PENNINGTON GAP, Va. — Years before there was an opioid epidemic in America, Sister Beth Davies knew it was coming.
In the late 1990s, patient after patient addicted to a new prescription painkiller called OxyContin began walking into the substance abuse clinic she ran in this worn Appalachian town. A local physician, Dr. Art Van Zee, sensed the gathering storm, too, as teenagers overdosed on the drug. His wife, Sue Ella Kobak, a lawyer, saw the danger signs in a growing wave of robberies and other crimes that all had links to OxyContin.
The Catholic nun, the doctor and the lawyer were among the first in the country to sound an alarm about the misuse of prescription opioids, the beginnings of a cycle of addiction that would kill 400,000 people in the ensuing two decades as it spread to illegal opioids like heroin and counterfeit versions of fentanyl. They led a burst of local activism against Purdue Pharma, OxyContin’s maker, that the company ultimately crushed. It would eventually help kindle national awareness that led to a wave of legal actions that are still awaiting resolution.
[Barry Meier reports on a confidential government memo that had the potential to change the trajectory of the opioid crisis, but it was hidden from the public. Watch The Times’s new TV show, "The Weekly,” on FX and Hulu.]
Today, two decades later, their experience, and their continued work with people struggling with addiction, illustrates the national failure to contain an epidemic that not only continues but also has grown more complex.
Those here who witnessed the epidemic unfold see it as a tragedy of missed opportunities. Dr. Van Zee said that he believed the Food and Drug Administration could have blunted the epidemic’s course in 2001 by forcing Purdue Pharma to reformulate OxyContin so that it was harder to abuse, a step the drugmaker did not take until 2010.
The three also believe that the Justice Department could have changed the behavior of other opioid makers if it had charged executives of Purdue Pharma in 2007 with felonies, as federal prosecutors had recommended, in connection with OxyContin’s illegal marketing.
Instead, department officials negotiated a deal under which the executives pleaded guilty to misdemeanor charges that did not include jail time. In the years that followed, executives of other opioid makers and distributors kept shipping millions of addictive pain pills into towns like this one apparently without fear of serious penalties.
“I think the trajectory would have been completely different,” Dr. Van Zee said recently. “It would not have reached the magnitude that it did.”
The consequences of inaction continue to haunt this former mining town of about 1,900, set in the far southwestern corner of Virginia near the border of Kentucky.
Dr. Van Zee, who is 72, rises at 4 a.m. to take care of paperwork before spending 10- to 12-hour days at a community health clinic. Some of his patients, still, are addicted to opioids. Sister Beth, now 86, continues to run her treatment center, and is seeing more people turning to heroin and fentanyl, which are cheaper and more deadly — and a new scourge, the return of methamphetamine.
“It never ends, the whole cycle,” she said. “We are still losing people to it.”
‘The worst disaster’
I came to Pennington Gap for the first time nearly 20 years ago, reporting for The New York Times about OxyContin’s growing abuse. I got to know Sister Beth, Dr. Van Zee and Ms. Kobak, and they became central characters in a book I wrote called “Pain Killer” that was set in this town.
Both Sister Beth and Ms. Kobak had previously taken on fights in this part of Appalachia, to protect the rights of workers and the environment. But Dr. Van Zee was an unlikely activist. When OxyContin came on the market in 1996, he prescribed it to his cancer patients to blunt their excruciating pain. He found it hard to believe that a pharmaceutical company would recklessly market a drug that had such an addictive potential to a much wider population.
A local pharmacist, Greg Stewart, said a sales representative for Purdue Pharma had told him that OxyContin was safe because it was a long-acting narcotic and so would not appeal to drug abusers who liked Percocet and other short-acting pain pills because they delivered a quick high. But teenagers and others in town quickly discovered that crushing an OxyContin pill released large quantities of the narcotic oxycodone.
Sister Beth recalls getting a phone call from Mr. Stewart as she was starting to see people addicted to the drug.
“Beth, believe me,” she recalled him saying, “this is going to be the worst disaster that ever hit Lee County.”
Dr. Van Zee began writing Purdue Pharma executives, urging the company to pull back on how it was marketing the drug. Feeling the company was ignoring his plea, he and others here launched a petition drive in 2001 to convince the F.D.A. to take OxyContin off the market until it could be reformulated and made safer.
