Hating Big Pharma Is Good, But Supply-Side Epidemic Theory Is Killing People

New books about the opioid crisis — “Dopesick,” “Fight for Space” and “American Fix” — have different ideas about who’s to blame and what to do next. Our critic says regulating supply can have deadly consequences, and we need to address users’ pain.

Zachary Siegel | Longreads | September 2018 | 20 minutes (5,459 words)

After breakfast each Sunday we had the option to attend a spiritual group. The facility’s spiritual counselor was a tall woman with greying frizzy hair who collected vaguely heart-shaped rocks, and always had several on her desk that she’d gift to patients who stopped by her office.

She wouldn’t give you just any old rock; no, the rock she’d choose for you had a story: its color, unique dents and chips resembled resilience, an ability to withstand harsh elements while retaining your heart’s shape. She insisted the Sunday group wasn’t religious. “Religion is for people who’re afraid of going to hell,” the popular saying around Alcoholics Anonymous goes. “Spirituality is for people who have already been there.” So we sang along to “Let it Be” by The Beatles.

We had mostly blamed ourselves for what landed us inside an addiction treatment facility. But we were young, so we also blamed our parents (thanks Obamacare!). The reason why we were all in treatment and not quarantined in jail is because we were mostly white and upper-middle class. It was the summer of 2012 and young people like me all over the country were developing opioid addictions. The difference between us and the vast majority of others was our family’s resources, namely insurance that covered the $1,000 per day cost for a residential stint at a spiritually tinged hospital-meets-lake-house just outside the Twin Cities (the land of 10,000 treatment centers). The campus edged Medicine Lake, which I always found cruel because the facility didn’t much like to use medicine at the time, medicine that would’ve eased my withdrawal and given me the best chance at kicking for good. “We don’t do that here,” I recall a nice Minnesota doctor saying.

Addiction experienced in the first-person feels like watching a movie shot entirely in extreme close-ups. No matter how hard you try, you can’t see the world beyond the frame. A tolerance builds after a while and you grow used to the shaky, nauseating ride. We couldn’t have possibly known it at the time, that we weren’t the stars in our very own drama. The content of our stories differed in the details, but the tone was uncannily similar: how prescription painkillers first took hold; after pharmaceuticals became scarce and expensive, how we, as a generation in unison, playing a fucked up game of Red Rover, beelined toward heroin. Another thing we had in common was a lot of dead friends.

How we define the origin of the crisis, its root causes, invariably informs which solutions are prioritized.

Really, we were just extras in a vast plot. Data points in a decadeslong “mass casualty event.” Epidemics are sort-of defined after the fact. After enough emergency room physicians start connecting the dots, after economists quantify labor participation and all-cause mortality, after a small hamlet’s population begins to shrink, after the morgue runs out of freezer space, after the president goes on TV.

What kicked off addiction on such an enormous scale has become an Odyssey for epidemiologists and journalists (like me), as well as parents and siblings who’ve lost loved ones. Grieving families and activists have turned up the heat on politicians and cops, urging a unified public health response that would reverse course. But how we define the origin of the crisis, its root causes, invariably informs which solutions are prioritized. Decades in, with each year deadlier than the one before, and no end in sight, what’s it going to take? The answer depends on who’s asking the questions.

***

Drenched in shame and broken by stigma, the impulse to blame ourselves for our addictions felt like a natural turn inward. Journalist Beth Macy’s new book, Dopesick: Dealers, Doctors, and the Drug Company that Addicted America, isn’t interested in victim blaming, as the title suggests. The villains, familiar to those following the news, are doctors cum dealers duped by Purdue Pharma’s marketing that downplayed the risk of addiction for their blockbuster drug, OxyContin. And after painkillers had their run, the story goes, enterprising heroin dealers tapped a hungry market outside the city, “picturesque” and “bucolic” markets demanding relief after years of physical labor and economic distress metastasized into despair.

In Dopesick, slang for opioid withdrawal, Macy goes deep but not too wide, hovering slightly above ground across desperate pockets of Appalachia, territory that she covered as a reporter at The Roanoke Times in Virginia for nearly three decades. Macy’s last book, “Factory Man,” about a furniture company’s fight to stay local by fending off Wall Street vultures and globalist currents, also took place in Virginia. Unlike coastal reporters on a poverty tour, Macy renders the plight of the working class, often caricatured today as President Trump’s forgotten rubes, with more texture than most on the post-industrial beat.

