Beth Macy, a veteran journalist and best-selling author based in Roanoke, will join the Richmond Times-Dispatch on Oct. 14 at the Virginia Museum of History & Culture to discuss her book that chronicles a still-unfolding disaster, the nation’s opioid epidemic.

“Dopesick: Dealers, Doctors and the Drug Company that Addicted America,” is the third best-seller for Macy, following “Factory Man” and “Truevine.” Tickets to this inaugural RTD Book Club event are available here.

In a phone interview Monday, the former Roanoke Times reporter discussed how this drug epidemic differs from its predecessors and how three Virginia communities offered vivid examples of its human toll.

Question: What first drew you to this topic and wanting to extend it into book form?

Answer: I had written this three-part series in 2012 about heroin landing not in the inner city of Roanoke but actually in a wealthy suburb called Hidden Valley. I had stayed in touch with the two moms that were featured heavily in that series. ... As I noted that the problem was just getting worse — in 2015 we had that kind of groundbreaking study from [Angus] Deaton and [Anne] Case [of Princeton University] showing that American life expectancy was going down for the first time in American history and one of the reasons, largely, was because of the opioid crisis — I kept thinking about those mothers.

And I kept remembering the prosecutor that put ... one young gentleman away telling me that ... there were 50 other kids in that suburb that were using and dealing with them and that clearly this was a problem that wasn’t going away because people don’t just immediately wake up one day and decide to stop using heroin.

Question: The geography of this drug epidemic differed from its predecessors. Can you talk a little bit about that?

Answer: Most drug epidemics before, like crack and cocaine, did start in the inner city, but this drug epidemic starts out in the late ’90s in exactly the opposite. It starts out in rural hamlets. These are places like central Appalachia, rural Maine, some parts of Cincinnati, some parts of New Mexico.

These are largely places where there have been, for decades, people reliant on dangerous work, like coal mining and fishing and logging, and jobs where people had legitimate workplace injuries. And the reason this epidemic starts there is because Purdue Pharma, when they introduced their new drug, OxyContin, they sent their sales reps everywhere, but they paid particular attention to places where there were already large numbers of opioid prescribing going on. ...

Not coincidentally, these were also places where the jobs were going away — coal mines shutting down, furniture factories, textile factories. And when you take those two things and interlay them on top of each other — rapacious behavior on the part of pharmaceutical reps that are out exaggerating the benefits and downplaying the risks of this very dangerous drug, and jobs going away — it was a just double whammy for these communities.

People quickly realized that the drugs could be diverted on the black market and sold for a dollar a milligram. ... In the beginning you could get multiple doctors to write you prescriptions for these drugs. You could take half and sell the other half and use that money to pay your bills. ... It was sort of like moonshine was in the old days. It became a way that people were living and of course it’s a very dangerous way to live.

Crime started immediately going up in those little towns in western Virginia. ... OxyContin came out everywhere in America, of course, but it first bubbles up as a problem in these real rural areas that were also taking job losses and were places where there were legitimate workplace injuries.

Question: One of the striking aspects of your book was what you call “the disappearance of work” in rural America. How did that compound this problem and help create a perfect storm?

Answer: People were numbing their psychic pain and their physical pain. ... I had a sociologist kind of help me go over all the economic and health indicators for the three communities I wrote about — Roanoke, Lee County [in far Southwest Virginia] and then up in the Shenandoah Valley, Woodstock and Shenandoah County. ... Lee County had far more opioid prescribing per capita than those other two areas I just mentioned, like well above the average, and also happened to have really high instances of, especially men, not working.

So you can see where there’s more opioid prescribing — and this is true everywhere, not in just rural areas, — where there is more opioid prescribing there is also a parallel increase in overdose deaths, whether that’s from pills or from heroin, and there is also a parallel incidence in lower workforce participation.

That was really striking when I had that sociologist help me really see (in data) what I was seeing on the ground with stories — like ... the seventh-grader [mentioned in the book] who’s asked what he wants to be when he grows up and he says “I want to be a drawer.” His teacher says, “You mean you want to be an artist?” And he says “No, I want to be a drawer of disability, like my mom, like my parents and my grandparents.”

That was all he could see as the only way out, the only way he could see himself getting his family fed. I mean, it kind of took my breath away when I heard that and yet the data totally bear that out.

