Huff didn’t fall for the reps’ pitches; in fact, he stopped accepting pharmaceutical gifts altogether, even Post-it notes and pens. At his first family medicine practice, in Stuart, Virginia, Huff prescribed OxyContin a time or two. But most of the patients returned, as miserable as ever and still complaining about pain, he said, along with new side effects that included sleepiness, confusion, constipation, and unsteadiness on their feet. “A few of them would stay on a stable dose once it was titrated properly, but more often than not it was causing problems” both for the patients and for Huff. He noted an uptick in depression and memory loss, too, among the long-term opioid users at the practice—as well as alarming news stories about drug seekers in the community breaking into those patients’ homes or cars to steal their drugs.
When he moved his practice to the Carroll County hamlet of Laurel Fork to fill a spot left by two departing doctors in 2003, Huff was “deluged” with young-adult and middle-aged patients who’d been prescribed large amounts of OxyContin by his predecessors, concurrently with benzodiazepines such as Xanax, Klonopin, and Valium—“nerve pills,” as most in Appalachia call them. There was nothing in their charts to justify why they were getting so many prescriptions, Huff said, and he knew the added benzos put the patients at enormous risk of overdose. As one recovering addict in Lee County schooled me: “Around here, pairing an Oxy with a nerve pill—we call that the Cadillac high. If you’re gonna write this book, honey, you better learn the lingo.”
Many of Huff’s patients lived in nearby Galax, a factory town that had just witnessed the closing of two of its largest employers, Hanesbrands clothing and Webb Furniture, and continued downsizings in the town’s remaining plants. In the wake of the 1994 North American Free Trade Agreement and China’s entry into the World Trade Organization in 2001, many of the sewing factories and furniture plants were gravitating to cheaper-wage countries south of the border and in Asia.
OxyContin wasn’t just numbing pain and the depression that came along with it; the drug was now its own resource to be plundered. “You could get a big bottle of eighty-milligram tablets and sell them for a dollar a milligram, and you could pretty much live on that for a month,” Huff said.
Until Huff slammed the brakes on the Laurel Fork narcotics train.
“People freaked out on me,” he recalled. They were sick and in withdrawal, some of them not yet understanding they were addicted.
“Just about every day I was having to go in and face another ten people, and tell most of them, ‘I’m discontinuing your narcotics.’ It was really strenuous. It drained me,” he remembered.
One period was so awful that he got in his car and drove to Mississippi to see his sister for a long weekend. Two patients had threatened his life that week.
*
To one of the region’s longtime health-department directors, Dr. Sue Cantrell, a former pharmacist, the premiere of OxyContin could not have been timed worse. With the exception of mining, production jobs in the coalfields had never paid much. Cantrell remembered setting up a mobile clinic in the parking lot of the Buster Brown apparel factory in the early 1990s because the women who worked there did piecework—they were paid by the number of sewn pieces they produced—and they had zero sick leave. “They couldn’t leave work to have a pap smear or a breast exam, so we took the clinic to them,” Cantrell recalled.
“Even though the pay wasn’t great, those [production] jobs gave two things to our communities: One, families on the margin didn’t always have to be on the brink of not having food on the table or money for utilities. And the second, more important thing was the behavior it modeled for families, where people got up in the morning and went to work. A lot of people never finished high school, just like the people who went into the mines, but they used to have a source of income before it dried up to nothing—and there have been no jobs to replace those,” she said. Jobs in coal mining, once the number-one industry in central Appalachia, were cut in half between 1983 and 2012, owing to pollution regulations and competition from natural gas and cheaper low-sulfur coal out west. Automation in mining and the closings of factories that burned coal for power also contributed to the region’s decline.
The closings were just sinking in when Cantrell took her first call about OxyContin from a doctor in tiny St. Charles, the next-to-poorest town (population 159 and waning) in the poorest county in the state.
Tall and skinny, Dr. Art Van Zee stood out. He was a Vanderbilt-educated minister’s son from Nevada who spoke softly, with no discernible accent. He’d come to the region in 1976 at the age of twenty-nine because he wanted to work in a medically underserved community. The town’s new federally qualified community center, with its sliding-fee scale, was as close to the socialized medicine model he admired as he could find.
That’s where he met his wife, Sue Ella Kobak, a firecracker lawyer and activist, a coal miner’s daughter raised in a Kentucky coal camp just over the mountain in Poor Bottom Hollow. Introduced by mutual friends, the two had their first real date at an NAACP rally in Bristol, Virginia, called as a response to a planned KKK rally and ending with everyone holding hands and singing “We Shall Overcome.” After they married a few years later—the flower girl was a three-legged goat—most locals began referring to the pair as “Doc and that woman,” as Sue Ella tells it, because she refused to change her name.
Van Zee seemed to have all the time in the world for his patients, never mind that he worked sixteen-hour days, rising at four in the morning to type up his patient notes from the previous day’s visits. A doctor who’d trained in Philadelphia recalled working with Van Zee during medical school and residency: “We’d rotate in and out of these big medical centers, and when we’d get back to school, it would occur to us, ‘The best doctor in America is actually out in Lee County, Virginia,’” he told me.
Locals often compared Van Zee, with his salt-and-pepper beard and gangly frame, to Abraham Lincoln. If Lincoln had worn a paper clip for a tie clip to work. If Lincoln had been spotted routinely jogging on the winding mountain roads.
I had read about Van Zee in Barry Meier’s deeply startling (but little-known) 2003 book, Pain Killer, which chronicled the country doctor’s early David-versus-Goliath battle to get OxyContin off the market until it could be reformulated to be abuse-resistant. I had not yet met Van Zee in early 2016 when I ran into one of his patients coming out of a town-hall meeting on opioids sponsored by the Obama White House. She was a nurse, a recent retiree with a thirty-year-old opioid-addicted son whose life, she swears, was saved by Art Van Zee. “When his patients are admitted to the ER, he comes there and sees them no matter what time of day. When my daddy died, he came to our house at two in the morning to pronounce his death.”
Tales of Van Zee’s dedication are as common in Virginia’s coalfields as the rusted-out coal tipples that blanket the bluffs. There was the time he bent his lanky frame into the back of an ambulance to accompany a patient in cardiac arrest for the hour-long ride to the nearest hospital. The time he was so tired from all the house calls and beeper interruptions that some neighbors found him at a train crossing inside his idling car, asleep. The time when he cracked three ribs in the middle of a birding class on his property in the shadow of Wallens Ridge—he’d heard the spectacular clang of a two-car wreck in the distance and ran toward the road, only to find one of his own patients dead and the other driver flipped over, bottles of liquor and pills scattered around his car.