue Pharma should be held accountable for the addiction there that had taken the lives of loved ones. The civil suits typically failed because it's hard to specifically pin the cause of death on a specific act.
MACY: Right. They always blame the user for misusing their drug.
DAVIES: Right. But eventually, a criminal case emerged. Just tell us a bit about that - who did it, how it happened.
MACY: Sure. U.S. attorney named John Brownlee out of the Roanoke office deputizes a couple of government prosecutors in Abingdon, Va., which is very close to the region where Art Van Zee practices in central Appalachia. And they start amassing all this data. They get all the lawyers from the civil cases that were largely lost. I mean, actually, they were all lost. They get all this data. They have boxes and boxes of files, hundreds of boxes of testimonials and depositions. And they start investigating Purdue.
And in 2007, there's a big series of negotiations. Rudy Giuliani is brought in to sort of initially try to thwart the investigation. Brownlee holds firm. And it gets negotiated down from - according to recent documents that The New York Times published from the Justice Department, it gets negotiated down from a lot of felony charges to one felony criminal misbranding charge for the company. And then the executives get three misdemeanor charges.
But during the hearing, which took place in Abingdon on a rainy day, all of these relatives against Purdue Pharma and all these mothers of the early children who had overdosed on OxyContin - mothers and fathers came from all over the country to look these executives in the eye. And the judge actually let them testify that day. It was quite moving. One of the mothers actually snuck in a little urn of her son's ashes. And as she pulled it out as she was walking down from the witness stand, she shook it at them. And she said, this is your drug. This is what you did to my son.
DAVIES: Shook it at the executives who were there on the defense table.
DAVIES: Yeah. But to be clear about what actually happened here, I mean, there was an indictment for fraud against the company and three executives, right? And in the end, the company pled to what? And the executives pled guilty to what?
MACY: They both pled guilty to misbranding. But the company - actually, the holding company, the parent company, Purdue Frederick, pled guilty to felony misbranding charges. The executives - they got it negotiated down, so they would only plead guilty to misdemeanor charges. And so all the parents on the stand that day said they should go to jail. Even prosecutors in the office now who are just deluged with heroin cases say they should've gone to jail because in a white-collar crime, if nobody goes to jail, the crime's just going to continue. And, of course, Oxycontin continued being sold - the same formulation for three more years.
DAVIES: Specifically, the company pled guilty to fraudulently marketing the drug for six years, right?
DAVIES: For misrepresenting it for six years, right?
MACY: Right. Downplaying the risks of abuse and sort of overselling. And at the press conference, John Brownlee showed charts that the sales reps took out to the doctor's office, showing that there were fewer peaks and valleys with OxyContin as opposed to the competing immediate-release opioids. And then Brownlee also showed what the truth was - was that it didn't do what they said it did. And, in fact, it set people up for addiction even more. And as I say in the book, the difference between the two graphs was the difference between truth and lies.
DAVIES: And did the company change its behavior? Has it?
MACY: Well, it reformulated the drug in 2010. A lot of people believe that they only did it because their patent was about to expire. Opioid makers and distributors - they've spent almost a billion dollars on political lobbying and campaigns. They've continued deluging American communities with these drugs. I mean, if you look at Eric Eyre's reporting, which won a Pulitzer last year out of Charleston, he writes about a tiny town - Kermit, W.V. - that has 400 and some people. They were sending 9 million pills to that town. And how did they not know that those drugs were being widely diverted and abused?
DAVIES: You write in this book that for people who have not ventured recently into rural America, the jaw-dropping and visible decline of work comes as a shocker. How is it visible?
MACY: The first time Dr. Van Zee drove me around the little coal camp communities, literally, my jaw was dropping. And even in small towns like where I grew up - I grew up in a small town in Ohio. And I was visiting my little nephews that live near there recently. And we were having chili dogs at this little restaurant stand. And we were going to walk to the park afterwards. And they said, Aunt Beth, let's drive. And I said, why not walk? It's right across the street. We can see it. They said, we don't want to step on heroin needles.
DAVIES: But how does this decline in employment, this growth in poverty and the number of people who are on federal disability payments - how did that feed or reinforce the opioid epidemic?