Several executives of Purdue Pharma traveled from the company headquarters in Stamford, Conn., to meet at a local motel with Sister Beth, Dr. Van Zee, Ms. Kobak and others. They listened as the executives tried to convince them to drop the recall petition — and offered $100,000 to help fund addiction treatment in the area.
One executive pulled out a full-page advertisement that Purdue Pharma, which would add a new warning label on OxyContin, planned to run in a local newspaper attacking the recall drive.
Ms. Kobak exploded. “You have done more to hurt Appalachia than the coal industry has ever thought about doing,” she said and stormed out.
Sister Beth implored people to turn down the drugmaker’s money. “This is blood money,” she said. “They are trying to buy us off.”
The recall drive fizzled out, and by the mid-2000s, the people of Pennington Gap were trying to combat a growing opioid epidemic in other ways. Dr. Van Zee received training that allowed him to prescribe buprenorphine, a medicine that blunts cravings for opioids, to his patients. Sister Beth, Ms. Kobak, Dr. Van Zee and others helped start a local inpatient addiction treatment facility, the only one for many miles.
They all were encouraged in 2007 when the Justice Department announced criminal indictments against Purdue Pharma and three of its top executives in connection with deceptive marketing of the drug.
That July, Sister Beth stood in drizzling rain outside a federal courthouse in Abingdon, Va., disappointed about the outcome of the case. In the courtroom, a judge had approved a deal struck between the Justice Department and the three Purdue executives. Under it, the men were allowed to plead guilty to a single misdemeanor charge that did not accuse them of personal wrongdoing and for which they would not face jail.
Sister Beth said recently she was glad that some justice had been done, but that it was not enough.
“I think it would have made a considerable difference if these people had been arrested and done jail time,” she said.
Twenty years on
The problems of today’s opioid epidemic still plague this town. Drugs tainted by counterfeit fentanyl are now sold on the streets. The ravages of methamphetamine can be seen in the hollowed bodies of addicts who suddenly fly into psychotic rages.
The inpatient treatment facility was forced to close after several years for lack of funding. Sister Beth also said that government funding, both state and federal, was woefully short of what was necessary for people to get the help they needed.
“It has just started to get better,” she said.
Virginia’s decision last year to expand Medicaid, which has paid for treatment of many low-income people in other expansion states, may have helped, along with an injection of federal grant money to states for addiction treatment and prevention.
Sister Beth, Dr. Van Zee and Ms. Kobak, who is now retired, have been reading with fascination the new documents about Purdue Pharma and its owners, members of the wealthy Sackler family, that have recently emerged in lawsuits and elsewhere. As it turns out, it was in 2001, the year they and others in town confronted Purdue Pharma executives about the overzealous marketing of OxyContin, that a son of one of company’s founders, Dr. Richard Sackler, wrote a now infamous email about the need “to hammer on the abusers in every way possible” for the drug’s problem.
“You lie so much you believe your own lies,” Sister Beth said. “That’s what devastates me; it was always profits over people.”
Both Purdue Pharma and a representative for Dr. Sackler insist that the email and others cited in recent lawsuits have been taken out of context.
Earlier this year, Dr. Van Zee and Ms. Kobak flew to Oklahoma so the physician could testify as an expert witness in that state’s lawsuit against the drugmaker. Plaintiff’s lawyers working for the state offered to pay him handsomely for his time, but he refused to take the money, and used vacation time to make the trip.
The lawyers assured him, he said, that they wanted exactly what he did: to finally see all of Purdue Pharma’s internal documents brought to public light.
“I was impressed by what looked like their commitment to get some type of accountability and responsibility,” he said.
But that never happened. In March, Purdue Pharma agreed to pay $270 million to settle. As a result, all its internal documents remain sealed. Oklahoma state officials said they struck the deal because of concerns that Purdue Pharma, which faces thousands of lawsuits, might soon file for bankruptcy.
Dr. Van Zee said he couldn’t question the state’s decision but was deeply disappointed by it. Now, he and the others are looking to a federal courthouse in Ohio, where nearly 2,000 lawsuits against Purdue Pharma and other opioid manufacturers and distributors have been consolidated under one federal judge.
After living through the opioid epidemic for 20 years, Dr. Van Zee, Ms. Kobak and Sister Beth all share the belief that the only way to prevent a similar catastrophe is for the truth to come out about the actions of corporations and the failures of public officials.
“I hope it puts a light on what huge systematic changes we can make so that this doesn’t happen again in 20 or 30 years,” Dr. Van Zee said.