True to her craft, Macy stays local in Dopesick, zipping readers up and down the tentacles of the I-81 Corridor, through Virginia’s Shenandoah Valley, past the smell of chicken entrails from George’s poultry plant, tracing the route of heroin “re-rocked” into four-ounce hockey pucks in a Harlem apartment, small enough to fit inside a tin of Pringles, cheddar flavored. You get to know every detail of the casualties delivered by those Pringles tins, mostly through desperate families and burnt-out, yet unrelenting health-care workers navigating Kafkaesque treatment systems. So many devastating stories, it’s hard to keep them straight without writing down the cast of characters to refer back to when they’re later re-introduced.

Like a suburban mom who became “obsessed” with the particulars of her son Jesse’s fatal overdose, “finding any missing details that might explain how he went from a high-school hunk and burly construction worker to heroin-overdose statistic.” She wants to know that her son, a gregarious football player, didn’t die alone. I knew a Jesse; only, his name was Alex, and we used to snort OxyContin together. In 2008, on a cold December day in the suburbs of Chicago, after OxyContin was long gone, and heroin was all that was left, Alex was found dead in his childhood bedroom. In his system was a lethal mix of heroin and benzodiazepines (Xanax). Like many others, he died alone. No one was there to save him.

One of my best friends dying dramatically raised the stakes of my own addiction. But by then my using had so much inertia that consequences — like death — couldn’t have stopped me in my tracks. I would go on to use, from the day of his funeral, for another four years. As would many of Jesse’s own friends.

Macy also grows close (sometimes too close for comfort) to a different Roanoke mother who painfully attempts to track Tess, her addicted daughter, through Facebook and online sex worker sites. I’ve know a few Tess’s, too. Macy tastes the chaos of Tess’s life when she received a text late at night, “Can yoi please come gwt me.” Unlike the more clichéd depictions of addiction, like on A&E’s Intervention, families in Dopesick are more than props and stand-ins for voyeuristic tragedy. Instead of hapless victims, the families in Dopesick become grief-stricken heroes, breaking silence and secrecy preferred in conservative, atomized suburbs.

The real tragedy of Dopesick isn’t that young people are using drugs. It’s that when they’re drowning and begging for help, they’re callously thrown deflated life preservers. The numerous attempts at treatment throughout the book — typically at abstinence-based facilities, a dangerous move for someone with an opioid use disorder — become maddening. These are places that prefer to give patients heart-shaped rocks instead of the two FDA-approved medications that reduce the risk of fatal overdose by 50 percent or more.

All the treatment failures in Dopesick read like screams into the void of America’s outdated patchwork of shoddy care. Macy finds just the right details that’ll make you pull your hair out. A police officer picks up Jesse’s cellphone at the scene of his fatal overdose, and on the other end is a treatment center (that he’d already been to once before, that doesn’t believe in medication) calling to confirm Jesse’s arrival. If you’re wondering why so many of us are still dying, in-patient, residential “treatment” is one place to start looking.

Purdue Pharma did not invent addiction in America. Especially true in Appalachia, where families have generations of substance use. Meth and alcohol have long had a grip on rural America. Opioids are merely the newest iteration in the pursuit of oblivion.

While doing media rounds, Macy comes out forcefully in favor of medication treatment, because that’s exactly what the science says works best. In Dopesick, however, her framing is weakened by a “both sides” approach to a debate that sings the tired tune of people who prefer abstinence as the only way to truly get better. “Objectivity,” in this case, is a disservice to readers who read many pages about how medications like methadone and buprenorphine are “diverted” (a medico-legal term for drug dealing) and misused to the point where critical information is distorted. (And left out of Macy’s reporting are several studies showing this “misuse” still has therapeutic benefits.) Macy writes,

“Subutex is the monoproduct version of buprenorphine; lacking the added naloxone blocker, it is therefore more coveted among some of the addicted, who like the option of being able to take additional opioids such as Percocet at night to get high, multiple users told me.”

