Sinners And Saviors

“I’m not asking you to play savior here. Just $500 to pay the electric bill and get my kids something to eat for a week.”

It was always going to turn out this way. Her path to impecunious single motherhood was unique in being spectacularly calamitous, but her fate — to languish as a stereotype of southern Appalachian indigence — was sealed from birth. That was my impression anyway. I tried to intercede, but the universe pushed back. Hard. As if the cosmos was righteously indignant that a mortal would be so arrogant as to alter an outcome he well knew was preordained.

She was adopted and never tried to track down her birth parents. Presumably she was scared of what she’d find. I didn’t blame her. Her adopted father was killed in a car accident shortly after I met her at the cheaper of two local Greek restaurants where, unbeknownst to me until years later, she ran a one-woman embezzlement scheme impressive not so much for its scope — it was apparently quite modest — as for its devilishly elegant design and methodical execution. Back then, she was flush with cash. And wine. Cases upon cases of wine. I didn’t think anything of it. She managed a bar. Wine’s part of the job. Cash was too. This was pre-dawn vis-à-vis the digital payments revolution. Most bar tabs were still settled in cash, distributors were paid with physical checks and some records were still kept in a written ledger, where enterprising, creative types could capitalize on misplaced trust.

By that time, the region was half a decade or so into the opioid epidemic. She was a victim years before painkiller addiction was widely recognized as a public health crisis. The national media was 15 years late to this story. In the late-1990s and early 2000s, the Upland South was the Wild West. Prescription pills were everywhere. If you didn’t have a doctor dealer, you knew somebody who did. She didn’t have a doctor. Not for that. But one of the wine reps peddled Lortab and Tylenol #3 with Beaujolais and Barolo. Then it was Ultram for a while.

When the crackdown on prescriptions started, she tried to quit, but Suboxone was no liberator. Just the opposite. That ostensible bridge to sobriety led to another kind of nightmare. The clinics were infallibly unscrupulous. A black market for the pink-orange tablets grew up virtually overnight. Rather than go to a clinic, she paid the street price ($30 each for hexagonal pieces of hell) to people who did. She broke them into fourths to make them last, wedging the segments between the cellophane and the cardboard of her Marlboro packs. The tablets were dissolvable, placed below the tongue. They turned her mouth pale orange. Poison Fun Dip. Her car ashtray was full of cigarette butts with pink rings around the filters. It wasn’t lipstick.

The end game was the same for her as it was for so many others whose lives were destroyed: OxyContin. The nature of the chase was every waking moment. If she was awake, she was trying to find it. There was no room for anything else. The only exception was when she had enough to last for more than a day, which meant I could only be around her when she managed to secure an OC 80, an 80 mg Oxy. On those days, she met the world with aplomb. If you didn’t know the outward signs of addiction and could ignore the chain smoking (which then wasn’t the kind of social faux pas it is today), she was the picture of equanimity. Solace — true repose — came only on the handful of occasions when this poor, suffering Captain Ahab somehow landed an elusive “blue whale,” the street name for 160 mg Oxy. That such a feat was possible years after Purdue Pharma discontinued the dosage, and in a city where any and all available supply was immediately met with price-insensitive demand, spoke loudly to her industriousness, a nauseating euphemism in this context.

Just before the financial crisis, she started to drift away. Or at least away from me. She might tell you a different story. I try to be an unforgiving self-critic, but even the most unflinchingly honest autobiographer can only give you one perspective. The life of a dedicated opioid addict (and there’s no such thing as a part-time opioid addict; if there were “casual” Oxy users, I never met any) eventually ceases to be compatible with the life of anyone who isn’t, even if the relationship is Platonic and not burdened by too much in the way of emotional baggage, as ours wasn’t. The logistics of the habit became more and more challenging, such that anything and everything else was subject to rescheduling, in many cases on very short notice. Alcohol became an afterthought for her, and fine dining wasn’t on the menu most days. In fact, nothing was on the menu when she was running low. Food diluted the high. So, no food.

We never had anything in common. We just had common interests. Those are two different things. When she no longer had time for those interests, I no longer had time for her. That seemed logical enough. I didn’t think of it as abandonment. She apparently did, and in that regard, she’s hardly alone in the world: Pretty much everyone I subjected to a logical severance during that period describes abandonment, even if they don’t use that word.

