Anyone writing about the subject of narco-trafficking must grapple with what could be called ‘the lie of legality’. It is duplicitous to try to draw a line between ‘licit’ and ‘illicit’ drugs when describing the present carnage in Mexico, the ravages of drug abuse and the idea of our upright society waging a war against drugs. Drug cartels are corporations meeting the demand for commodities. Banks like Wachovia and HSBC get caught, and admit to, laundering their profits, but no one from these companies ends up in jail. HSBC carries on, while their clients, such as the drug baron Joaquín ‘El Chapo’ Guzmán Loera, go on trial.

What would happen if the US Drug Enforcement Administration turned its attention to the proliferation of a prescription medicine? What would happen if senior officials from the prestigious manufacturer of a legal drug were to enter court opposite the families of those killed by their products? This, in fact, is what happened to executives from the Sackler family’s pharmaceutical firm Purdue when it was finally called to account in a courtroom in Kentucky for its role in peddling America’s deadliest drugs: painkillers, such as OxyContin, containing a hyper-addictive, high dosage of the powerful opioid oxycodone. The outcome was the same as it was for HSBC: a settlement and a fine that the company paid with small change. No one went to jail. 

Beth Macy calls heroin OxyContin’s ‘illicit twin’. In both her and Chris McGreal’s books, legal opioids and illegal opiates entwine murderously: where one spreads, the other proliferates to feed the need.

These excellent works form a whole greater than the sum of their parts. Each author might feel frustrated that the other has published on the same subject more or less simultaneously. They needn’t. The two books enhance one another. Both are essential to understanding not just the epidemic of opioid addiction and death, but also how America and Big Pharma work.

The statistics are staggering: ‘the crude calculation’, writes McGreal, ‘is that prescription painkillers have claimed more than a quarter of a million American lives, although there are good reasons to believe the toll is higher because of under-reporting and stigma.’ Opioids ‘now kill more people in the United States each year than AIDS at its most destructive, and more in a single year than all the American soldiers who died in the Vietnam war’. For years, legal drugs killed more than illegal ones. Only very recently did heroin and fentanyl overtake them, feeding the escalating demand for opioids in any form. Together opioids and opiates kill more than guns, car accidents, cigarettes or heart failure. America, with 5 per cent of the world’s population, consumes 80 per cent of its opioids, although – as with tobacco – manufacturers are also turning a keen eye towards the developing world.

Macy’s narrative is a mosaic of suffering and bereavement, punctuated by stories of manhunts: the arrest of hapless ‘user-dealers’ who sell drugs and commit crimes to feed their own cravings and the pursuit of the bigger fish who have flooded Appalachian communities with heroin tucked into Pringles packs.

The stories in both books unfold against a backdrop of decline and despair in America’s hinterland, areas once bustling with manufacturing, mining and mills but desolate today. They are set in regions with poetic names, such as Shenandoah County, now cursed to suffer decline and depression. These are places that American politicians left to fester until they elected the present incumbent of the White House. As Macy points out, while most drug crazes – cocaine, heroin and synthetics – tend to start in cities and bleed gradually outwards, opioids do the opposite: they start in Trump country, then move up the line, in this case Interstate 81, to the metropolis.

Macy and McGreal both chart the history of opiate painkilling and what McGreal calls the ‘junk science’ used to promote it. ‘Addiction and abuse are not a problem,’ an OxyContin advocate called Russell Portenoy declared in 1993. Macy cites a promise made by Purdue of an addiction rate of 1 per cent among users. Studies, by contrast, have indicated an addiction rate of 5 to 12 per cent.

Both authors describe the culture Purdue championed: sales reps, like pushers, peddling OxyContin to doctors willing to accept bribes and freebies, who in turn unleashed deadly drugs on communities from their prescription pads. Readers who think that ‘legalisation’ of hard drugs would solve the problem might like to imagine these sales reps pushing crack, cocaine and crystal meth. I doubt they’d be trying to sell as little as possible out of social responsibility. Macy finds a doctor who solicits reps to sponsor her daughter’s birthday outing to an adventure park. McGreal reports how reps arrive in doctors’ offices with gifts of fishing hats, mugs and copies of a CD entitled Get in the Swing with OxyContin. In Mingo County, West Virginia, he locates a pharmacy, called Sav-Rite, that is among the top twenty-five dispensers of the opioid hydrocodone in the USA – three million dosages a year, worth $6.5 million. It is situated in a town, Kermit, with a population of a little over four hundred. The pills dispensed by the Sav-Rite pharmacy travelled so far and wide that investigators could not identify how many deaths they were responsible for.

McGreal’s book is more literary than Macy’s, Zola-esque in its dark twists and turns. He describes, for instance, how a doctor struck off in Kentucky and convicted of bribery for running a scam that involved overprescribing drugs crossed into West Virginia and recruited doctors struck off in other states (including one who had exchanged prescriptions for sex) to get the OxyContin flowing out again and the cash flowing back. At her side was Henry Vinson, a family friend and ex-convict with business acumen, which he had ‘honed in the mortuary trade’ and as a pimp to politicians in Washington. It was, writes McGreal, ‘a system that turned doctors into drug dealers. Best of all, as far as Vinson could see, it was all legal.’

McGreal casts the net high and wide, finding a health system hijacked by corporations, complicity within the Federal Drug Administration and apathy in Congress towards victims, who are betrayed ‘to protect business interests’. He finds doctors and hospitals that resist Purdue sponsorship, and lawyers who are prepared to fight back. West Virginia attorney general Darrell McGraw filed a civil case against Purdue for aggressively marketing OxyContin, in spite of opposition from the state’s governor, Joe Manchin, and obtained an out of court settlement. But he was persuaded by Manchin not to pursue criminal charges. ‘Why?’ asks McGreal. ‘Now you’re back into politics,’ replies McGraw. Today Manchin is a senator. His wavering vote recently secured the confirmation of Brett Kavanaugh to the Supreme Court.

Oh yes: it’s a horror show replete with familiar faces. Representing Purdue against McGraw was Eric Holder, appointed attorney general by President Obama. And who was the celebrity lawyer who rescued Purdue in its hour of need in Virginia? Why, Rudy Giuliani, now legal adviser to the man many voted for to get America out of this mess.

After reading both books, one is sadder and wiser – about the matter of opioids, for sure, but also about America.