Dopesick: Dealers, Doctors, and the Drug Company That Addicted America is a 2018 nonfiction book in which journalist Beth Macy describes how a liberal prescription policy for opioid drugs like OxyContin led to a heroin epidemic in rural Appalachia and adjacent suburban communities. The book is the first in a two-book series on the opioid epidemic; the second, Raising Lazarus: Hope, Justice, and the Future of America's Overdose Crisis, is due for publication in 2023. Macy has won national awards for her journalism and nonfiction on overlooked corners of America. Hulu adapted Dopesick as a limited dramatic series that won a Peabody Award for achievement in broadcasting. This guide is based on the 2018 print edition published by Little, Brown.

Content Warning: This book includes descriptions of substance abuse, violence, sex-trafficking, and profanity.

Summary

Dopesick is an account of how the pharmaceutical company Purdue Pharma, owned by the Sackler family, introduced opioid painkiller OxyContin in 1996 and touched off a wave of addiction to opium-derived drugs in rural America. Macy uses anecdotes, interviews, research from on-the-ground volunteers and doctors, and scholarly sources to provide an exhaustive picture of the corporate greed that created the opioid epidemic.

In the Prologue, Macy explains that the genesis of her book was her effort to understand how heroin ended up killing many young people in suburban and rural towns in Virginia and other Appalachian states. Her search for answers brought her to an interview with Ronnie Jones, a drug dealer who brought heroin to Woodstock, Virginia, as people unable to obtain OxyContin pills turned to heroin.

In Chapter 1, Macy describes the history of morphine, an opium derivative that was so widely prescribed after the Civil War that addiction became known as “soldier’s disease.” Near the beginning of the 20th century, heroin, many times more powerful than opium, was available in drug stores and in commercial cough syrup preparations. At the time, most doctors contended that the drugs were not addictive. When use shifted to people in the inner city, including immigrants and people of color, the prevailing attitude towards opioid use shifted sharply. The Harrison Narcotics Taxation Act created a drug scheduling system and criminalized use of opioids. History repeated itself when Purdue Pharma convinced the Food and Drug Administration to approve OxyContin for mild and moderate pain; in the past, such drugs were not likely to gain approval unless they were for the use of people dealing with pain from illnesses like cancer. Purdue Pharma was able to convince the FDA to approve the drug by claiming it was addiction-proof, which was misleading.

In Chapter 2, Macy discusses the impact of the company’s aggressive marketing on doctors. Using educational seminars, salespeople incentivized with large bonuses, and a campaign to make pain an important vital sign to monitor health, Purdue Pharma racked up millions of prescriptions. Doctors like Art Van Zee, pharmacists, and law enforcement in rural Virginia recognized in the late 1990s that an epidemic was inevitable, but Purdue Pharma, the government, and the FDA ignored their campaign to make the drug more tamper-resistant or to pull it from the market entirely.

In Chapter 3, Macy adds cultural and economic context to her stories of the opioid epidemic in Appalachia. These towns were already suffering from the loss of jobs due to globalization, and the lack of a strong public healthcare system meant the resources to stop the development of the epidemic simply were not there. Under pressure from parent-activists and doctors like Art Van Zee, the FDA finally put a warning label on OxyContin to indicate its potential for addictiveness. By 2010, the drug was reformulated to be more tamper-resistant, and a prescription monitoring program was in place. However, people with addictions kept ahead of these interventions by injecting and snorting the drugs, and some also turned to heroin.

In Chapter 4, Macy continues the saga of Purdue Pharma’s corporate greed by describing United States v. Purdue Pharma (2007), a case in which attorneys for the Western District of Virginia were able to prove that the company mislabeled OxyContin. A multimillion-dollar fine and hours of community service for some executives comprised the sentence, but no Sackler served time.

In Chapter 5, Macy uses the stories of young people in Hidden Valley, a subdivision in the suburbs of Roanoke, Virginia, to show how an OxyContin epidemic led to a heroin epidemic. Young people in these affluent suburbs came from families with ready access to prescription drugs and money, and experience taking prescribed pills like Adderall normalized the use of prescription medicine. Families were slow to realize that addiction was in play; parents assumed drug addiction—especially to heroin—was a problem for inner-city communities composed of people of color. A perceived stigma made families keep quiet as they sent their children to expensive rehabilitation programs.

In Chapter 6, Macy describes how she and others in her community became aware that heroin was a problem in their small city and the suburbs. While rural communities were susceptible to the epidemic because of a lack of jobs and health resources, economics in middle-class communities contributed to the problem as well. Diversion of drugs, property theft, financial fraud, and the need for rehabilitation were all but invisible to the agencies tasked with addressing these issues because families had the financial resources to shield their children from public view. When OxyContin became hard to get, rural and suburban people alike shifted to heroin.

In Chapter 7, Macy recounts how Ronnie Jones began importing bulk heroin into Woodstock, Virginia, because it provided a new market for him. Rather than going to cities like Baltimore to secure diverted prescription drugs or even heroin, people could now buy their drugs at home.

In Chapter 8, Macy follows stories of individual people with addictions to show that the arrest of Jones did little to stem the growing heroin epidemic. Rehabilitation models were part of the problem. Twelve-step programs like “Narcotics” Anonymous were cheaper and more popular in the rehabilitation programs available. Although research shows that medication-assisted treatment for addiction may be more effective, it is almost impossible to find programs that use it, especially for clients who are pregnant.

In Chapter 9, Macy returns to law enforcement efforts to track down high-level dealers by dramatizing the extraordinary efforts of specific agents to take down one drug ring. The task proved fruitless because heroin arrived via commuter-dealers, seemingly ordinary people in the community handling large amounts of heroin in exchange for a portion of the drug. A cascade of consequences—disease from dirty needles, referrals to child protective services, overburdened providers—overwhelmed rural and suburban communities.

In Chapter 10, Macy includes an extended anecdote about Tess Henry, a young woman who struggled to get the addiction recovery support she needed during her pregnancy. Although medication-assisted treatment initially worked for her, she lost access to it, leading to a spiral of relapses.

In Chapter 11, Macy develops an argument about how the preference for 12-step programs, the rejection of medication-assisted treatment, and inadequate support from Medicaid made it hard for a volunteer-driven referral organization to get people with addictions to the resources they needed.

In Chapter 12, Macy includes her interview with Jones, the man credited with bringing heroin to rural Virginia. Jones was polite and discussed the impact of racism and classism in the criminal justice system on Black men like him. Without contradicting Jones’s structural assessment, Macy uses background research to show that Jones (like Purdue Pharma) was more interested in profit than the people he harmed with the drugs he provided.

In Chapter 13, Macy outlines policy solutions that may help to stem the opioid epidemic, and in the Epilogue, she returns to the story of Tess Henry, who died before she could get the treatment she needed.

Although the book is nonfiction, Macy relies on narrative techniques such as strong characterization of stakeholders, empathetic portraits of dealers and those with addictions, and rich descriptions of settings to paint a complete picture of the impact of the epidemic.