In April 2019, federal prosecutors charged sixty health professionals with illegally prescribing pain medications; some of those charged were doctors accused of having traded sex for pills.1 This was the largest pill mill bust in U.S. history. Around the same time came an announcement that, in Cleveland, U.S. district judge Dan Aaron Polster was sorting through hundreds of city, county, and state lawsuits aimed at both opioid manufacturers and distributors. Those suits targeted the companies that, plaintiffs say, created an unprecedented health crisis over the course of twenty years.2 But there have been plenty of other doctors, other pain clinics, other so-called pill mills. The model for a pill mill is straightforward. All you need is a prescriber (typically the only person with any kind of medical background in a given clinic), an office, some prescription pads, a few pens, and a cash box. People who use prescription opioids like Purdue Pharma’s effective time-release painkiller OxyContin (the brand name of the generic drug oxycodone) can sometimes visit multiple clinics in a day—there is plenty of cash to be made. It’s a story that has been told by intrepid reporters like Beth Macy, who focused on southwest Virginia in her book Dopesick, and by Sam Quinones, who focused, in part, on Portsmouth, Ohio, in Dreamland.3 To understand the rest of Ohio, it helps to understand what happened in Portsmouth. At one point, Scioto County and its roughly seventy-five thousand inhabitants had half a dozen clinics.4 Most were based in Portsmouth, but some were in nearby Wheelersburg and across the Ohio River in South Shore, Kentucky, a point Quinones underscores in his book.
Portsmouth is about two hours south of Newark. According to a 2019 Washington Post analysis of Drug Enforcement Agency (DEA) numbers, from 2006 to 2012, about 76 billion oxycodone and hydrocodone pills were shipped out in the United States, and 68.5 pills were prescribed per person in Scioto County (compared to 33.1 in Licking County).5 In 2010 alone, at least 9.7 million doses of opiates were dispensed in Portsmouth’s Scioto County—123 doses each for every person in the community, child and adult alike, more than any other county in Ohio.6 In early 2011, Lisa Roberts, a nurse for the Portsmouth Health Department, got a call from a Purdue Pharma representative.
“We might have a PR problem,” Lisa remembers him saying. (The representative did not respond to requests for verification.)
The “PR problem” was a public health crisis created, in large part, by health care, or the lack thereof.7 And Portsmouth felt like ground zero, where pills—oxycodone being the most popular—were being sold on the illicit market with an incredible street value. Pill mill doctors made money, but so did the underemployed people in this part of Appalachia, those eking out a life through Supplemental Security Income (SSI) and a reformed federal welfare system. For many, selling and taking Oxy were adaptations for survival—but adaptations that came with great risks, as many overdosed.
“It’s more than a problem,” Lisa replied. “It’s a nightmare.”
The Purdue rep told her he was coming down for a meeting with a group of local officials.
Lisa is a slight woman with dark hair and eyes, and an Appalachian accent. Charming but uncompromising and tough—and intensely smart. Before she hung up the phone she added, “If I were you, I wouldn’t mark my car in any way, because half the people will kill you because they think you’ve got the product and the other half will kill you because you made it.”
Portsmouth feels at once both Appalachia and Rust Belt. Perched on a bluff above the Ohio River, looking out over the dramatic cliffs of Kentucky on the other side, the area was once home to a steel mill—shut down for good in the 1980s—and once burned the coal buried in those hills. The small city lies at a crossroads for trains, rivers, and highways. In its heyday, it was a manufacturing behemoth, making everything from bricks to steel to shoes to golf clubs. For decades, Shelby Shoe and Empire-Detroit Steel each employed thousands. The shocks of deindustrialization have resonated throughout the community. Portsmouth’s population peaked at 42,560 in 1930. It’s about half that today, and about 35.1 percent of its citizens live below the poverty line. People who would have worked in those steel mills now have limited options, coupled with the stress of being poor. Opioids are useful because they make people feel better and offer an escape—and, perhaps, help them bury deeper issues.