Question: How does the pill problem morph into a heroin problem?

Answer: A lot of people were slow putting this together. Basically, OxyContin and other opioid painkillers all work on the opioid receptors [in the brain] and when you look at them, they’re chemically related to heroin in that they both work on opioid receptors. They’re chemical cousins. ... If you’re addicted to one, taking the other will do in terms of keeping “dopesick,” or withdrawal, at bay.

So when the pills got hard to get in the late aughts and the early teens and the [Drug Enforcement Administration] finally starts cracking down — although not to the extent that they should have — you and I may not have known that OxyContin and heroin were related, were chemical cousins, but [Joaquin] “El Chapo” Guzman [a Mexican drug lord later sentenced to life in prison] certainly did.

Dealers just started bringing heroin in, knowing that an addicted person’s fear of becoming dopesick was really a helluva business model. If your steady supply of pills suddenly cut off — [becoming] very expensive, very hard to get — heroin comes in. It’s much cheaper, it’s much easier to get. It makes you feel exactly the same way — i.e. not dopesick.

Question: You talk about this disconnect that you’ve observed ... between law enforcement, the 12-step groups and some other treatment experts over medication-assisted treatment — for instance, whether or not to give folks [in recovery] access to Suboxone [a brand name for a medication used to treat opioid dependence that includes buprenorphine and naloxone.] Talk about how pervasive this disconnect is and whether you see this as an impediment to solving this terrible problem.

Answer: I see the lack of understanding about medication-assisted treatment as the number one barrier to turning this crisis around. It sounds very definitive [but] it took a lot of reporting and a couple of years to understand it all. Because in the beginning all you hear about from law enforcement [is] “It’s a terrible drug, they’re diverting it, they’re selling it. They’re shooting it up ...” And yet the science is very, very clear. Every scientific study supports the use of buprenorphine and as I witnessed — and as you read about in story after story in the book — people who lose access to it are the ones that are most vulnerable for relapse, overdose and death.

And so, it’s a matter of if you’re on one of these lifesaving medicines — buprenorphine or methadone — you stand a 60 or 65% chance of getting better. Whereas, if you’re on abstinence only — not on anything, just on tough love and counseling and 12 steps, about 6 to 8% get better from this. It’s a really tough nut to crack and most people can’t do it without the help of these lifesaving medicines.

Question: Since you completed the book, we’ve had news about the Purdue Pharma bankruptcy. ... What has changed, if anything? Where are we now in this crisis and Purdue’s status?

Answer: You probably read Purdue filed bankruptcy. We knew that was coming — part of the 2,000 lawsuits [by local and state governments] being in what’s called a multi-district litigation up in Cleveland. [The Associated Press reports that Purdue Pharma has offered $10 billion to $12 billion to settle the claims.] Only half of the [state attorneys general] agreed to the settlement. The other half are still fighting that.

Purdue has meanwhile ... called a halt right now and the case has been transferred to bankruptcy court in White Plains in New York. This has angered a lot of people, especially those states that weren’t willing to agree to the settlement. [Virginia Attorney General Mark Herring has not agreed to the deal.] I think we’re going to be a couple of years before it shakes out. But so far what they’ve said is they’re going to give $10 billion to $12 billion but ... mostly ... that money will come from future sales of OxyContin. A lot of people are like: “What? That’s what got us into this.”

So, it’s fraught. The Sackler family [which owns Purdue Pharma] has said they would put in $3 billion of that, but we’re talking about a family that’s made more than $13 billion off that drug. And what the families of the OxyContin dead want — what the families who are the biggest victims of this crisis want — they want them to admit that they did wrong. First of all, there’s no admission of guilt in the settlement.

They want them to lose their wealth that was created off the backs of their dead loved ones, in their opinion. And $3 billion — versus the $13 billion and however much money they socked away in offshore banking accounts to get out of it — isn’t cutting it for the victims of this crisis. And most of all, they want them to make sure that the money gets down to the level of the people who need help. Only 1 in 5 people with opioid use disorder have access to medication-assisted treatment.

And so what they want is for the treatment to be as accessible as the opioids once were. And in order to do that, most of the families believe that the Sacklers and Purdue are going to have to pay up. Whether that’s going to happen, that’s something I’m following closely.

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