That twice as many Americans now die from drug overdoses as from gunfire — 72,000 in 2017, and that’s only a preliminary estimate — seems significant. An engine of death even more potent than the firearm, that most American of fatal means, inspires something akin to awe. Opioids, implicated in more than three-quarters of all overdoses, have become a common cause of death in the United States over the past generation, an increase led not only by prescription painkillers like OxyContin but also by street drugs like heroin and so-called synthetic opiates like fentanyl. Thus, the increasingly heated colloquy: almost anyone you talk to today has a theory about opioids.
Among educated liberals, an extremely popular theory is the purportedly rising rates of despair. Such a view has been advanced by economists Angus Deaton and Anne Case, who argue that the declining life expectancy among white Americans, especially those with little education, has led to what they call “deaths of despair,” including drug overdoses. Echoing the leftist critique of an economy that increasingly leaves the have-nots with even less, the despair theory is widely embraced by coastal elites to explain what is wrong with those other Americans. Neuroscientist Marc Lewis argues that the rise in overdose mortality is evidence of a “broken society” — whatever that means. An analysis by researchers at Penn State found that Donald Trump’s vote count in the 2016 election was greatest, relative to Mitt Romney’s in 2012, in those counties with the highest rates of death from “despair” causes, especially in the so-called industrial Midwest. A 2018 article in the Journal of the American Medical Association reports a correlation between opioid overdose deaths and county-level support for Trump.
Studies such as these are uncontroversially understood to mean that “despair” not only causes people to drink or drug themselves senseless but also to vote stupidly; indeed, a UC Berkeley historian has dubbed these voters the “Oxy electorate.” Actual Trump voters might have been hopeful, confused, patriotic, misogynist, racist, or simply swayed by the candidate’s promises, but in the despair narrative, drugs are the truest cause of an American unease whose apotheosis Trump is alleged to represent.
Despite this prevailing narrative, despair enters into few of the stories of opiate addiction canvassed in Dopesick: Dealers, Doctors, and the Drug Company that Addicted America. Indeed, the modal story of the overdose detailed by Beth Macy is quite different: drug users turn out to be not trailer trash in MAGA hats, but rather the high school football star, the kid who put himself through college, the “happily married twenty-seven-year-old mother,” the soccer-playing regular guy, the down-and-out young person “putting her life back together,” the girl who is “looking to turn things around” after a stint in rehab — in short, the hopeful, not the hopeless. With empathic sadness, Macy surveys the harrowing histories of western Virginia overdose victims, their parents, and the small coterie of law-enforcement officers and health-care providers who are trying, against the odds, to do something to help.
Another key theory for the opioid overdose phenomenon is the putative role of the drug companies — specifically, the activities of Purdue Pharma, maker of OxyContin. Patrick Radden Keefe’s 2017 New Yorker article “The Family That Built an Empire of Pain,” offered an exposé of the Sackler family, owners of this private company. The New York Times and NPR picked up the Sackler story, leading to a “die-in” protest by Harvard med students and numerous state lawsuits against Purdue. Macy’s book supports this theory. She points out that the marketing tactics of Purdue were evident much earlier in those parts of the country where opioid overdoses were already increasing. Yet she perhaps spends too much time on the Sacklers themselves since the real value of her recounting of the duplicity of Purdue Pharma is the light it sheds on how business is done in the United States today.
Americans spend nearly half a trillion dollars on medicines each year, three-quarters of it for branded drugs (read: profit for the main pharmaceutical companies). One drug alone, Humira (an immune modulator for rheumatoid arthritis), attracts more than $16 billion in sales each year for its marketer, AbbVie. AbbVie, like Purdue, makes money by marketing products that make us feel better. They profit from the sale of drugs that people use, mostly correctly, although sometimes too much so. Of course, we hate the drug companies when they produce something that kills, but we really love their products.
Despite her fidelity to the conventional narratives — poor white despair, evil Big Pharma — what emerges from Macy’s detailed account is a radically different view of the opioid epidemic. Where the factories and mines have closed down and the safety net, after years of budget cutting, is in tatters, selling drugs is a way to get by. You can clear a few grand a month as a low-level distributor, even more if you don’t dip into the product yourself. The street trade in illicit drugs and prescription pharmaceuticals has been a solid business in many minority neighborhoods of US cities for decades, a source of employment when lack of education, racial bigotry, and the absence of jobs makes it hard to get work. That drug-dealing is financially more attractive than a minimum-wage job has long been self-evident when it comes to, say, Baltimore or north Philadelphia. But it has been much harder to see when the unemployed in question are white. The simple truth doesn’t sit well with us: today, even for white people, selling drugs pays better than working.
Even Macy has a hard time grasping this fact, perhaps because of the curious racial bias that deforms her narrative. Other than Purdue Pharma, the only figures on whom she specifically pins responsibility for overdose deaths in the region are two black heroin dealers. According to her account, heroin enters Virginia’s I-81 corridor from “Harlem,” a shadowy vector of contagion. When black people are quoted, they speak in dialect (she’s inexplicably fascinated by their habit of pronouncing heroin as “herr-on”); whites, by contrast, speak standard English. She has set out to tell the story of a neglected part of the once-productive Appalachians, yet she ignores the fact that, in parts of Appalachia, the rate of overdose among black Americans is nearly as high as among whites. A lesson of this epidemic is that racial divisions are less meaningful, ultimately, than a shared class horizon of narrowing expectations.
What comes through most clearly from Dopesick is that we have to undo the vast transfer of wealth from poor and middle-class Americans to the rich. The pharmaceutical industry isn’t going away. Americans aren’t going to stop needing relief from suffering and aren’t going to stop buying what they can afford, legal or not, prescription or not, to assuage it. Public policy that allows for more effective assistance for people who are trying to overcome drug habits (which Macy strongly advocates) might help lower the toll from opioid misuse, but it will do nothing to stop the next drug crisis.
Macy points out that “the heroin highway [from Appalachia] to Baltimore ha[s] become one of the few avenues left for America’s small-town working class.” As long as there are great swathes of the United States where gig work and below-cost-of-living menial jobs are all you can get, and as long as there are entrepreneurs willing to pay people to ferry and distribute drugs to the people who want them, the next drug crisis is waiting just around the corner.
Philip Alcabes is an epidemiologist on the faculty at Hunter College, City University of New York. He is the author of Dread: How Fear and Fantasy Have Fueled Epidemics from the Black Death to Avian Flu (2009).