Portsmouth’s prime real estate in the region, a driver for industry, also made it easier for people using pain medication to get more. The city is just across a bridge from Kentucky and about forty miles to the West Virginia border, making it easy for people to get multiple prescriptions in multiple states within hours. This is where the opioid crisis percolated, a place where OxyContin was marketed, a place that many believe was targeted.8 In 2018, Scioto County ranked first in the state for overdose deaths.9
Lisa says the Purdue rep drove down to Portsmouth—in an unmarked car—to attend a meeting at the health department with the prosecutor, the head of a recovery center, and the police chief. The prosecutor brought along a stack of newspaper stories highlighting the effects of the legal and illegal trade in prescription pain medicine in the community dating back to 2001. It was a contentious meeting, to put it mildly, Lisa says.
“I felt a little bit bad for the guy,” she says with a grin, “because we had not been very good hosts.”
After the meeting, Lisa walked her guest over to a storefront a few blocks away. Members from a grassroots organization called Surviving Our Loss and Continuing Everyday (SOLACE) had been filling up the large glass window of the old Marting’s Department Store with photos of loved ones who’d died in the pill epidemic. Lisa recalls that the rep was speechless; all the people, young and old, all the lives lost. He responded, Lisa remembers, by saying simply, “I understand.” And then he left. Purdue followed up with a letter explaining that it was working to better track prescriptions and drugstore robberies and to educate the public. Lisa was unimpressed. None of that would help her community, she thought. It was too little, too late.
She realized then, she says, “The cavalry’s not coming.”
For years, people like Lisa Roberts had been putting out fires, trying to figure out how to combat this crisis on their own. She says that the story of how people in power outside of Portsmouth responded to this crisis is really just the story of Appalachia. People want timber, so they build roads and trains to take it out. They want coal. They take that. They want steel. Same thing. Every time, she says, industry comes in, extracts, and leaves without having to deal with the outcomes—that becomes the responsibility of the people living there. The pills were no different.
The pharmaceutical companies had an army of reps and, as Lisa tells it, they had flooded the Appalachian region—a place just ready to soak up what they had to offer. It was a place with numerous manual laborers whose bodies were wracked by pain and injury, men and women who lacked access to sophisticated hospitals that may have instead treated pain with physical therapy, massage, acupuncture, or surgery, which insurance companies might not have paid for anyway.10 Instead, these people with chronic pain or injuries would go to their primary care physicians, many of whom had been visited by those drug reps and been convinced that there was no need to fear prescription opioids. There was so much driving all of this—a confluence of pain, pills, poverty, and people looking the other way. Certainly corporate greed played no small part. But the crisis was also fueled by lax federal oversight. Writing for The New Republic, Zachary Siegel points out that “nearly every step of the pharmaceutical supply chain is implicated in the soaring death rate,” that many are responsible for the “obscene quantities” of pills sent to towns around America—this includes the manufacturers and distributors as well as regulatory bodies.11 Siegel notes that more pills were being manufactured and more were being shipped, steps that require DEA approval.12
It would be easy to blame the DEA, Big Pharma, and the pill mill doctors for their roles in what happened in places like Portsmouth, but that wouldn’t completely explain why so many people are overdosing now, nor would it explain how opioids caught on so quickly or why they continue to appeal to people in the United States or why opioid use disorder is a thing. It’s not the drug itself—the majority of people who use opioids will not become addicted.13 For many people, the pain relief from opioids can be life-changing and life-improving. So what is happening? Canadian physician Gabor Maté argues, “We can never understand addiction if we look for its sources exclusively in the actions of chemicals, no matter how powerful they are … Mere exposure to a stimulant or narcotic or to any mood-altering chemical does not make a person susceptible. If she becomes an addict, it’s because she’s already at risk.”14
In some cases, addiction can be situational. Probably one of the more relevant examples involves American soldiers in Vietnam.15 In May 1971, U.S. congressmen visiting Vietnam were alarmed by the widespread use of heroin among soldiers. A follow-up study by Lee Robins, a professor at Washington University in St. Louis, revealed that over 90 percent of returning veterans who had been addicted in Vietnam were not addicted once they returned to the United States to their families or communities and were distanced from the stress and death of war. It would seem, then, that their heroin use in Vietnam was a response to a unique and dangerous situation, and that people can grow out of problematic use. Robins’s study counters much of what popular culture purports to be true about drug use and addiction: that the drug itself is the culprit and that once addicted, always addicted.
