Opioid addiction accelerated in the late 1990s and early 2000s due to Purdue Pharma’s ramping up of marketing to doctors. The company used aggressive and unethical sales tactics like giving out free dinners to doctors to listen to salespeople’s pitches. Salespeople vied for “$20,000 cash prizes and luxury vacations” (33) for being top sellers. In addition, changes in FDA rules allowed Purdue Pharma to market drugs directly to consumers.

There was high demand for the drug in towns where factories and industries that were the traditional sources of employment left due to globalization. Macy uses anecdotes to show how average, productive people became addicted to the drug. Once addicted, people actively sought out the drug by visiting emergency rooms, prescription-shopping doctors known to be liberal with prescriptions, and engaging in Medicaid fraud, i.e., using the safety-net medical program to get prescriptions, then selling a portion to others in order to fund their habits. Macy includes the story of a homemaker who went from a pain prescription for surgery to stealing drugs and rehabilitation. Even high-school students showed up in local emergency rooms after overdosing.

Reporting on the problem was already emerging in urban places like Boston, but there was little reporting on the same problems in rural communities like Van Zee’s.