Buprenorphine is an opioid used to treat addiction. What makes buprenorphine unique from other opioids like heroin and OxyContin is that it only partially activates receptor sites in the brain, while most opioids fully activate those receptors. The partial activation prevents the user from suffering withdrawal while providing minimal opportunity for euphoria. Another interesting quality of buprenorphine is its high affinity for opioid receptors. It binds so tightly to the brain’s receptors that other opioids (like Percocet) are unlikely to activate the receptor while buprenorphine is locked in (and buprenorphine stays locked much longer than other opioids), regardless of the presence of naloxone.

Naloxone is an opioid receptor antagonist, meaning it knocks opioids off receptors in the brain (that is why it is used to reverse overdoses). But it’s usually only effective when administered directly into the bloodstream, typically in the form of an injection or nasal spray. Naloxone has minimal effects when swallowed orally. It’s added to buprenorphine (brand name: Suboxone) to deter patients from misusing their medication by grinding it up and injecting it (which people try and do anyway, but that’s the point — it doesn’t work when they do it).

Macy’s reporting that Subutex (the brand name for just buprenorphine) by itself isn’t blocking the receptors is medically inaccurate. It would take time, probably more than a day, for new receptors to generate or for the buprenorphine to break down enough for another opioid to lock on. Bad news for the users she interviewed, but they’re probably wasting their Percocet — or good news, since their risk of overdose when they take buprenorphine is drastically reduced. (To be clear, overdose is possible on buprenorphine, but almost always when mixed with other (non-opioid) types of drugs, like alcohol or Xanax, and those deaths are rare — and overdose deaths from buprenorphine alone are much rarer.)

This is not the first time Macy has reported medication treatment from the side of non-professionals. “In a region where Suboxone seems to have replaced coal as the economic driver,” Macy wrote in 2016 for the New York Times, “80 percent to 90 percent of all crimes committed in Russell County are drug-related, most involving black-market Suboxone, law enforcement officials say.” Few science and health reporters would ever ask cops for a quote about nutrition or climate change. Yet because of the intersection of addiction and street crime, addiction in media finds itself in a special category of social ill, where anecdotes from judges and concerned parents outweigh decades of pristine medical literature.

Macy goes on to argue for families and users who think that “Suboxone only continues the cycle of dependence and has created a black market that fuels crime.” Street demand for Suboxone is unlikely the result of people wanting to “get high” because for opioid tolerant patients, the high is honestly pretty weak, although possibly a new user might find it satisfying. More plausible is that tight control of the drug, insurance refusing to cover it, and the bureaucratic hoops people must jump through for a prescription, all contribute to its scarcity, and therefore, its demand among street users, who use it to keep nasty withdrawal symptoms at bay. I guess you can call that a crime.

Misunderstanding the science of treatment leads to more misleading equivalencies in
Dopesick, such as equating buprenorphine diversion with OxyContin diversion, which drown out what should otherwise be clear, forceful stances: Until medications like buprenorphine and methadone are easier to obtain than heroin spiked with illicit fentanyl, there’s little hope for the crisis to end. When France was inundated with HIV and overdoses in the ’90s, a nationwide policy rollout allowed any doctor to prescribe buprenorphine with minimal oversight. Since 2004, France has seen an 80 percent reduction in overdose deaths. So when the subtitle of a book is “The Drug Company that Addicted America” and pages are spent recounting how one of the most effective treatments — a pharmaceutical — is being misused, readers are left with the impression that righteous anger at Big Pharma, and the doctors trying to treat a marginalized population, will somehow put an end to addiction and overdoses.

The villains in Dopesick are the usual suspects. In 2015, Los Angeles Times crime reporter Sam Quinones wrote one of the first major books about the modern day opioid crisis, Dreamland, in which he sketches out the mechanics that drove the first wave of painkiller overdoses in Ohio and the Rust Belt. Quinones calls Ohio the epicenter of the crisis; Macy calls Virginia the epicenter of the crisis. But both Macy and Quinones find the same culprit: Purdue Pharma’s false marketing, which assured doctors that their time-released opioid analgesic rarely addicted patients.

Central to the origin story of the crisis in both Dreamland and Dopesick is the over-supply of OxyContin, dulled out by sometimes well-intentioned but misinformed doctors, or in bulk at greedy pill mills diverted for street sale. Either way, in the late ’90s and into the aughts, during a climate of deregulation and a “patient-centeredness” movement obsessed with smiley-faced rate-your-pain scales, these drugs flooded vulnerable regions of America.

