Book Review: Three Takes on the Opioid Crisis [FEATURE]

Appalachia RX: Stories of Treatment and Survival in Rural Kentucky, by Lesly-Marie Buer (2020, Haymarket Books, 264 pp., $22.95 PB)

Death in Mud Lick: A Coal Country Fight Against the Drug Companies That Delivered the Opioid Epidemic, by Eric Eyre (2020, Scribner, 289 pp., $28.00 HB)

White Market Drugs: Big Pharma and the Hidden History of Addiction in America, by David Herzberg (2020, University of Chicago Press, 365 pp., $27.50 HB)

America remains in the grip of what is arguably its third great opioid crisis, which began in the late 1990s as a massive tide of prescription opioids swamping the country and, as regulators and law enforcement cracked down on pain pills, then morphed into the current deadly wave of illicit heroin and fentanyl addiction.

[image:1 align:right]The authors of the three books reviewed here take on various aspects of the phenomenon, from the granular nitty-gritty of the lives of poor, white, female drug users ensnared in the treatment and rehab system in present-day Appalachia, to a state-level look at how drug distribution companies flooded West Virginia with literally billions of prescription opioids, to a long-term overview of the effort to regulate drugs and the subsequent—and enduring—historic division of drug use and users into markets black and white. (And by white markets, we are referring not only to legality but also, sadly yet unsurprisingly, skin color).

Taken together, the three books weave a damning indictment of pharmaceutical companies, the people and entities that are supposed to regulate them, and the moral crusaders who—too often, successfully—use the issue of drug use to call for repressive policies, especially aimed at people who aren’t “good people;” that is, poor and/or non-white people.

Lesi-Marie Buer is a Knoxville-based harm reductionist and medical anthropologist whose Appalachia RX is a compelling examination of the socially constructed suffering of mainly poor, white women who use drugs in a cluster of eastern Kentucky counties. She spend months living in the area, followed the women to court, to drug treatment, and opioid maintenance programs, and interviewed them extensively over time.

The result is nuanced portrayal of these women’s lives and struggles as they contend with the demands of institutions of social control even as they contend with poverty, child custody issues, and their stigmatization as drug users and therefore bad mothers. In that very important sense, Appalachia RX gives voice to the voiceless.

It also voices an unrelenting critique of a social and political system that provides unequal access to resources, chronically underfunds services to the poor and needy—including but not limited to drug treatment and mental health services—and is more willing to impose social controls on these women than to help them deal with the complexities of their lives. Appalachia RX is an important contribution to our understanding of the way drug policies, as well as broader social and economic trends, play out on the bodies of these multiply oppressed women.

[image:2 align:left]How some of those women got strung out in the first place is the subject matter of Death in Mud Lick, still in Appalachia and just across the West Virginia line from those Kentucky women. Charleston Gazette-Mail reporter Eric Eyre won a Pulitzer Prize for his years of doggedly chasing down the story of how drug distribution companies pumped billions of opioid pain pills into the state in just a few years, and here, he puts that reporting in book form. It’s quite a tale.

It starts with a single drug overdose death, and by the time he’s done, Eyre has unraveled a tangled tale of greed, negligence, and indifference that left 1,728 West Virginians dead of drug overdoses in a six-year period. Thanks to Eyre’s journalistic persistence and to a legal team determined to get to the bottom of the flood of pain pills that overwhelmed the state (and the region and the nation), we now know that drug companies dumped some 780 million hydrocodone and oxycodone tablets into the state during that same period.

There’s plenty of blame to go around. Greedy Big Pharma companies such as Purdue Pharma aggressively promoted their opioid products, greedy Dr. Feelgoods turned medical practices into pill-prescribing machines attracting clients from hundreds of miles around, greedy pharmacies blithely filled numberless prescriptions (a pair of pharmacies owned by the same man in Kermit, West Virginia, dispensed nine million hydrocodone pills in 2007 and 2008, enough to provide every town resident with 11,000 pain killers), greedy drug distribution companies such as Cardinal and McKesson just as blithely delivered all those pills to the pharmacies, despite all the warning signs.

Just as culpable were the regulators, who failed to regulate. Whether it was the state Board of Pharmacy or the DEA, regulators were asleep at the switch as an opioid epidemic grew right in front of them. And state officials were compromised by ties with the pharmaceutical industry and the distributors.

Eyre tell his tale with journalistic panache, taking the reader with him as he and his struggling newspaper take on the state political establishment and the distributors in the court battles that ultimately forced the companies and the DEA to release the records that documented the deluge of opioids. Death in Mud Lick is a real eye-opener.

[image:3 align:right]But for David Hertzberg, an associate professor of history at the University of Buffalo and author of White Market Drugs, Eyre’s story is just the latest chapter in the long history of America’s effort to control drugs. Hertzberg begins with the opioid crisis of the late 19th Century and ably describes how the competing forces seeking to deal with it—therapeutic reformers, repressive moral entrepreneurs, pharmaceutical companies, the medical profession—created a class- and race-based bifurcation of the world of psychoactive substances into “medicines” and “drugs.”

If it was prescribed by a physician, it was medicine. If not, not. The world of legal, regulated drugs became Hertzberg’s white market. The world of repressed, prohibited drugs is the familiar black market. One serves middle-class white people and is concerned with consumer safety The other serves the poor, the unconnected, the immigrant, the people of color, whose drug use and sales are considered crimes.

The history of drugs in America is well-trodden ground, but Hertzberg brings both new revelations and a new perspective to the subject. The drug reform movement’s archvillain, Harry Anslinger, the master of Reefer Madness propaganda, becomes more than one-dimensional as Hertzberg tells the story of his strict scientific approach to opioids. As head of the Federal Bureau of Narcotics, Anslinger enlisted a Committee on Drug Addiction to closely study opioids, and those scientists even developed their own new opioids (they were market flops), as well as closely measuring the addictive potential of other potential new opioid products. Here, Anslinger was acting not as the heavy-handed lawman, but as the protector of white market consumers.

And as he tells the story of pharmaceutical companies continually coming up with new psychoactive products, patterns begin to occur. After the original drug prohibition laws a century ago effectively suppressed opioid use for decades, the pharmaceutical companies came up with barbiturates in the 1930s, amphetamines in the 1940s and 1950s, benzodiazepines in the 1970s and 1980s, before hitting it big again with opioids in the OxyContin-led bonanza beginning in the 1990s and lingering like a bad hangover to the present day. In all those cases, the profit motives of the drug makers overwhelmed regulatory structures designed to protect those good, deserving consumers of the white market—even as the drug companies demonized black market drug users for causing the problems.

Given the history of pharmaceutical company greed and regulatory fecklessness, Hertzberg comes to a shocking, but not really surprising conclusion: Capitalist drug companies peddling addictive products are pretty much incompatible with the public health. In his own words:

Profit-driven drug markets follow a predicably damaging cycle. Companies hype new medicines as safe and beneficial and sell with insufficient regard for consumer safety; a health crisis ensues as consumers are left ill-equipped to make informed decisions; authorities respond with consumer protections and destructive drug wars; the pharmaceutical industry devises strategies to circumvent the new restrictions and start the cycle again. After umpteen repetitions of this cat and mouse game, it may be time to acknowledge the impossibility of establishing a safe, for-profit market for addictive drugs. Alternatives exist: state monopolies, for example, or public utility models. We need to consider these and other creative ideas for dramatically minimizing or even eliminating profit from psychoactive capitalism.

Ending drug prohibition isn’t enough. Reimagining the white market is necessary, too.