A Book Review of Dopesick: Dealers, Doctors, and the Drug Company that Addicted America by Beth Macy

Beth Macy is an investigative journalist and advocate from Ohio who has covered the US opioid epidemic for decades.¹ In her book, Dopesick, she uses masterful storytelling to humanize those negatively impacted by opioid misuse and abuse by rolling back the stigma and shame that has harmed the powerless and protected the more powerful drug companies.¹ The material covered in this book, such as responsibility for the epidemic,¹ is still very relevant today. In 2020, “Purdue pleaded guilty to an information charging it with three felony offenses: one count of dual-object conspiracy to defraud the United States and to violate the Food, Drug, and Cosmetic Act, and two counts of conspiracy to violate the Federal Anti-Kickback Statute.”² More recently, in the fall of 2021, a judge in California ruled that drug companies, including Johnson & Johnson, aren't “legally liable” for the state’s opioid crisis.³ Prescribers, including podiatric physicians, despite being lied to for years, can still be held legally liable though.¹

The history of the US opioid epidemic is dirty, dark, and disturbing.¹ It represents a failure of many stakeholders.^1,4,5 Few physicians might know that heroin used to be sold over the counter in the United States by Bayer, the German multinational pharmaceutical company.¹ It was used to treat coughing and “soldier’s disease” (morphinism).¹ The name is derived from the German word heroisch meaning heroic.⁶ Initially, the drug’s packaging featured a beautiful ribbon around the name since it was marketed for soldiers and meant to appear patriotic.¹ From the very beginning, there was a lack of understanding of the addiction potential of these drugs.¹ And once that addiction potential was revealed, drug companies that were making record profits covered it up.¹ Many politicians, who tend to be lawyers rather than medical professionals, were reportedly confused by conflicting reports appearing in medical journals.¹

Beth Macy notes that when a new drug sweeps the country, it usually starts in the big cities before spreading to rural America, as was the case for crack and cocaine.¹ However, the opioid epidemic started in the opposite fashion.¹ Isolated Appalachia, the Midwestern Rust Belt states, and rural Maine were some of the first places to experience the harsh realities of this epidemic.¹ Working class families, many who lived in politically unimportant places and were hours away from treatment options, were among the first to be hit.¹ The beginnings of the opioid epidemic were cloaked in stigma and shame¹; although difficult to pin point, the inclusion of pain as the fifth vital sign in the mid-1990s and the introduction of the painkiller oxycodone in 1996 are commonly cited as fuel to the fire, a first wave.^7–10 Over the years, there was a shift from oxycodone to heroin.¹ As the epidemic grew, heroin use spread to the suburbs and cities, leaving a wake of destruction in its path.¹ Beth Macy recounts the graves of those who overdosed; noting no shortage of graves for minors adorned with R2-D2 action figures and teddy bears.¹ She recalls tales of “straight A” students and athletic stars who were imprisoned or who have turned to prostitution.¹ Many parents struggle in dealing with children suffering from addiction.¹

Beth Macy touches on the topic of stigma several times throughout her book.¹ Erving Goffman, a sociologist who famously deconstructed stigma, notes that the word stigma comes from an ancient Greek word that means a bodily sign, such as a mark, tattoo, or scar¹¹; however, today we use stigma as a metaphor related to an identity, usually relating to moral character, gone wrong or an abnormality.¹¹ Abnormality is any a deviation from a socially constructed “normal.” Normal, of course, varies from place to place, culture to culture, people to people. Once stigma is created, it has a real impact and power despite being only a social construct.¹¹ Judgmental people can be and often are damaging to themselves and others.

Entire groups can be stigmatized,¹¹ such as people who struggle with addiction to opioids. Stigma really resides in the eyes of the beholder. Goffman further identifies three different broad types of stigma: abominations of the body (ie, amputations, scars, loss of hair, deformities, etc), character defects (ie, dishonest, addicted, adulterer, convict, unemployed, etc), and tribal stigma (ie, race, religion, and national origin).¹¹ Regarding the opioid epidemic, people with opioid use disorder (OUD) are often stigmatized and blamed for their chemical addiction because abusing opioids is seen largely as a moral failing in the United States.¹ It is both interesting and bizarre that the blame for OUD falls squarely on the hands of the patients. Are drug companies not to blame also? Physicians and patients were lied to by these companies.¹

Beth Macy notes that opioid-related stigma largely functions as a simplistic explanation for our complex and nuanced opioid epidemic.^1,12–16 Sometimes there are not any easy explanations. Reality is not always black and white, there is a lot of gray in the world and there is especially a lot of gray in the US opioid epidemic.¹ It is important to note that by stigmatizing other people, we open the door to dehumanization. Of course, by dehumanizing others, we can neglect them and do much worse, which is why the study of stigma remains important, especially in conjunction with opioid misuse and abuse today. By removing shame and stigma, we can help those struggling with OUD. Overall, Dopesick is a wonderful, albeit deeply saddening, book that digs deep to reveal the roots of the problem with the opioid epidemic.¹ It can serve as a case study on how many stakeholders and systems failed.¹ A good take-home message to all opioid prescribers is that many families do not know what resources are available for OUD¹; if you suspect that your patient is struggling with OUD, do not hesitate to make a referral to addiction medicine. It is worth reading for those who seek to understand how we got to the current state of the US opioid epidemic.