Dopesick: Dealers, Doctors, and the Drug Company that Addicted America

Drug diversion occurs when legally prescribed drugs end up in the hands of anyone other than the person for whom they were prescribed. Young people’s diversion of prescription drugs from each other or family members fueled the opioid epidemic in affluent Roanoke, Virginia, homes. Macy blames Purdue Pharma for the heroin epidemic in these communities because Purdue Pharma’s prescription drugs led to heroin use once young people with substance use disorders were addicted and could no longer divert legally prescribed OxyContin.

Harm reduction is an effort to minimize the social, legal, and health costs of addiction. Proponents of harm reduction support programs such as providing clean needles to prevent the spread of hepatitis, creating sites where those with substance use disorders can inject themselves without fear of arrest, and providing testing strips to detect drugs laced with fentanyl.

The Harrison Act is a federal law passed in 1914 that established the system whereby certain drugs such as marijuana and heroin became strictly regulated by the government. Drugs that were formerly widely available when affluent people with substance use disorders relied on them became criminalized as a result of the law. Macy traces the history of how opioids were normalized and then criminalized in the 19th and early 20th centuries to remind readers that attitudes toward drug use are malleable and shaped by ideas about race, class, and place.

Iatrogenic drug use is drug dependence resulting from a drug legally prescribed by a doctor. This concept of drug use dominated in the 19th century when many Civil War veterans had addictions to morphine, but social mores did not attach any stigma to the signs of addiction. Few members of the medical establishment were willing to call people with this form of addiction “addicts.” Pseudo-addiction is a modern iteration of the normalization of the signs of addiction and withdrawal. In its marketing, Purdue Pharma claimed that obvious signs of addiction and withdrawal were pseudo-addiction and could be treated by upping the dosage of OxyContin. According to Macy, belief in iatrogenic drug dependence reflects the medical establishment’s beliefs about drug use during the 19th century, while Purdue Pharma’s advancement of the idea of pseudo-addiction reflects their profit-driven and misleading advertising about OxyContin.

The liminal phase is the “moment an addict is willing to leave for treatment” (227). Macy uses this concept to explain the problem with the broken system of healthcare and referrals available to connect people with substance abuse disorders to help: the liminal phase usually ends before the person can get help.

Medicaid is a federal program that provides free or low-cost insurance to help people with low income, pregnant people, and children gain access to healthcare. Because Medicaid is managed care—care that minimizes costs by placing limits on reimbursements to doctors/facilities and finding cost-savings by negotiating prices for care—not all medical facilities and providers are willing to treat patients with Medicaid as their primary insurance. Macy documents that many of the most effective rehabilitation programs, including those that rely on medication-assisted treatment, do not accept Medicaid, leaving only patients who can pay cash to take advantage of the programs. Medicaid benefits are based on income limits, but the passage of the Affordable Care Act in 2010 allowed states to expand eligibility for Medicaid by increasing the upper-income limit used to determine eligibility. The politics in many of the states in Appalachia were such that most rejected Medicaid expansion; the lack of Medicaid expansion is a contributor to poor options for rehabilitation in the communities Macy describes.

Medication-assisted treatment is a rehabilitation approach that relies on drugs like Suboxone and methadone to minimize the pain of physical withdrawal from opioids and tamp down cravings for opioids. According to Macy, medication-assisted-treatment is increasingly supported by scientific studies. Despite its potential to help people enter recovery, not enough facilities provide access to it. When such programs are available, they may be far from the rural communities of people with addiction. Macy also argues that the volunteers and law enforcement organizations who provide referrals to rehabilitation prefer 12-step programs over MAT; their thinking is that those with substance use disorders may divert or abuse the medications used in MAT.

An opioid or opiate is any drug that acts on receptors in the brain to reduce pain or induce euphoria. Opioid drugs are derivatives of opium, which is produced from the poppy plant. Morphine, codeine, Roxicodone, heroin, OxyContin, and fentanyl are all opioids. Also known as “narcotics,” opioids are useful in treating severe pain like that experienced by people at the end of life, but they come with a high risk of addiction. Macy believes the opioid epidemic developed rapidly because Purdue Pharma labeled OxyContin (the brand name for oxycodone) as nonaddictive and encouraged doctors to use it for mild and moderate pain.