In an Appalachian culture that prides itself on self-reliance and a feisty dose of fatalism, peddling pills was now the modern-day moonshining. Some passed the trade secrets down to their kids because, after all, how else could they afford to eat and pay their bills?
*
“It’s our culture now, taking pills,” said Crystal Street, whose father, an octogenarian, got hooked on morphine and Dilaudid in the wake of a coal-mining injury. By 2016, he was on house arrest for selling prescription pills from his nursing-home bed. “I come from a long line of distributors,” Street told me.
We spoke at an addiction clinic in Lebanon, where she and Honaker were being treated with the medication-assisted treatment (MAT) drug Suboxone. Like its methadone predecessor, Suboxone staves off dopesickness, reduces cravings, and, if prescribed appropriately and used correctly, doesn’t get you high.
Both middle-aged, Street and Honaker had each been jailed. They took turns telling twin near-death stories, one beginning where the other left off. They’d both lost their teeth. “You get sick and throw up. Or you leave pills in your mouth and it takes the enamel off,” Honaker said. Neither had ever had steady work. “You couldn’t keep a job because you’d steal if you worked at a restaurant,” Street added. “Or you just couldn’t get up and go—you were too sick.”
Honaker put in: “At the end of your journey, you’re not going after drugs to get high; you’re going to keep from being sick.”
*
Art Van Zee saw it unfolding, and he was terrified. Within two years of the drug’s release, 24 percent of Lee High School juniors reported trying OxyContin, and so had 9 percent of the county’s seventh-graders. And Van Zee not only met with worried parents; he’d been called out to the hospital late at night about the overdose of a teenage girl he’d immunized as a baby. He remembered the exact position at the St. Charles clinic where he’d first held her. He was standing by the counter, made of materials recycled from a long-gone coal company’s commissary where coal miners once gathered to collect their pay in scrip.
The miners had portions of their pay deducted from their salary to build the clinic in 1973. They’d also organized bake sales and talent shows, and spent years soliciting donations, many of the efforts shepherded by a trio of plucky nuns who’d migrated to the region a decade earlier, heeding LBJ’s and Robert Kennedy’s call to help Appalachia fight the War on Poverty. Nicknamed the Nickel and Dime Clinic, it was literally built by coal miners and community activists, people who chipped in every penny of their spare change.
These weren’t simply Van Zee’s patients who were showing up in the ER; they were also dear friends, many of them descendants of the coal miners whose pictures lined his exam-room walls. They hailed from nearby coal camps with names like Monarch, Virginia Lee, and Bonnie Blue. When patients recognized a relative in the old black-and-white photos, Van Zee took the time to write their names down on the back of the pictures.
*
In the spring of 2000, small-town newspaper stories weren’t yet available online, and rural news typically didn’t travel far. Van Zee had no idea that the force he was now wrestling with already had a hold elsewhere until a young doctor working in the clinic went home to visit relatives in the Northeast and hand carried a Boston Globe story back to the clinic in St. Charles. The story was headlined a prescription for crime.
Machias, Maine, was a remote town known for its juxtapositions—of coastal beauty and blueberries, of poverty and population decline. Its parallels to Lee County were stunning: In a region of just thirty-six thousand residents, the Washington County jail population had doubled in two years. It was overcrowded with young adults and middle-aged women and men, drug users and diverters who were facing charges of break-ins and robberies. A level of violent crime that was wholly unprecedented in the region had begun, including the firebombing of a police cruiser. The plainspoken sheriff blamed the new criminal landscape on OxyContin, and the DEA agreed, noting that Purdue’s drug was being prescribed more than twice as often as in other parts of the state.
And though OxyContin’s initial converts in Maine were fishermen and loggers, not coal miners, the results were the same:
People were “walking” prescriptions, or stealing prescriptions pads the moment a doctor turned his or her back. They were “shopping,” too—quietly soliciting concurrent prescriptions from multiple doctors. Selling prescribed pills, available for a pittance with an insurance or Medicaid card, was now seen as a viable way of paying your bills in a county where the unemployment rate hovered around 22 percent.
In a place where people had once left keys in cars and didn’t bother locking their homes, a forty-one-year-old resident told the Globe reporter, he now kept a loaded gun inside the house. A quarter of his former high school classmates had developed addictions to Oxy.
Van Zee’s co-worker distributed copies of the Boston Globe story to others in the clinic, marveling: “That’s us!”
Near the other end of the Appalachians, some eighteen hundred miles from Maine, it dawned on Van Zee and his wife that they were not alone. And they needed to get organized.
*
Within weeks, Van Zee had put on several public meetings under the auspices of the Lee Coalition for Health, a grassroots group of ministers, social workers, and other community-minded people. Edited and coached by his lawyer wife, a plucky former Vista volunteer, he wrote letters of complaint to Purdue, noting injecting patterns, frequent overdoses, abscesses, and a higher incidence of hepatitis C.
“The extent and prevalence of the problem [are] hard to overemphasize,” he wrote on August 20, 2000, in his first letter to Dr. David Haddox, then the company’s medical director, beseeching him to investigate Purdue’s prescribing patterns in the region. In another, he wrote, “My fear is that these are sentinel areas, just as San Francisco and New York were in the early years of HIV.” The company replied by sending Van Zee and his medical partner some paperwork called Adverse Event Report Forms. At a forum for area doctors and families, Van Zee brought in Yale University substance abuse experts to describe the sudden physical and psychological stress caused by dopesickness, outlining a hard truth that many Americans still fail to grasp: Opioid addiction is a lifelong and typically relapse-filled disease. Forty to 60 percent of addicted opioid users can achieve remission with medication-assisted treatment, according to 2017 statistics, but sustained remission can take as long as ten or more years. Meanwhile, about 4 percent of the opioid-addicted die annually of overdose.
When the researchers recommended that area doctors prescribe other, less abuse-prone drugs to patients with severe pain, a Purdue Pharma rep who’d been sitting incognito in the crowd rose to sharply challenge him. The problem was inadequate pain treatment, he insisted, not OxyContin’s abuse.
Sue Ella, Van Zee’s wife, worried that the patient load was getting her husband down. But, instead, she witnessed a burst of energy and something she’d never seen in her mild-mannered husband: righteous anger. By November, his letters took on a sharper tone as he described patients who drove the five-hour round-trip to Knoxville, Tennessee, for maintenance methadone—including a twenty-three-year-old woman who woke at 4 a.m. and made the drive to the clinic with her four-year-old daughter in the car.