We didn’t speak for seven years. I’ll never know how she found my personal email address in 2014, but my name was in the news, so I didn’t blame her for reaching out. She wasn’t the only echo from the mid-2000s I heard that year. We talked on and off after that. There were pretexts and pretenses, some convincing others emphatically not, but she invariably wanted money. Or needed money. Not a distinction without a difference, as she liked to point out. I never obliged. Not one time.

“It’s not about the money,” I told her, clumsily tapping a text message like the novice I still am despite 17 years as an iPhone owner. Almost as a rule, I don’t send text messages. I find them puerile, and distressingly so. In this case it was the lesser of two evils. The alternative (a phone call) would’ve been exasperating and fruitless besides. “It’s bad precedent,” I said on what, as far as I can tell, will go down as our final conversation. She painted a predictable picture: An absentee father to three young children whose care prevented her from getting a job, a delayed application for food stamps, a failed attempt to sell her cookware and other household items to raise money for groceries, late mortgage payments, a car that barely runs and so on.

“I take some responsibility for how things turned out for you, but the kids — most of this, honestly — has nothing whatever to do with me,” I told her. “How can you separate?” she wondered. She meant “delineate,” and it was a good question. If you alter someone’s life trajectory, it’s hard to say where your responsibility for subsequent developments stops. No dice, though. “I’m not sending you any money.” I don’t know how many times I told her that since 2014. She tried again: “Forget the kids. I can’t believe you’d let me go hungry.” I thought back to all the dinner plans she canceled two decades ago to chase the dragon. “I’m sorry.”

According to the CDC, there were 106,699 documented, suspected and/or confirmed US drug overdose deaths in 2021. More than three quarters of those deaths involved an opioid. In a 2023 Cureus article, Dallin Judd, Connor King and Curtis Galke summarized a set of astounding statistics. “An estimated one in three [US adults] are currently using or have used some form of a prescription opioid,” they wrote. “While the US makes up 4.4% of the world’s population, it consumes over 80% of the world’s opioids [and] in 2015 alone, there were enough prescription opioids dispensed in the US to medicate every adult with 5 mg of Vicodin every four hours for three weeks.”

The figure below uses data from The National Center for Health Statistics at the CDC to illustrate the truly dramatic increase in overdose deaths witnessed over 22 years.

2021’s 80,411 opioid-related fatalities were more than 10 times the number of such deaths recorded in 1999, three years after Purdue Pharma first brought Oxy to market in the US. Of those 80,411, nearly nine in ten were traced to a synthetic opioid, namely fentanyl.

The ubiquity of fentanyl in national news coverage tends to inadvertently obscure the backstory. The drug trade, like any other market, is defined by supply and demand. The fentanyl epidemic is linked to an upsurge in heroin use, which voluminous research traces to the introduction of reformulated Oxy.

On August 9, 2010, Oxy tablets designed to resist common types of abuse became commercially available. As the Clinical Journal of Pain recounted in a 2022 study, “shipments of the original formulation ceased that same month.” “There was no notification to the general public or prescribers,” the authors noted, adding that “by December 2010 and December 2011, 90% and 99%, respectively, of OxyContin prescriptions dispensed were for reformulated OxyContin.”

That constituted a major supply shock. According to multiple studies, including a 2015 article published in JAMA Psychiatry, the introduction of reformulated Oxy was associated with “an immediate drop in abuse rates” and ~40% reductions in nonmedical usage. But, as the linked study noted, data on misuse and diversion of prescription opioids indicated “the past-month use of heroin… steadily and significantly increased during the four years after the introduction” of the abuse-deterrent Oxy formulation. “When participants were asked open-ended questions about the drugs with which they replaced Oxy,” 70% said heroin, the authors, Theodore Cicero and Matthew Ellis, observed.

A 2018 paper published in American Economic Journal: Economic Policy described the 2010 Oxy reformulation as “one of the largest supply disruptions to date to abusable opioids.” As Abby Alpert, David Powell and Rosalie Liccardo Pacula put it, “supply-side interventions which limit access… may have the unintended consequence of increasing use of substitute drugs, including heroin.”