But to be sure, addiction is not a term about which everyone agrees. The most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) asserts that “substance use disorder is a chronic, relapsing brain disease characterized by compulsive drug seeking and use, despite harmful consequences.”16 In September 2019, the board of directors of the American Society of Addiction Medicine adopted its own new, updated definition, which reads:
Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.17
As these definitions show, addictions are associated with negative consequences and are generally believed to be shaped by genes, behavior, and/or environmental factors, and are described as distinct from the symptoms that imply a physiological transformation, or dependence on a substance.18 In other words, a person may experience withdrawal symptoms without being addicted to a given substance per se.
Thinking about addiction as a disease is convenient—and certainly this concept is central to many self-help and abstinence-based traditions, in part because it combats the idea that addiction is somehow a moral failing. But in her book Unbroken Brain, Maia Szalavitz writes that “the term ‘brain disease’ is both vague and stigmatizing. It doesn’t capture the critical role of learning in addiction.”19 And research shows, too, that framing addiction as a disease can make people feel like their situation is a fixed state.20 Szalavitz, one of the most important writers covering addiction and health care in America today, defines addiction as a learning disorder—a person learns to associate use of a drug, for example, with pleasure or respite. This “compulsive behavior despite negative consequences” is learned over time—and you come to believe that it can solve problems.21 People who are in difficult situations (e.g., unemployed, without proper health care, homeless) can face even more harms because they will likely seek out the thing they’ve learned will give them comfort. Thus, a person transitions from needing to wanting, or as neuroscientist Marc Lewis writes, desiring.22 Much as it does in learning a new skill, the brain adapts; it’s a maladaptation for sure, but an adaption to circumstances nonetheless. Indeed, stress23 or trauma24 can produce the circumstances for addictive behavior to be cultivated. Szalavitz writes, “Addiction isn’t just taking drugs. It is a pattern of learned behavior. It only develops when vulnerable people interact with potentially addictive experiences at the wrong time, in the wrong places, and in the wrong pattern for them.”25 And some places are especially wrong; certain environments make people more susceptible to addiction and overdose.
For many years, what Canadian psychologist Bruce K. Alexander calls the “Myth of the Demon Drug”—that drugs themselves inevitably cause addiction—held sway, and still does given our policies of prohibition and the ongoing drug war.26 Alexander questioned this myth, which he said was based on early experiments with rats held in isolated cages. Through a series of studies in the late 1970s and early 1980s, he demonstrated that rats housed in isolated laboratory cages are more likely to drink a morphine solution than are rats living in a more social and natural environment (a structure he created and dubbed “Rat Park”).27 Alexander’s “Rat Park” studies underscore the importance of environments in mitigating behaviors or fostering dependence on substances.28 More recently, in his 2008 book, The Globalization of Addiction, Alexander argues that “dislocation” is the root of addiction in the twenty-first century, that humans are social beings for whom interdependence and connection are necessary, and that we have created a world that seems to undermine both.29 This concept is rooted in the work of Erik Erikson and Karl Polanyi, but Alexander says it can also be found in the writing of thinkers as diverse as Plato and Charles Darwin and can be called “alienation” or “disconnection.” Dislocation comes from a lack of “psychosocial integration,” which is a “profound interdependence between individual and society that normally grows and develops throughout each person’s lifespan.”30 Alexander suggests that this dislocation is a kind of “poverty of the spirit.”31 A lack of psychosocial integration is deeply problematic for an individual and his or her community.