MACY: Sure. Well, as the jobs were closing - I tell the story of a woman at the beginning who had gallbladder surgery. And at the end of taking 30 days' worth of OxyContin, she finds herself addicted. And her neighbor, who has just lost her job - she sort of coaches her to go to the doctor to get the doctor to write you a prescription for OxyContin. So this woman talks her neighbor, who's just lost her factory job and needs a way to get her blood pressure medicine, into going and getting written prescriptions for OxyContin. And then they share it. The woman who doesn't really need it sells it in order to pay her bills. And the woman who's just had gallbladder surgery and is now trying not to be dopesick and in withdrawal is taking half of her pills. And that just happened times a thousand out in that region.
DAVIES: So people were using - were selling the pills as a form of income?
MACY: Yeah. It was like moonshine.
DAVIES: You talked to so many players in this drama - I mean, police officers and heroic doctors and community activists and so many parents and kids - parents who'd lost kids, kids who were in and out of treatment, families in pain. I was struck that you wrote that one woman, Robin Roth (ph), was so determined to deal with her son's addiction that, at one point, she had doors removed from every room in the house, so there was no place he could hide.
MACY: Yeah. Yeah. There's a drug court judge out in rural Russell County, not far from Lee. I watched his hair turn from salt and pepper to white in the course of about a year. And people come up to him at the grocery store. And they have kids who are addicted but haven't been charged. And they beg him. Judge Moore (ph), please put my child in drug court, you know, before they even have charges. Of course, he can't do that. But there's just so much desperation out there.
GROSS: We're listening to the interview FRESH AIR's Dave Davies recorded with journalist Beth Macy, author of the new book "Dopesick." After a break, they'll talk about medication-assisted therapy and about how her reporting was affected by having a father who was an alcoholic. And Maureen Corrigan will review a new, unusual apocalyptic novel. I'm Terry Gross. And this is FRESH AIR.
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GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to the interview FRESH AIR's Dave Davies recorded with journalist Beth Macy, author of a new book about the opioid epidemic called "Dopesick." She describes Appalachia as among the first places where the malaise of opioid pills hit the nation in the mid-1990s. She began reporting on the epidemic in 2012 and has since spoken with cops, judges, drug dealers, young heroin users and their long-suffering parents, doctors and health activists struggling to fight the epidemic and executives of a pharmaceutical company that aggressively marketed opioids.
DAVIES: You refer in the book, in passing, to having grown up in an alcoholic household and living on the periphery of addiction. I wonder if you want to explain that at all and how it affected your reporting.
MACY: Sure. My dad was an alcoholic. He died of alcohol-related complications and lung cancer at the age of 57 when I was a sophomore in college. I didn't really have much of a relationship with him growing up. I didn't understand it. I still don't completely understand it. I knew the only way I could stand to live in this material was to write about the people fighting back. So if you notice, in the book, at no point do I watch somebody put a needle in their vein. I - the only way I could stand to write this book was to write about the people fighting back - so the families I - the only way I could stand to write this book was to write about the people fighting back, so the families and the first responders. I mean, I did spend time with users. But - you know, I would visit Tess Henry, for instance. I'd visit her in rehab. I would drive her to NA meetings, walk her baby around the back of the room when he got fussy, things like that. But I wasn't hanging out on the streets with them unlike other reporters just because I didn't think I could handle that. This was dark enough as it was.
DAVIES: Was that because of memories of what - of your father or fear...
DAVIES: ...On your own part? Yeah.
MACY: Yeah, partly. And then I just thought - a friend of mine who's a writer, Roland Lazenby, he said - he quoted Mister Rogers. He said, find the helpers. And I just thought, if I'm going to tell this comprehensive story that spans 22 years, this is the way I'm going to be able to be mentally healthy and write this book. And also, maybe it's a way that people are going to relate a little bit more to a mother or to a physician or to a police officer.
My goal was to mobilize people to care about this. And there's so much stigma against, quote, "addicts." That was another way - like, write about the helpers. But because of - you know, you get so close to these people, and this young woman, Tess Henry, who was 26 when I met her, there were moments where the lines - the journalistic lines blurred. And I wasn't sure how much I was supposed to do. It was OK to drive her to an NA meeting when she was ostensibly, quote, "clean."
