A personal but very balanced history of how the opioid epidemic erupted in Appalachia, drawing heavily on the authors’ experiences in her home town of Roanoke, VA.

It’s a story that starts with drug company malfeasance, and I expected that to be the core of the story – but it’s really only the start, as the impact of available prescription painkillers triggers an avalanche of users switching to heroin and then to fentanyl, with each change of drug generating fresh overdoses. There’s a fascinating change in the dynamic between healthcare and law enforcement as the user population changes and the drugs invade more affluent areas, as well as being an indictment of America’s very disjointed and vey much for-profit healthcare system. Many of the treatments that are available are snarled in a culture-wars debate about the “rightness” different approaches, entirely divorced from the evidence. It’s also interesting (and somewhat terrifying) to understand exactly how many pathways there are to addiction, how many “gateway” drugs there can be, and how social pressures can prevent many people from seeking treatment even if it’s readily available. Very sobering.

5/5. Finished Thursday 23 December, 2021.

(Originally published on Goodreads.)