Both Macy and Quinones look intently at the supply of drugs. But did flooding the market with opioids create the demand? Drugs, after all, are like any other product: people have to like and want it or they won’t buy it. So, can a doctor create addiction in their patients? Can a drug company addict an entire country? Only if you believe opioids are like mosquitos carrying Malaria, and whoever touches them comes down with the disease.

The vast majority of people who use opioids do not become addicted to them. A conservative estimate for rates of addiction among pain patients is less than 8 percent (still much higher than Purdue’s < 1 percent claim). But among those who do become addicted, they’re typically using diverted medications that were never prescribed to them, or had misused illicit drugs and were well on their way to addiction prior to receiving a prescription, thanks to trauma, mental health, and other factors that increase one’s risk. Nobody walks into a doctor’s office with a clean slate.

The fact is, injecting a regulated pharmaceutical of known dose and purity is less risky than injecting a bag of white powder purchased on the street. Bags of dope come with no proof of ingredients. At the end of the day, an 80 milligram OxyContin is always 80 milligrams.

The supply-side narrative is much messier than the authors make it out to be. In the Columbia Journalism Review, science journalist Maia Szalavitz concisely summarizes “What the media gets wrong about opioids”:

“Companies like Purdue Pharma, the maker of Oxycontin, profited egregiously by minimizing the risks of prescribing in general medicine. Purdue also lied about how Oxycontin’s effects last (a factor that affects addiction risk) and literally gave salespeople quotas to push doctors to push opioids.

The industry flooded the country with opioids and excellent journalism has exposed this part of the problem. But journalists need to become more familiar with who is most at risk of addiction and why—and to understand the utter disconnect between science and policy—if we are to accurately inform our audience.”

In other words, Purdue Pharma did not invent addiction in America. Especially true in Appalachia, where families have generations of substance use. Meth and alcohol have long had a grip on rural America. Opioids are merely the newest iteration in the pursuit of oblivion, a more effective reliever of emotional and physical pain. As reprehensible as it is, Purdue exploited, profited, and even targeted this vulnerability. To be sure, growing up in a financially stable and supportive family didn’t immunize me from addiction. It’s not just poor people in despair who get addicted. Opioids muted the harsh voice in my head, a relentless critic attacking me from within, that told me I was undeserving of love. I quickly learned that I could synthesize and manufacture warmth and connection by self-administering opioids.

As satisfying the feeling is to rail against Big Pharma and unenlightened doctors, the iatrogenic (doctor-caused) narrative isn’t without caveats and shortcomings, which are becoming painfully evident as the government rolls out strategies to rein in the supply of opioids. A recent study out of Stanford that modeled public health policy shows that aggressively controlling the supply of prescriptions, in the short-term, is actually increasing overdose deaths by the thousands. Other strategies to reschedule drugs like Vicodin also backfired, new studies are finding. In a powerful commentary by public health experts, “Opioid Crisis: No Easy Fix to its Social and Economic Determinants,” they argue wrangling the supply of opioids fails to address root causes. Targeting supply is important, the authors of “No Easy Fix” agree, but doing so without addressing people’s pain is one of the reasons things are this bad.

Macy spotlights several such supply control efforts without offering the flipside of their consequences. For example, we hear about Barbara Van Rooyan, of Relatives Against Purdue Pharma, who lobbied the FDA to require “abuse-deterrent” reformulations that make prescription painkillers more difficult to crush and inject. In 2010, Purdue Pharma did exactly that for their blockbuster drug OxyContin. But not out of concern for public health and safety. Purdue modified their original formula with the new technology to fend off generic competitors, and cunningly retained its share of the pain market by “evergreening” their patent (over 13 times!).

This company is no doubt both culpable and rotten. But the effect of their patent maneuver (that activists advocated for!) meant that the reformulation forced those of us addicted to OxyContin to start using much more dangerous heroin, which has lately been spiked with super potent, illicit fentanyl — often referred to as the third wave of the opioid crisis. The mass exodus of users from black market pharmaceuticals to black market heroin was documented in a 2017 study by the RAND Corporation and the University of Pennsylvania’s Wharton School of Finance, which connected the reformulation to thousands of heroin overdoses. The researchers conclude that supply-side efforts are not achieving their intended effects, chief among them: reducing overdose deaths.