But was it OK when she texts me a barely legible text at 10 at night and says, please come get me, and she's in a drug house? Was that OK? I had to talk that out with my husband, and we decided, no, that wasn't OK. I wasn't going to do that. So I called her mother, and I called her HOPE Initiative volunteer, a person who was trying to help her get access to treatment, instead. I just thought that was a bridge too far ethically...
MACY: ...As a journalist.
DAVIES: Yeah, no, I would think - I mean, dealing with the kind of pain and destruction that you're dealing with and getting to know these people so well, it would be very hard not to feel the kind of personal connection that would want to make you involve yourself in a ways beyond chronicling what's happened.
MACY: Right, even to the point of when her mother's making decisions about her treatment. And I've been reading all the data. I've been calling up the nation's experts. And I see her mother sending her off to an abstinence-only-based treatment. Like, do I say something? Is it my role to say, yeah, but the best kind of treatment shows that Tess is going to have a better chance of getting out of this if she gets medication-assisted therapies?
You know, there was - at one point, she was trying to get her home when she was living homeless on the streets. And I actually said, she needs to get back on Suboxone again. She's not going to be able to make a bus ride home for three days. She's going to be dope sick and in withdrawal and having fevers and sweats and diarrhea. She's not going to want to do that. She's not going to be able to handle it. She wasn't able to handle it before. Why do we think she's going to handle it now?
DAVIES: So when that came up, when you thought, you know, decisions were being made and the mom was making decisions that you thought weren't going to take this kid in desperate need in the right direction, did you speak up? Did you say, think of it differently?
MACY: I spoke up gently, I should say. I mean, some of the stuff took place over text. And I remember I quoted one of my texts in the book. I said, I know Suboxone is abused - because she kept seeing examples. She works in a hospital of people coming in with abscesses from injecting Suboxone. I said, I know Suboxone is abused, and that's wrong, yes, but at least there's no fentanyl in it. I mean, the whole thing is we've got to get these people better. And in order to do that, we don't want them dying from fentanyl and even harder stuff.
DAVIES: You write a lot about fentanyl and the impact of this chemically produced opioid, which began to be shipped in from China and was used to lace heroin in some cases. What was the impact?
MACY: Well, it really first hit Roanoke here where I live in 2015. There was a big spate in June. We had the highest rate in the state. And dealers started cutting their heroin with fentanyl. And so that's mainly what people are dying of now. It's heroin that's been stepped on with fentanyl. And a lot of that is being ordered off the dark web, coming in from China and India.
DAVIES: And why do the dealers put the fentanyl in the heroin?
MACY: Because it's easier to smuggle because it's much tinier. Just a few granules, you know, can really go a long way.
DAVIES: And why is it more deadly? Why does it cause more overdose deaths?
MACY: Because it's 50 times stronger than heroin.
DAVIES: You write about an effort to deal with this crisis in Roanoke, something called the HOPE Initiative, which involved a lot of moms who had dealt with this, some who had lost kids overdoses, others who had kids who were struggling. And Roanoke's police chief was involved. What did they try and do? And what were the obstacles they faced?
MACY: Yeah, so they were basing a program on a Gloucester, Mass., police chief program where they were - the goal was to divert users into treatment instead of jail. In Massachusetts, they already had Medicaid expansion. You know, in fact, the Affordable Care Act was sort of based on what was earlier called Romneycare, so they had much more treatment facilities. And most of the treatments facilities in Massachusetts - all of the treatment facilities in Massachusetts that get Medicaid and Medicare funding by law have to offer medication-assisted therapies, which is buprenorphine, which goes by the brand name Suboxone, or methadone. Those are the two most efficacious drugs for preventing overdose deaths in Virginia, which did not, until very recently, expand Medicaid. And it has yet to trickle down because the general assembly just passed it a few months ago.
Other - there were fewer options to send people to treatment, so these women, very well-meaning recovery advocates, would end up sending people away to rehab, many of them in other states and largely faith-based and - where people were not permitted to take medication-assisted therapy. So I watched people die.