Alexander defines addiction in multiple ways, but the one most relevant to this book is that addiction “is overwhelming involvement with any pursuit whatsoever that is harmful to the addictive person and his or her society.”32 He makes it clear that he is concerned with addictions writ large, not solely those that entail drug use. For Alexander, addiction is not a disease without cure but an adaptation to the overwhelming sense of dislocation in the modern world—it’s a response to that dislocation. To that end, he argues that addiction is not a medical or criminal problem but, in his words, “a political problem.”33
Alexander writes, “Along with dazzling benefits in innovation and productivity, globalization of free market society has produced an unprecedented, worldwide collapse in psychosocial integration.”34 In such a society “virtually every aspect of human existence is embedded within, and shaped by, minimally regulated competitive markets. This sort of social system would have been inconceivable a few centuries ago, but it is fast becoming a planetary standard.” The effects of this system are seen in persistent homelessness, mass shootings, environmental destruction, and entrenched poverty, but we are all affected by this “free market society,” as Alexander calls it, because every aspect of our lives is framed by it. Within this cultural and economic milieu, he writes, dislocated people “struggle valiantly to establish or restore psychosocial integration—to somehow ‘get a life’ to ‘figure out who they are’ or to build community.”35 Many are successful, but others adapt to the dislocation and become known by such names as “junky, miser, shopaholic, workaholic, crackhead, alcoholic, religious zealot, anorexic, bulimic, etc.”36
Alexander’s assessment is clear and brutal when he writes, “As psychosocial integration is a fundamental human need, and free market society, by its nature, produces mass dislocation at all times (not just during times of collapse), and as addiction is the predominant way of adapting to dislocation, addiction is endemic and spreading fast.”37 We have two options, Alexander declares: transform society or live with the “poverty of spirit” that dislocation produces.
Central to this book is the idea that addiction is a political problem. I will try to describe those behaviors that, when coupled with illicit substances, can degrade a person’s health and well-being and can lead to increased risk of overdose. Through this lens, addiction can be viewed as a response to socioeconomic conditions. This is not to say there are no other contributing factors. Addiction is complex, and there are many risk factors in addition to socioeconomic realities: genetics, a history of trauma, and mental health struggles, for example. Effective treatment should also consider these things, which in general as a country we have not created political policies to do. Journalist Zachary Siegel writes elsewhere that “treating addiction with medicine and compassion, not tough love, is what works best. We know that stigma, alienation, and incarceration make things worse.”38 Currently, we do not have a political framework that truly supports a treatment approach combining medicine and compassion—and this is the problem.
The concept of dislocation incorporates and privileges many of the experiences of the people I have been following for the past few years—not only those who have experienced substance use disorder but also those who seek to reduce its harms. These people are responding to a deep sense of dislocation in our modern world. For that reason, Alexander’s research is especially important in the Rust Belt and in Appalachia, where this dislocation feels especially acute.39 Pennsylvania State University sociologist Katherine McLean studies the environmental, or contextual, factors that exacerbate the overdose crisis in the Rust Belt area of Monongahela Valley, Pennsylvania.40 She discovered that social isolation, poor housing stock, lack of transportation, and, in general, lack of opportunity were driving heroin use in McKeesport, a deindustrialized city near Pittsburgh. In a sense, overdose was a political problem. “While state and county efforts to ameliorate overdose mortality have focused upon creating an open market in naloxone,” writes McLean, “this study suggests the need for interventions that address the poverty and social isolation of opiate users in the post-industrial periphery.”41 She points out that most media coverage of the present overdose epidemic has been focused on the middle class but that “the links between disadvantage and drug risk” are largely absent.42 In the part of the country where she does research, environment and history are significant risk factors for addiction and overdose. She writes that those she interviewed “forced a consistent connection between overdose, drug use, and poverty. On the one hand, a widespread lack of jobs and money was seen as increasing the local lure of drug use … The dearth of legitimate employment opportunities was a theme reiterated across multiple interviewees who inevitably compare the current economic plight with the city’s midcentury heyday.”43
Brooklyn College sociologist Alex S. Vitale writes succinctly, “There is no way to reduce the widespread use of drugs without dealing with profound economic inequality and a growing sense of hopelessness.”44 The research is clear that the most poor and marginalized in our communities are the most vulnerable to overdose and are also the most susceptible to substance use disorder.45 And if addiction is a dislocation problem, as Bruce Alexander posits, we have bigger things to deal with. But Big Pharma shouldn’t get off easy here. Purdue still pumped OxyContin into the region, exploiting underlying problems. It and other companies still marketed their drugs as an easy fix to pain. They still sent emails that revealed their intentions: “Just like Doritos, keep eating. We’ll make more,” they wrote. “Keep ’em comin’!” they urged. “Flyin’ out of there. It’s like people are addicted to these things. Oh, wait, people are …,” they joked.46 According to allegations in a March 2019 lawsuit, Purdue’s president, Richard Sackler, wrote in a company memo that he opposed “criminal addicts … being glorified as some sort of populist victim.”47 Portsmouth, along with most of Appalachia, was likely targeted because it faced economic challenges, because it was a place where people were struggling. In a sense, capitalism targeted its own victims, buzzards surrounding a wounded animal.
