Wednesday, December 12, 2018

Beth Macy’s Dopesick

By: Arthur Robin Williams, M.D., and Frances R. Levin, M.D.

Editor’s Note: There's no shortage of statistics about the depth of America's opioid epidemic: 72,000 overdose deaths just last year, more than 2 million with problems, and so on. But numbers only begin to tell the whole story. Beth Macy, who has spent three decades reporting on central Appalachia—which she claims is the birthplace of the modern opioid epidemic—focuses her book on social and economic trends and how they affect ordinary people. Our reviewers, colleagues at the Columbia University Division on Substance Use Disorders, are well qualified to comment.

A new volume can be added to the panoply of books detailing the tragedies of the 21st century opioid epidemic. Beth Macy’s Dopesick (Little Brown & Co., 2018) is anchored in a handful of increasingly vocal and public Appalachia families afflicted by the expansion of opioid dealing into small towns and suburbs formerly thought immune to inner-city plagues of addiction. Dopesick largely reads as a human interest story, a series of intertwined portrayals of grief and terror as young family members descend into OxyContin  (one quarter of the local high school students had reported trying the drug within two years of its 1996 market launch), then heroin, then synthetic opioids, reflecting the epidemic’ s tragic course.

These painful and personal stories form the heart of Macy’s book and make it perhaps the most empathic of the volumes regarding the epidemic. That she can represent a major drug dealer with as much compassion as the grieving families of teenagers and young adults who died because of his trade speaks to her Southern warmth. Her shrewd tirelessness as a journalist enables her to discern the fault lines of the stories that matter most.

But to describe Dopesick simply as a series of human interest stories shortchanges its comprehensiveness. Macy adroitly interweaves the history of earlier drug epidemics caused by “the morphine molecule,” and of law and drug control efforts in response. Detail from important prior works on addiction, notably those of acclaimed historian David Courtwright and journalist Sam Quinones, provide scaffolding for a tower of misery, loss, and angry activism. 

In contrast to the notorious northeastern and western drug corridors, Macy’s portrayals of grief line bucolic I-81 in western Virginia, an area of the Shenandoah region better known for bridal parties at local wineries and septuagenarian farmers. Against this pastoral backdrop, she sets out to determine why so many young Americans were dying from opioid overdoses. The midsize city of Roanoke, “just big enough where all the stories meet,” she writes, serves as a key location to bear witness to the unfolding of the epidemic across all lines of class and race as well as the mounting efforts to thwart its progression.

In opposition to local dealers and pharma reps, Macy profiles such unsung heroes as “country doctor” Art Van Zee and his activist wife Sue Ella Kobak. Together with grieving mothers calling on the Food and Drug Administration (DFA) to recall OxyContin, enraged activist-oriented public health officials and nuns like Sister Beth Davies attempted to sound the alarm about an emerging epidemic—an astonishing 20 years before it would regularly receive coverage in national media—leading to one of the largest class action lawsuits in the nation’s history.

The third part of Macy’s book, “ A Broken System, ” details the gauntlet of challenges patients and families run in to attempting to access quality care. S he chronicles these struggles in heartbreaking detail—patients discharged from rehab and told they can’t be admitted to a sober home or intensive outpatient program if they remain on gold-standard maintenance medications such as methadone or buprenorphine. She addresses grievous practices of 12-step groups (e.g., Alcoholics Anonymous and Narcotics Anonymous), persistently hostile to patients receiving medication, who are told they aren’t truly sober.

The ever-rising death toll from opioid-related overdose reflects our nation’s long-standing   ambivalence toward treating addiction as a public health problem. As a result of this moralistic stance, active opioid misusers are more likely to encounter a punitive and retaliatory criminal justice system than health professionals dedicated to their care. Many so-called addiction treatment programs, especially in lower-income and rural counties, are 12-step-focused sober houses, mom-and-pop operations led by peers and recovery coaches without any licensure or medical staff. Because they employ no physicians or nurses, many such facilities are incapable of prescribing medications or submitting claims for health insurance reimbursement.

Medic al treatment is a part of the picture to which Macy devotes less attention than she might . Appropriate use of the three medications approved by the FDA for opioid use disorder—methadone, buprenorphine, and extended-release naltrexone —have repeatedly been shown to reduce drug consumption, overdose, and crime, and to cut mortality by more than half . Hundreds of thousands of patients have stabilized their lives in methadone programs, and perhaps a million more benefit annually from buprenorphine. Yet only 20 percent of patients receive specialty care that would facilitate use of these medications. The myths that continue to surround them , among patients, families, providers, and policymakers alike, no doubt play a role in their underuse . Stigma, arguably, further complicates access to them.  

There is an asymmetry in Dopesick, with the modal family’s story being one of loss and tragedy. Rarely was a family profiled in such granular detail that ended with loved ones reaching quality care provided by doctors and nurses and the many years of hard work it takes to establish a stable foundation of recovery. More likely than reflecting a shortcoming of Macy’s work, this asymmetry speaks to the tremendous gaps in care patients continue to face and the hard work ahead of all of us over the next 20 years.

Personal and humanizing stories Illuminating the life-changing promise of medical approaches would provide direction and hope for the estimated 2.1 million individuals actively struggling against the morphine molecule. But these for the most part remain untold. While Dopesick effectively chronicles the heartache of an ongoing chemical plague, we still await a book that can show how medication-based treatment can be transformative, how families can triumph over addiction, and how we as a nation can end the opioid epidemic.

About Cerebrum

Bill Glovin, editor
Carolyn Asbury, Ph.D., consultant

Scientific Advisory Board
Joseph T. Coyle, M.D., Harvard Medical School
Pierre J. Magistretti, M.D., Ph.D., University of Lausanne Medical School and Hospital
Helen Mayberg, M.D., Icahn School of Medicine at Mount Sinai 
Bruce S. McEwen, Ph.D., The Rockefeller University
Donald Price, M.D., The Johns Hopkins University School of Medicine
Charles Zorumski, M.D., Washington University School of Medicine

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