The so-called opioid crisis (or epidemic, depending upon who you ask) has been a news story for many years now, although its roots go back much further than the political and media attention. Beth Macy’s 2018 book Dopesick: Dealers, Doctors, and the Drug Company that Addicted America traces the origins of this national catastrophe as far back as the 1980s when medical opinions began to favor more liberal treatment of pain. Even though opioid use was still fairly modest for another decade or so, the advent of a medication called OxyContin (an extended-release formulation of the already potent oxycodone) truly kicked off the crisis. This happened, in large part, through a combination of aggressive marketing by Purdue Pharma (the drug’s manufacturer) and considerable regulatory failures ranging from incuriosity to borderline corruption.

Before reading this book, I thought Purdue Pharma was just a scummy private drug company owned by a family of billionaires who were more interested in their portfolio returns than actual medicine. I worked in retail pharmacy for several years starting in about 2010 and while the crisis was in full bloom by then, there were still plenty of reminders how far people and physicians would go to get opioids into people’s hands. I did not, however, fully understand just how conniving and calculating Purdue was in their efforts to get OxyContin into the marketplace. I did not, for example, know that the company had been careful what studies to present to the FDA during the approval process (their internal studies demonstrated the risk of dependence to be many times higher than what they reported) and I did not realize just how hard Purdue’s sales reps leaned on vulnerable rural and small-town physicians to prescribe their product to out of work and chronically hurting former coal miners and factory workers. The level of scummy-ness was far worse than anything I imagined.

Still, Macy largely avoids examining pharmacy’s role in this story. She says how pharmacies were often targeted for robbery by people looking to get medication to either sell or use, but she fails to really address how pharmacies were participants in the unfolding tragedy. As the final step in a legitimate medication dispensing process, pharmacies and, more specifically, pharmacists have a uniquely difficult job — they are gatekeepers but they are also dependent upon all the other players (i.e. the drug manufacturers, the physicians and even the patients) being honest. The pharmacist can only operate on their instincts and the evidence before them, and often those instincts are overruled by the demands of their employers. In a more perfect world, pharmacists would feel supported and empowered to say no to questionable prescribing, even if the prescription is legally valid. Sadly, however, pharmacists and their staff are often unable or unwilling to put their feet down and decline to fill a clearly suspicious prescription.

Take an example from my own time as a pharmacy technician. I was employed by one of the major national chain pharmacies and we had our share of suspect or outright fake prescriptions. However, the ones that, in retrospect, should have been the most concerning were often the ones we filled without much question. Take the regular customers (a married couple) who would bring in prescriptions written by a doctor in Florida (we were in North Carolina). They had matching prescriptions for oxycodone tablets (if memory serves, they each were prescribed 240 tablets of 10mg immediate release oxycodone). We always filled out the company’s required ‘due diligence’ form and, as the prescriptions were valid, we would dutifully fill them at the appropriate time. We all suspected some kind of malfeasance, but we were never concerned enough to report anything to anyone. We had another patient who would, every month, bring in a prescription for 330 methadone tablets and we would follow the same rules, never really questioning why such enormous amounts of medication were being used — they had a diagnosis code on file, and that satisfied the company’s policy.

Macy alludes to these shady practices by highlighting how one pharmacy in one small town somehow procured millions of hydrocodone tablets without raising any alarms (169), but while she does a superb job of showing the human toll the opioid crisis has taken on users, their families and the people trying to stem the tide, she largely ignores the people who were in the midst of the epidemic without fully understanding their role in it. How many times could a pharmacist have prevented diversion or overdose by simply declining to fill a prescription that was clearly improper?

More recently, there have been efforts to hold pharmacies, pharmaceutical distributors and manufacturers accountable for their part in the crisis. After years of profiting from rabid opioid consumption, these parties have been forced to settle various lawsuits for tens of billions of dollars. While this might provide an element of justice, there has been no apparent interest in examining how the FDA was duped (or allowed itself to be duped) into approving OxyContin at all. Macy provides plenty of evidence that, even though Purdue was far from transparent in their filings and applications, the Food and Drug Administration proved shockingly lax in their reviews and seemed perfectly content with keeping the drug on the market even after its safety claims began to be seriously questioned. Sadly, fumbles like this do not help reinforce the idea of the medical regulatory bodies as upright and dutiful defenders of American health and safety. This is particularly true in a time such as now where faith and trust if the FDA and CDC are, whether rightly or wrongly, sorely lacking. We expect Big Pharma to be sneaky, but we also expect our regulatory bodies to see through the ruses and at least force manufacturers to address questions and not just turn a blind eye.

In short, Dopesick is an excellent study in both the nature and cause of the opioid epidemic. It expertly, but efficiently, traces the crisis from the advent of the “Pain: the 5th Vital Sign” campaign to its morphing into a heroin crisis and, finally, it metastasizing into highly dangerous imported fentanyl. Through the statistics and the figures, however, Macy never loses sight of the people, those who fought, those who died, those who overcame. Dopesick is not a joyous work, but it is a celebration of hope even in the face of a horrific addiction and an inept government response. There are answers, Macy is constantly reminding her readers, but we have to be willing to accept some unpleasant realities in order to hear them.

Macy, Beth. Dopesick: Dealers, Doctors, and the Drug Company that Addicted America. Little, Brown and Company: New York, NY, 2018.