In short, it was far, far too late for a supply-side intervention. Demand among opioid addicts is typically only extinguished in death. When Purdue curbed supply of the original Oxy tablets, demand quickly shifted to alternatives, resulting initially in what, on some accounts, was the most acute heroin epidemic since Nicky Barnes and Frank Lucas ran Harlem in the 1970s.

In 2010, the NCHS recorded 3,036 overdose deaths involving heroin. In 2011, that figure rose 31% to 4,397. By 2017, it was 15,482, an astounding 410% increase since shipments of the original Oxy formulation were discontinued.

In the 2018 study mentioned above, the authors suggested there’s little room for doubt regarding the causal link. Alpert, Powell and Pacula analyzed the “cross-state variation in pre-reformulation rates of OxyContin misuse” in an effort to determine whether states that experienced above-average pre-2010 abuse rates also saw disproportionately large increases in heroin overdoses. As it turns out, they did.

“States with the highest initial rates of OxyContin misuse experienced the largest increases in heroin deaths,” they wrote, adding that “event study results show that this differential increase in heroin deaths began precisely in the year following reformulation.” Do note: The study found that before the introduction of reformulated Oxy, levels and trends in heroin deaths were “nearly identical across states.”

The authors did the math: Every percentage point decline in the rate of Oxy abuse attributable to the introduction of the abuse-deterrent reformulation led to three addition heroin-related deaths per 100,000. They scaled up (which is to say extrapolated) those estimates to the national trend. The implication (and I’m quoting directly from the paper): “As much as 80% of the three-fold increase in heroin mortality between 2010 and 2013 may be due to the OxyContin reformulation.”

Needless to say, heroin addiction has some undesirable side effects beyond those directly attributable to the drug. Specifically, it’s associated with higher incidence of infectious disease, including hepatitis C. In 2019, the same authors set out to determine if the introduction of abuse-deterrent Oxy might’ve had an indirect role (i.e., through the heroin substitution effect) in facilitating what they described as an “alarming” rise in hepatitis C infections. You’ll never guess what they found.

Hepatitis C infection rates rose more than 220% in states that experienced higher-than-normal (i.e., in excess of the median) Oxy abuse rates prior to the 2010 reformulation. That, compared to a 75% increase in states where the misuse rate was below the median.

The authors’ message was straightforward: “The shift to injection drug use affects more than just overdose risk, it also raises the risk of spreading highly lethal diseases that will place an enormous burden on the health care system in the future.” As we saw in 2020, the health care system sometimes struggles with heavy burdens. As Penn’s Leonard Davis Institute of Health Economics noted in a summary of the 2019 Alpert, Powell and Pacula article, lifetime treatment costs for hepatitis C “exceed $200,000 per patient.”

The heroin addiction epidemic was fertile ground for the black market fentanyl trade. As the CDC put it in a simple explainer, the “rise in opioid overdose deaths can be outlined in three distinct waves.” The first wave was that associated with the late-90s surge in prescription opioid abuse. The second wave was the rise in heroin fatalities following the discontinuation (after 14 years) of abuse-amenable Oxy. The third wave, the CDC explained, “began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly-manufactured fentanyl.”

The chart could scarcely be any clearer. Again: America’s opioid epidemic began with the introduction of Oxy into the US market, evolved into a heroin crisis when a reformulation made Oxy tablets harder to snort and inject, then morphed into a fentanyl scourge as addicts chased an even more powerful high.

Plainly, the pandemic played a role in exacerbating an already dire situation. Depression and anxiety tied to the new public health crisis worsened the old one. Just three months in, the CDC suggested more than one in 10 Americans “started or increased substance use because of COVID-19.”

Overall drug overdoses rose nearly 30% in 2020. Those involving opioids jumped 38%. It was a bitter pill coming just two years after the first annual decline since at least 1990.

On July 17, 2019, The New York Times highlighted the previous year’s drop in overdose deaths. “It looks like there’s a light at the end of the tunnel,” Andrew Kolodny, an expert on opioid policy research at Brandeis University, remarked, before quickly noting that because the death toll was still quite high, there was “nothing to celebrate.” He was right about that. By 2021, overdose fatalities in the US were 58% higher than they were three years previous. That figure for opioid-related overdose casualties: 72%.

