‘Dopesick’ and ‘The Addiction Solution’ review: Examining an epidemic

In the last election cycle, presidential primary candidates came to town halls prepared to discuss jobs and were blind-sided when impassioned locals turned the focus to their communities’ struggles with pain pills and heroin. Since then, news reports have made nearly everyone — even politicians — aware of the “opioid crisis” and the damage it has done: cratering heartland communities, boosting fatalities in urban neighborhoods and, yes, invading “good” suburban homes.

Why did it take so long for the nation to wake up to the opioid epidemic? Why did it happen in the first place? These questions are at the core of Beth Macy’s “Dopesick: Dealers, Doctors, and the Drug Company That Addicted America.” As a resident of Roanoke, Va., and a former reporter for the Roanoke Times, Ms. Macy focuses on southern and western Virginia, though the lessons of her narrative apply broadly. She describes a “perfect storm” that fueled the epidemic: “the collapse of work, followed by the rise in disability and its parallel, pernicious twin: the flood of painkillers pushed by rapacious pharma companies.”

Ms. Macy embedded herself in the lives of four heartsick families whose children’s lives were ravaged — and sometimes lost — because of opioid addiction. All of the teens described in the book had struggled with psychological problems or used drugs before they turned, fatefully, to opioids. The emotional devastation is staggering, but so is the economic fall-out. Families are nearly bankrupted by their teenagers’ trips to in-patient rehabs. One young man went into rehab 15 times but managed to stay drug-free only when he went to prison at age 23.

Another family, with two addicted sons, spent $300,000 on treatment. The mother of that family, Ms. Macy writes, hadn’t realized the depth of her sons’ addiction “until she found them both passed out in separate incidents in her home — her oldest, breathing but slumped over in a chair from a combo of Xanax and painkillers, his cellphone fallen to the ground; her youngest, passed out on the bathroom floor, heroin needles and blood sprawled around him.” Ms. Macy stands in a field of sunflowers that one mother has planted to memorialize her son, who died of a heroin overdose at age 21. She accompanies another mother to the headstone of her 19-year-old. It is festooned with the “Star Wars” figures he loved.

Although opioid pills began fanning out to upscale bedroom communities in the mid-2000s, Roanoke viewed the overuse of OxyContin and other such pain killers as a rural problem until as late as 2010, Ms. Macy says. “We were safe in our ignorance, or so we thought — content to stereotype drug addiction as the affliction of jobless hillbillies” and other American subcultures. Part of the problem, she notes, was that local newspapers had missed the story. Short-staffed after budget cuts, they didn’t cover the unfolding crisis as well as they might have.

Ms. Macy devotes a large segment of her book to the role of pharmaceutical companies — especially Purdue Pharma, the maker of OxyContin — in aggressively marketing addictive medications and of doctors liberally, even carelessly, prescribing them. She notes the high rates of opioid use among people on federal disability. For a low co-pay, they can use their Medicaid cards to buy physician-prescribed pain relievers, thereby sustaining their addictions or becoming informal dealers. Readers familiar with components of the opioid crisis will see that “Dopesick” covers well-tilled ground, but for those new to the topic there is much to learn.

Like many journalists, Ms. Macy writes about the tenacity of addiction as if it were a purely physiological process. “Nothing’s more powerful than the morphine molecule,” she writes and refers elsewhere to a “morphine-hijacked brain.” She paints drug withdrawal, or “dopesickness,” as the primary engine of sustained use. One begins to wonder: How could anyone ever stop using?

The answer to that question and others may be found in “The Addiction Solution” by Lloyd Sederer, a psychiatrist and the chief medical officer of the New York State Office of Mental Health. Dr. Sederer argues that many facets of a person’s mental state — not least, the fear of facing life “unmedicated” or the failure to find a reason for doing so — contribute to drug use. To emphasize that the morphine molecule is far from the whole story, he revisits the classic concepts of “set” and “setting.” The first term refers to a mindset — the expectations of a particular user and the reasons behind the choice to use drugs. The second term encompasses the physical and social environment in which drug use takes place. Certain settings are conducive to becoming addicted, others to quitting. Some even affect the intensity of withdrawal.

In a chapter titled “Dimensions of Character,” Dr. Sederer outlines the “ego defenses” that protect against addiction. If the phrase sounds quaint, or Freudian, fear not. Ego defense simply points to traits we can all value: among them, the capacity to delay gratification and to redirect anger, anxiety and sorrow toward constructive activity. The best addiction-treatment programs seek to shape such capacities.

Aside from its broad insights, “The Addiction Solution” will be useful to those with afflicted loved ones. It describes tested treatment methods and the rationales behind them. Dr. Sederer ends with a plea for a “shift toward understanding not just the neuroscience of addiction but also the psychological and social dimensions.” Only in such a way, he suggests, can we solve the riddle of self-sabotage.

Dr. Satel is a psychiatrist and a resident scholar at the American Enterprise Institute.