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America’s draconian conception of drug policy has life and death consequences. Jesse, the football player in Dopesick, preferred to inject pharmaceutical oxycodone. This was true for my friends and me. Jesse, like my friend Alex, didn’t survive the leap to heroin. This isn’t retold to condone the misuse of prescription painkillers. The moral world of addiction is shaded with greys. And the fact is, injecting a regulated pharmaceutical of known dose and purity is less risky than injecting a bag of white powder purchased on the street. Bags of dope come with no proof of ingredients. At the end of the day, an 80 milligram OxyContin is always 80 milligrams. It may not be pretty, and Purdue executives might be dead-eyed ghouls, but at least there was measure of safety. That safety’s gone now. Hello, fentanyl.

Unfocused anger at Big Pharma also winds up harming a different vulnerable group, one that’s typically an afterthought in stories about opioids: chronic pain patients. In the name of “battling the epidemic,” patients who need opioids are being abandoned by their doctors. With Jeff Sessions and the DEA breathing down their necks, they’re afraid of prescribing any narcotic. In response to the opioid crisis, the prescribing pendulum has rapidly swung. Doctors who treat pain are receiving threatening letters to prescribe fewer opioids, patient outcomes be damned. As a result, some of these patients are killing themselves, which has caught the interest of investigators at the Human Rights Watch, who are documenting patient abandonment in the new, restrictive climate. A sweeping package of opioid legislation recently passed by the Senate will also be studying whether opioid prescribing limits have led to patient suicide.

A simplistic narrative yields cheap, simplistic solutions. America’s opioid reporting has the tendency to chronicle lengthy police investigations that feature cops, federal agents, and prosecutors high on the delusion that shutting down the right pill mill or locking up the right dealer will put addiction and overdoses to a grinding halt. They think they’re in an episode of The Wire.

The primary drug investigation featured in Dopesick netted the state’s biggest dealer, Ronny Jones, who was arrested in 2014. The agents claim heroin was no longer available in the state after Jones’s arrest. Such a claim flies in the face of the overdose data. Time and again, research shows locking up dealers has little effect on a state’s drug problems. But after locking up Jones in 2014, overdoses of illicit fentanyl jumped 361 percent from 2014 to 2016. It’s difficult to disentangle cause and effect at this scale. But all over the Northeast, heroin dealers were being replaced by illicit fentanyl dealers. At best, arresting Jones had minimal effect on Virginia’s supply; at worst, his arrest opened the door for fentanyl.

Macy calls this game “Whac-a-Mole,” with new dealers and more dangerous products popping-up after each bust, otherwise known as the Iron Law of Prohibition: painkillers replaced by heroin, and heroin replaced by fentanyl. Choking off the supply of prescription painkillers early on in the crisis, without first installing a safety net to catch the fallout, was a major policy failure that worsened America’s opioid problem by orders of magnitude. What would such a safety net look like? In Fighting for Space: How a Group of Drug Users Transformed One City’s Struggle with Addiction, Canadian journalist Travis Lupick exhaustively details the architecture of a demand-centered strategy that prioritizes saving the lives of active drug users.

America’s inadequate response to the opioid crisis, too often argued in wonky terms and technocratic incrementalism, rests with the inability to recognize the pain that fuels drug use is felt by human beings.

Lupick rarely mentions supply-side interventions in his book. Instead, he stays close to people actively injecting heroin and cocaine several times per day, learning what makes them desire drugs in the first place, listening to what they say they need. Fighting for Space, more than anything else, is a testament to the organizing power of drug users. In 1997, with the help of compassionate public housing and healthcare workers on the Downtown Eastside, where poverty and trauma are heavily concentrated, drug users came together to form a union called the Vancouver Area Network of Drug Users (VANDU). Rather than flinch at their drug use, Lupick portrays Downtown Eastside users as they truly are: fierce but flawed heroes. Like the manic energy of user-activist Dean Wilson, whose injection cocaine habit made him an untiring debater, dunking all over City Hall’s bureaucrats. He was one of VANDU’s early presidents.

For the uninitiated, Lupick’s harm reduction history might read like inside baseball. But as you slowly come to meet the activists, like the recalcitrant Ann Livingston and the mysterious heroin-poet Bud Osborne, you can’t help but root for them as they break all the undignifying rules that make life a living hell for those addicted on the street. From an American perspective, Lupick’s encyclopedic history also reads as a blueprint.