“There’s sort of a perfect storm of factors that we know increase drug use,” behavioral psychologist William Stoops, a professor of behavioral science, psychiatry and psychology at the University of Kentucky, told the American Psychological Association in March of 2021, for an article about opioid abuse during the pandemic. “People are stressed and isolated, so they make unhealthy decisions, including drinking and taking drugs.”

At the same time, the health care system was hopelessly overburdened with COVID. Even if you wanted to get help for a new or existing drug abuse problem, you couldn’t, or it’d anyway be more difficult than pre-pandemic. Getting in-person treatment in 2020 would’ve been well nigh impossible for obvious reasons. Note also that supply chain disruptions impact the flow of illicit goods just like they do legal commerce, and restrictions on movement affected the distribution of contraband just as they affected the dispensation of other products and services. And yet, just as people still have to eat during a pandemic, addicts still need to get high. COVID-related disruptions likely “forced people to turn to drugs they were less familiar with,” as the Council on Foreign Relations put it, and in many cases, users were probably compelled to take more risks in terms of who they trusted to get their fix.

The above-mentioned Kolodny discussed all of that at some length in a November 2021 piece published by Brandeis. “The geographical distribution of opioid deaths makes it clear that there has been a change during the pandemic months,” he said, adding that prior to COVID, fentanyl-related overdoses were concentrated in the eastern part of the country, and particularly in urban areas like D.C., Baltimore and Philadelphia. Kolodny offered an explanation for that. “In the eastern half of the US, heroin has mainly been available in powder form rather than the black tar heroin more common in the West [and] it is easier to mix fentanyl with powdered heroin,” he wrote. Then, he tied it all together: “COVID-19 resulted in less cross-national traffic, which made it harder to smuggle… bulkier drugs, resulting in smugglers’ increased reliance on fentanyl which is more potent and easier to transport in small quantities and as pills [which] may have helped fentanyl spread to areas that escaped the earlier surge.”

The economic cost of this ongoing, multi-phase crisis is huge by any estimate and astronomical by some. The Joint Economic Committee, one of four standing joint congressional panels, adapted a methodology from a 2021 paper for a report released in September of 2022. That report put the cost of the opioid epidemic in America at $1.5 trillion in 2020 alone. So, ~7% of GDP.

As noted, that estimate builds on work published in 2021 by Curtis Florence, Feijun Luo and Ketra Rice who, writing in Drug and Alcohol Dependence, estimated the combined cost of fatal opioid overdoses and opioid abuse in 2017. The authors assessed that cost in terms of health care, criminal justice and lost productivity. Their conclusion: “Costs for opioid use disorder and fatal opioid overdoses were [an] estimated $1.02 trillion” that year, with “the majority of the economic burden” attributable “to reduced quality of life from opioid use disorder and the value of life lost due to overdose.” Those latter calculations were based on guidelines published by the Department of Health and Human Services for appraising reductions in morbidity and mortality.

Congress in 2022 said the cost of the crisis is likely to keep rising. The “massive sums,” the congressional report noted, include “the price of health care to treat overdoses, the costs of fighting fentanyl trafficking and pursuing criminal justice efforts, and lost productivity in the workforce, as well as the economic costs of human lives lost.”

Of course, there’s no way to quantify the cost of the fatalities. Human life, after all, is priceless. For the families and friends of the dead, this was, and remains, a nightmare of incalculable proportions. Everyone’s likely read at least one compendium of personal accounts from spouses, mothers, fathers, siblings and friends of the deceased. Reading those accounts is no substitute, I can assure you, for being in the trenches of the late-90s opioid epidemic wars. Tens of thousands in the upper south wiped off the map, including a succession of high school graduating classes who saw their futures destroyed, figuratively by the trauma of addiction or literally in death. “Purdue Pharma introduced OxyContin in 1996, when the Class of 2000 entered high school,” The New York Times ominously wrote, in a searing 2019 retrospective.

On the supply side, it was more than one company and irresponsible doctors. It was pharmacy techs who knew how to “lose” pills. Secretaries at veterinarian offices who called in tramadol prescriptions for non-existent pets. Elderly cancer patients who morphed into wholesalers. And it was a windfall for a small handful of street entrepreneurs with the self-discipline to follow the simplest commandment of the hard drug trade: Never sample the goods.