I watched one young girl, who had been successfully on Suboxone - she wanted to get into treatment. They found her a faith-based treatment center in Charlotte. And - but they would only accept her if she was totally off of any drugs, so she started breaking her Suboxone pills in half. She wanted so badly to go. She told her dad, I want to be somebody that helps other people get off drugs. And then she relapsed. She just couldn't do it. And she ended up overdosing and dying. She was 28 years old.
DAVIES: Beth Macy's book is "Dopesick." We'll continue our conversation after a short break. This is FRESH AIR.
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DAVIES: This is FRESH AIR, and our guest is journalist Beth Macy. She spent many years reporting in Roanoke, Va., dealing with social and economic trends affecting the Appalachian region of the country. Her new book is a ground-level look at the opioid crisis. It's called "Dopesick: Dealers, Doctors, And The Drug Company That Addicted America."
Let's talk a little bit more about this medically assisted therapy. And when we talk about using medications like Suboxone and drug treatment as opposed to abstinence treatment where you don't use drugs, just explain what we mean by that.
MACY: Sure. Most rehab centers in America are - do not offer medication-assisted therapy. Very few offer all three kinds of medication-assisted therapy. Rehab centers historically came out of treating alcoholism. And they are AA- and NA-based, largely, which just isn't as effective with opioid use disorder - effective in 10 or 11 percent - as opposed to Medicaid-assisted therapies, which have shown to prevent overdose deaths in 40 to 60 percent. It's a tough thing to get better from. John Kelly at Harvard says it takes the typical opioid use disorder patient eight years and five to six treatment attempts to achieve just one year of sobriety.
DAVIES: And when you mentioned these drugs like buprenorphine, Suboxone, what do they do?
MACY: They stave off cravings, and they allow - they're opioids themselves, but they have a blocker, so if you take them correctly, you don't get high, and in the meantime, you - while you're taking this drug and you're getting your counseling and your check-ins with your support groups, you can be getting jobs back. You can be getting your kids back. Some people in the coalfields now who have been on this program are even getting off of disability now. And that gives me a lot of hope.
DAVIES: You write that almost every law enforcement official you interviewed for the book despised Suboxone. Why?
MACY: Because they see it being widely diverted and abused. And the other thing we haven't talked about yet is...
DAVIES: When you say diverted and abused, you mean what? Diverted?
MACY: Sold. So diverted means, like, taking - getting Suboxone and then selling it to somebody else on the street, right? And - because there are a lot of people that want it. And in Appalachia, there are a lot of cash-only Suboxone clinics. And the first user I ever interviewed at a Suboxone - she was in recovery. She was going to this good Suboxone program in Lebanon, Va. She said she had been to a lot of the cash-only clinics before, and she said the doctors give you twice as much as you need because they know that the only way you can afford to come back next week - because it costs a hundred dollars each week - is if you sell half of it. And I almost didn't believe it, and then I just heard it from one person after another.
DAVIES: Let me understand this. I mean, so this drug, which has shown to be somewhat effective in helping addicts kick their addiction - clinics have popped up which take only cash, right?
DAVIES: And they want to sell more of it so that the users will then sell part of it to other people. And why would people buy it?
MACY: Because they don't want to be dope sick, because there's a huge need for it. There aren't enough physicians who have been waivered to provide buprenorphine, and the people who are addicted to pills, who are trying to get their life back, they'll even buy it on the street.
DAVIES: So they're not buying it to get high. They're buying it to...
MACY: Stave off dope...
DAVIES: ...Get off...
DAVIES: ...Off of heroin, right? So why don't they...
MACY: Or pills. Yeah.
DAVIES: So why don't they go to the cash clinics themselves and buy it rather than buying it illicitly from somebody?
MACY: There aren't enough doctors is one big reason. In 1987, France was having a bad opioid problem - a bad heroin problem. They took the waiver requirement off, and they made it so that all doctors - just like with opioids - you don't need special training to prescribe opioids. They made it so that all doctors prescribed buprenorphine, and they cut their overdose rate by 87 percent. They expanded capacity times 10.
And in Roanoke, where I live, you see these buprenorphine providers in these outpatient clinics. They are just working their tails off. They're working through lunch. They need help. But there's so many doctors that don't want to deal with, quote, "addicts" in their waiting room.