Treating addiction like the public health issue that it is didn’t happen because Canadians are naturally nicer and friendlier toward drug users. After decades of highly organized, politically strategic activism by a dedicated, at times disabled and tense group of drug users and health care providers, Vancouver’s most marginalized community was seen and heard. They didn’t merely get what they wanted; they got what they needed by fighting for their space: their space to do drugs with dignity, in the presence of radically compassionate nurses, but also space at the policymaking table where decisions about their fate are made. “Nothing about us, without us,” the saying goes. Canadian drug users had the insight to make their needs political, and had the stamina and support to sustain pressure on the city.

Reminiscent of ACT UP during the HIV epidemic of the ’80s and ’90s, VANDU targeted the media and politicians who seldom made a peep about their friends who overdosed alone behind dumpsters in the alley, or others who died from untreated AIDS and Hepatitis C. One of their first media-grabbing demonstrations occurred in July 1997, when roughly 200 people gathered at Main and East Hastings, which the Vancouver Sun once described as “four blocks of hell.” A gigantic banner blocking six lanes of traffic read, “The Killing Fields – Federal Action Now.” The demonstrators then marched a few blocks to Oppenheimer Park, where the Portland Hotel Society, an activist-oriented public housing provider, had their nifty maintenance crew stake 1,000 crosses into the ground, representing the tragic, preventable deaths.

The inspiring takeaway in Fighting for Space is that as drug users recognized the humanity of each other, they began to see humanity in their own selves. Their political project was to convince the city and country that drug use does not negate that humanity, or their right to healthcare. And it worked. Today, the Downtown Eastside has a fully functioning health-care system designed by drug users, for drug users: supervised injection facilities, syringe-exchanges, prescription heroin and hydromorphone, public housing, peer-support programs, and a police force that (mostly) stays in its lane. This harm reduction package was largely cribbed from Switzerland and other countries across Western Europe, countries that are not seeing devastating rates of overdoses and HIV like America and Canada. Without drug users looking out for one another, their needs would’ve never materialized the way they have in Vancouver.

Reading Fighting for Space, America’s merciless response to the overdose crisis comes into sharper focus. Communities like Virginia, where not even poor people have access to basic healthcare, let alone drug users, are treating a public health crisis with both hands tied behind their back. But on the horizon, however grey and bleak, drug users and addiction activists are making progress. Few are aware that there are currently multiple unsanctioned supervised injection facilities operating in American cities. Like in Vancouver, public health workers, researchers, and drug users have even teamed up to study their efficacy. The results surprise no one: Drug users feel safe, cared for, and most importantly, they’re staying alive. In fact, no one has ever died inside a supervised injection facility, where staff is on standby with naloxone, an overdose reversal agent, in case something goes wrong. America has other unsanctioned sites all around, like at gas station bathrooms and McDonalds. As of this writing, a bill to open a sanctioned supervised injection site is sitting on Governor Jerry Brown’s desk.

During an interview on NPR’s “Fresh Air,” Macy says she mostly stayed away from active drug users, for the sake of her own mental health and stability. Her father, who died young while Macy was in college, suffered from excessive drinking. Macy’s friend, quoting Mr. Rogers, told her to “find the helpers.” Lupick’s book proves active drug users are helpers in the cause, and deserving of a place at the policymaking table. And Ryan Hampton, author of American Fix: Inside the Opioid Addiction Crisis and How to End It, is making his debut as an activist trying to rally a different group: some 20 million people in America who are in recovery from their addiction.

American Fix is a unique manifesto that breaks the spell of anonymity, per the traditions of Alcoholics Anonymous. “The entire culture of recovery and sobriety starts with the concept of ‘anonymity,’” Hampton writes. “Some people have used this word to mean that, if you’re sober, you must be silent. That you have to hide and never speak of your experience to someone who isn’t in the ‘club.’” Hampton convincingly argues that anonymity isn’t only outdated but akin to ACT UP’s slogan: “Silence = Death.” He’s not only loud and proud about his recovery, he’s angry.