One day just after Christmas in 2006, I was reading Barron’s and eating a croissant in the living room of her condo, where a Marilyn Monroe figurine smiled seductively from a hopelessly tawdry coffee table. We were just back from Panera Bread, and it was going to be a good day. She had what she needed, we had lunch and dinner reservations, and I had some shopping to do in-between. “You seein’ this?!” I waved my croissant at the TV. She was sitting cross-legged on the couch with a vintage silver serving tray in her lap. She inhaled one of three freshly-chopped lines arranged in a row on a Vogue cover, put the tray back on the table, lit a Marlboro and exhaled. “What’d he do?” “That’s Saddam Hussein!” I shrieked. “They hung him!” She laughed. “Ok, calm down.” I ignored her: “This is history!” “You’ll have to fill me in. Who was he again?” I gave her the short version. She shrugged: “I guess he had it comin’.”

It was months before I heard from her again, and when I did she sounded distressed. She wanted to go for a drink. It wasn’t even noon, but it would be by the time we met up and besides, there’s never a bad time for drinks. “Somewhere they won’t know us,” she insisted, calling from a number I didn’t recognize. “P.F. Chang’s, maybe.” We never went to chain restaurants. I got there a few minutes early and ordered a bourbon with a splash of Sprite, my day drink at the time. 15 minutes. 30 minutes. I tried her old phone. It was disconnected. And I wasn’t about to call a number back I didn’t know. “I’ll take the check.” I don’t wait on people. If I give you half an hour, you’re somebody pretty special. Or you owe me money, in which case you shouldn’t be late.

Several weeks went by, and I’d forgotten all about it. Not about her. Just about her no-show for drinks. It was unusual she wouldn’t call to cancel. But she was increasingly unstable and prone to disappearing, so I didn’t think much of it when she fell off the map for more than a month. By the time I found out what happened, it was the dog days of summer, and I had a new gadget: A magical new device called an iPhone.

“Fuckin’ thing.” I held Steve Jobs’s miracle up over my head and swept it around in an arc, hoping to catch a signal, not even sure if it was set up or how to go about setting it up if it wasn’t. He glanced up at me from behind his morning paper. The local paper. He only read the local paper. And he only drank gas station coffee. He judged, not incorrectly, my affinity for the Times and Starbucks to be pompous and off-putting. He offered no input on my tech troubles that day, prompting my standard joke: “You know ‘silent partner’ is a figure of speech, right?” He never laughed, but it was usually enough to get him talking.

“I told you,” he sighed, letting the paper relax on the table in front of him. “You should’ve just taken what they had and let them owe you the rest.”

I put the iPhone on the table and slid it towards him. “Have you actually looked at this thing?” I exhorted. “It’s worth three times what they owed.”

He pushed it right back across the table to me, using one finger as though the new technology might be dangerous, or radioactive to the touch. “It ain’t worth shit if you can’t get it to work.” I laughed: “You know what? I changed my mind. Read your paper.”

A few minutes later I noticed his body language shift. “What?” He stared across at me. “Whaaat?” I pressed. He folded the paper back on itself, then in half, and handed it to me. There she was. Armed robbery. Seven pharmacies. Three states. Two accomplices. One of them dead (of an overdose), the other in custody. With her.

“Goddammit.” I read the story again and handed him back his paper. “Did you know?” he asked. “No.”

We sat there for a minute. Maybe two. Maybe three. One of us had to state the obvious. He took the initiative: “She’s gonna be facin’ a lot of time.” “Yeah.”

It was Saturday, which meant we had five stops to make. And it was nine, or thereabouts, which meant if we left then, we’d be done by five. Just a couple of nine-to-fivers doing God’s work.

There’d be plenty to say later, but none of it was worth saying just then. So we drove in silence, Lord Willin’ playing faintly on repeat through the car speakers: “It shames me to no end/ To feed poison to those who could very well be my kin/ But where there’s demand, someone will supply/ So I feed them their needs, at the same time, cry/ Yes, it pains me to see them need this/ All of them lost souls and I’m their Jesus.”

---