And I actually said this at an addiction science meeting of mostly doctors. I maybe got a little worked up. I said, it's my opinion that any doctor who ever took a free item from Big Pharma should feel morally compelled to become waivered to prescribe this drug because it's - the epidemic has spiraled out of control, and we need more providers to be prescribing it and caring for these patients along with counseling and social supports in a collaborative way. We need to start working on this crisis. It's been going on 22 years.
DAVIES: You know, you said that judges who have drug courts in Virginia - and these are courts where people who have addiction problems can get, you know, treatment as an alternative to incarceration - that the judges in those drug courts didn't like the idea of medication-assisted therapy. They didn't want Suboxone or other stuff. And as a result, they've been less effective than they might have been. Is that changing? Are the - are judges and law enforcement more open to it now?
MACY: I think it's starting to change. Judge Moore, who is not against having MAT in his court - medication-assisted therapy - his prosecutor was against it, but now the prosecutor is starting to allow Vivitrol, which is a shot. You know, you take it once a month. It's something that's controllable, so law enforcement's a little more comfortable with it. Experts believe buprenorphine and methadone are actually more efficacious. But let's start making inroads where we can.
DAVIES: You know, for a long time, people have been using nicotine patches to get off cigarettes. Is this a reasonable analogy? Why is it OK for that and not for someone with a more destructive drug addiction?
MACY: That's a great comparison, actually, and a lot of people think it's like giving a diabetic insulin. You know, it's a maintenance drug, and it's a harm-reduction strategy.
DAVIES: The Centers for Disease Control has just come out with some preliminary estimates of the opioid crisis for 2017, I think, and showed that overdose deaths overall has just come out with some preliminary estimates of the opioid crisis for 2017, I think, and show that overdose deaths overall continue to grow. There is some improvement in some states, particularly in New England, where they've - been more attention to it paid by policymakers. Do you see reasons for optimism?
MACY: I mean, yeah, that's the first time we've had them going down in some regions. But overall, we lost 72,000 people last year, up 10 percent from the year before. And every one of those 72,000 people and their family members and their friends - that's a tragedy. This is an unprecedented level of a drug epidemic. And we really need a comprehensive model to mitigate it. And I just don't see any leadership coming. Our police chief just came out against syringe exchange in Roanoke. Our drug courts don't allow the use of medication-assisted therapies. Some do, but most of the ones of Virginia do not.
And I think we just have to have leadership at the state, at the local, at the federal level of a big scale and intensity. The House has passed 60 opioid bills, but most of the recently approved monies are going to short-term programs. And what we really need - Andrew Kolodny, who's one of the leading voices in the epidemic, says we need $60 billion, not the $4.5 billion that's been allocated. We need $60 billion over the next 10 years in order to start a whole new system that would be integrated into our health system. That's what it's going to take, according to him.
DAVIES: Are you still in touch with these families that you got to know so well in this book?
MACY: Oh, of course, of course. The woman who shook the urn at the 2007 trial from Florida - her name's Lee Nuss. I'd only interviewed her on the phone. Her husband died about two weeks ago. And it was his dying wish that her niece drive her up to Roanoke for my book event. And here she came - she's about 4-feet-10. And she had Randy's urn with her - the little, tiny, brass urn.
DAVIES: That's the ashes of her son who died of an overdose, right? Yeah.
MACY: Yeah, that she had shook at the Purdue Pharma executives. And she came to my book event and spoke a little bit. I'm in touch with Patricia (ph), Tess's mom, almost every day. She is going to go out and do some of my book talks with me. And this is, you know - this is now the cause of her life. She doesn't want her beautiful daughter to have died in vain. She wants us to talk about opioid addiction the way we talk about cancer - to pull it out from under the rug.
DAVIES: Beth Macy, thanks so much for talking with us again.
MACY: Oh, I really appreciated it, Dave. Thanks.
GROSS: Beth Macy is the author of the new book "Dopesick." She spoke with FRESH AIR'S Dave Davies, who is also WHYY's senior reporter. After we take a short break, Maureen Corrigan will review a new apocalyptic novel. This is FRESH AIR.
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