American Fix begins by unraveling how Florida pill mills fed Hampton’s OxyContin habit. That is, until his addiction got him booted from the medical system, and lying in wait was cheap and plentiful heroin. Hampton forcefully rails against the evils of deregulated Big Pharma that showered pills down on South Florida, a third epicenter of America’s ongoing opioid crisis. He’s not a journalist, and wastes no time dancing around the subject. He wants Purdue Pharma executives behind bars, or at the very least to fund a massive overhaul of America’s shoddy treatment system. Like Macy, Hampton doesn’t look closely at the wrinkles in the supply-driven narrative. But the number one villain in American Fix isn’t Big Pharma. Instead, Hampton finds a culprit in America’s treatment industry.

In a chapter, “‘We Save Lives,’ The Big Lie Treatment Centers Sell to Desperate People and Their Families,” Hampton goes off on a 20-page long diatribe against treatment providers: fraudulent moral grifters peddling snake oil, who profit off insurance loopholes amid a massive public health crisis. Hampton’s vision for addiction treatment is to first bulldoze the fly-by-night, strip mall operations in South Florida and Southern California, and then fully integrate the remains into mainstream healthcare systems. Hampton argues that family doctors should be treating addiction the same way they treat diabetes, and imagines a cancer center style model for addiction treatment. He also emphasizes the need for peer-support, which means people in recovery looking out for one another.

Instead of cerebrally sketching out the mechanics of this infrastructure, Hampton appeals to readers hearts. He knows in order for any of his wishes to materialize, much like the struggle for drug users in Vancouver, the world (and insurance companies) must see drug users not as damaged goods, but as human beings who deserve better. “We are not different from you,” Hampton writes. “Instead of criminalizing our mental illness, we deserve help.”

Hampton’s most effective when he speaks directly to his 12-Step peers. Central to his project is to bridge a longstanding, ideological chasm between the harm reduction community and the 12-Step, abstinence community. It’s no easy task, but he’s arguing that medication treatment and a Vancouver-style harm reduction response does not fundamentally contradict or threaten abstinence-based recovery. “Harm reduction programs can accelerate someone’s escape from addiction,” he writes. “They are opportunities to show people — daily, in some cases — that there’s a way out.” As someone living with Hepatitis C, Hampton personally knows the dangers of unsafe, unsanitary injection. And as a non-journalist, he cuts through the “both sides” dance, demanding syringe-exchange, medication, and supervised injection facilities. There’s an urgency to Hampton’s writing, reminding the reader that by the end of a sentence, several people in this country have just died. He writes,

“Recovery isn’t just a single, straight path. It’s a puzzle of interlocking pieces. We tend to think of it as one holistic thing, but it’s not. If you break down someone’s recovery plan, it will probably include aspects of mental health, physical health, housing, peer support, community, employment, and some kind of harm reduction… Recovery is not a zero-sum game, and treating it that way pushes out people with different needs.”

Hampton’s perspective is a happy medium in the supply-demand debate. He puts blame on the flooded market, but intimately knows that taking the drugs away without addressing the pain that’s driving people to use in the first place is a fool’s game. America’s inadequate response to the opioid crisis, too often argued in wonky terms and technocratic incrementalism, rests with the inability to recognize the pain that fuels drug use is felt by human beings. Hampton believes if enough people shed their anonymity, and come out as recovering drug users, that an unignorable coalition will win the day.

America’s cold, hyper individualistic culture of “personal responsibility” might be slowly melting. Sympathy for addiction (partially thanks to American society’s greater credulousness when it comes to white, rural victimhood) is growing. Drug users and recovery activists are finally being seen in this country, and their needs are being heard. Cities like San Francisco, Philadelphia, and Seattle are close to opening supervised injection facilities. Family physicians practicing rural medicine are obtaining waivers to prescribe buprenorphine, and doctors are convincing their field to treat addiction like any other chronic illness they see everyday. Cops are saying, “we cannot arrest our way out of this epidemic,” and activists like Hampton are holding them to their word. America’s drug crisis hasn’t reached its peak. But the activists, families, and the people supporting them, who are fighting for space, are just getting warmed up. Policy and political will lag far behind knowledge. Do 72,000 more people have to die before it catches up?

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Zachary Siegel is a freelance journalist in Chicago. He covers public health and criminal justice and co-hosts “Narcotica,” a podcast about drugs.

Editor: Dana Snitzky