But Portsmouth is decidedly not dead; it never was. It fought back. The community let the so-called pain clinics know that they were no longer welcome. Activists, many of them connected to SOLACE, began picketing the clinics, organizing town halls, and pushing the state and federal government to act. Portsmouth’s city council passed an ordinance in late March 2011 that said pain clinics must register with the state pharmacy board, be affiliated with a hospital or university, have malpractice insurance, and be subject to random inspections.48 When the ordinance was challenged in court, a group of women sat in the front row wearing teal-green SOLACE shirts, Lisa Roberts among them, looking on.49 The judge ruled in the city’s favor, and afterward a reporter from the Ohio News Network asked Lisa for a comment. Eyes wide, face beaming, she replied, “Today was a victory. An important victory.”
Around the same time in 2011, every Thursday for seven weeks, a group of churches marched while holding signs, blowing shofars, and calling on the God who brought down the walls of Jericho. On the seventh march, a miracle occurred: It rained hard, and then a double rainbow appeared. It seemed like the flood was over. In that same week, the DEA conducted mass raids and House Bill 93, known as the Pill Mill Bill, passed unanimously.50 When Governor Kasich signed it into law, a group of women from SOLACE were standing behind him. The law closed many legal loopholes and required Ohio’s board of pharmacy to license physicians and distributors of dangerous drugs. As a result of these measures, Scioto County saw a dramatic reduction in prescription opioid use.
However, one recent study “found no effects of pill mill laws on prescription opioid, heroin, or synthetic opioid overdose deaths in Ohio.”51 And, Lisa Roberts says, “Contrary to many people’s beliefs, opioid-addicted people don’t just go away when the supply goes away.” It didn’t take long for people to find other opioids—first heroin, then synthetic opioids like fentanyl—and now more methamphetamine.52 There was a boom in intravenous drug use, and that was when Lisa pushed for a syringe exchange. Overdose deaths involving fentanyl began to rise dramatically around Ohio and West Virginia, and police and journalists ramped up fear around this new scourge.53 Police claimed that if your skin came in contact with these drugs, you could overdose (which is extremely unlikely and has led to media panic and lawmakers pushing harmful policies).54 Nonetheless, people were dying; there was real danger. What was happening in Portsmouth and elsewhere in Ohio had moved well beyond pills. By 2016, only 13.9 percent of overdoses in Ohio involved prescription opioids, while 58.1 percent involved fentanyl or another closely related synthetic opioid.55
Overdoses involving synthetic opioids can’t be addressed by lawsuits. In Portsmouth, solutions are both immediate and long term, effective and otherwise. Those solutions include protests outside pill mills, syringe exchange, and rallies for addiction recovery. The activists and organizers haven’t done it all on their own. Lisa Roberts points out that they have had some help—Senator Rob Portman has listened to them, the DEA has helped raid the pill mills, and the state has sued Big Pharma—but the socioeconomic struggles that make opioids an attractive choice ultimately feel like a burden that places like Portsmouth will carry on their own. Prescription opioids kicked off a series of what Lisa calls “plagues” for Portsmouth—and for all of Ohio: first heroin, then fentanyl and all the overdoses, and now (because of the rising intravenous drug use) rising hepatitis C rates, cases of endocarditis, abscesses, and infections.
Lisa takes the long view and says she knows this is not a sprint. She is excited about the growing advocacy coming from people in recovery. “First it was the parents and caregivers, and now it’s the people they saved who are helping other people,” she says. “No one’s going to save us from this; we’re going to have to save ourselves. It really is about figuring out what your community needs are, working really hard together, to make sure you’re doing what you can, minimizing the damages to people who became addicted.”
But Lisa says she would not turn down any money that comes to her community as a result of the lawsuits against pharmaceutical companies. The cost of all of this has fallen on the public sector. “We’ve all paid for this,” she says. “And they’ve been on the receiving end and have not had to pay for this catastrophe that they made.” Social services, emergency medical services, police, jails, prisons, foster care, treatment—the list is long. But Lisa says you have to be creative with a problem of this magnitude. It will take many systems working together to address the overdose crisis. “I wish that the heartland could have an economic boom because that is probably the only thing that’s going to fix this,” she says. “Drugs are a symptom, really.”56
Lisa speaks of her community health work matter-of-factly; she continues, like a bulldog, and snubs the patina of sadness that surrounds it. “I don’t have a choice, somebody has to do it,” she explains. “Even though we’ve had a lot of deaths, we’ve had way more that don’t die. Last year, we know that one hundred fifty-five of the people that we trained to give naloxone used it and they lived.”
She has been a trendsetter in Ohio. She helped start Project DAWN (Deaths Avoided with Naloxone), the first public naloxone distribution program in Ohio. She also runs a syringe exchange, a monumental accomplishment in a conservative stronghold, and advocates for medication-assisted treatment (MAT), which uses methadone, Vivitrol/naltrexone, or buprenorphine to treat opioid use disorder.57 Because of her work in Portsmouth, Lisa has become a resource for researchers from around the country—researchers from Yale to The Ohio State University come calling. And Lisa tells anyone who will listen that naloxone should be cheaper and more readily available, as should MAT, especially in rural America. (Curiously, dispensing buprenorphine requires additional training for physicians, whereas dispensing OxyContin did not.)58 Right now, she says, these responses are overregulated. Ohio lists naloxone as a dangerous drug and therefore requires a license to distribute it, which makes it more difficult to get to the people who use it and need it the most.59
Because she can distribute through her health department, Lisa gets naloxone into the hands of as many people as she can. “If you want to do the Lord’s work, carry naloxone!” is one of her favorite slogans. Every Friday, about two hundred folks from the community take advantage of the health department syringe exchange, started as a response to soaring hepatitis C cases in the county. On one Friday I watch as person after person files through the health department’s conference room. Pop music plays while clients and workers chat and catch up with one another like old friends.
Abby Spears, a longtime health department employee, is responsible for counting the used syringes brought in. Abby tells me that, when not helping with the exchange, she is using data and geomapping to identify health disparities in Portsmouth.60 The concept of a “food desert” is well-known, she explains, but there are also “resource deserts.” She mapped overdoses on top of blighted and abandoned properties and discovered some clear patterns: that where there is poverty, there are more overdoses, and that where the social determinants of health lag—“the conditions in which people are born, grow, live, work, and age that shape health” like education, neighborhood, and socioeconomic status—there are more overdoses.61 Now that she knows where the greatest needs are, she can work to get resources to people living in those places.
Today, Abby greets everyone warmly, counts what they have, and ushers them to one of the three or so intake workers who give them new works. She tells me that despite all of Portsmouth’s troubles, she could never imagine leaving. “It’s something that lives in your bones,” she says. And so she appreciates the work she is engaged in at the health department—she feels like she’s building the place up rather than bringing it down. But it’s difficult work, she says, because the struggles that this community faces have existed for a long time and because both unspoken nihilism and stress run deep here. In some ways, she says, that stress is rooted in trauma and has been ramped up in the past decade as so many people have died.
“I’ve lost …” She pauses. “I’ve truly never counted.” And then she adds, “Every time there is a loss, the desire to fix this becomes profound. I’ve been here thirty-seven years, so most of my life has been spent in a place that has been defined by the opioid epidemic.”
“Were you traumatized by this or are you just especially resilient?” I ask her.
“The two aren’t mutually exclusive,” she responds.