1990s

The 1990s were the decade in which a new opioid wave took shape inside ordinary medical care, even as its early effects remained easy to mistake for isolated incidents. In rural Appalachia, prescription painkillers entered communities already facing economic decline; commercial promotion and changing standards for treating pain helped normalize their use, while law enforcement and the public had not yet recognized the scale or reach of the problem. The decade’s importance lies in that convergence: the epidemic’s first alarms sounded amid conditions that made them seem local, and a rapidly expanding medical market helped carry the risk much further.

A rural region under pressure

The decade opened against a long decline in the coal economy. In 1997, Lieutenant Richard Stallard was patrolling in Big Stone Gap, in Wise County near the Lee County line, when he encountered the beginnings of a new problem. Across Central Appalachia, mining jobs had been falling for years, and the region’s earlier poverty had not disappeared. The social landscape had changed: the area recorded high obesity and disability rates, while the diversion of prescription drugs for nonmedical use was becoming a serious concern. The book’s compressed image of the transition is that pills were becoming the new coal: they occupied an economic and social space left by an industry in retreat, though with devastating consequences rather than stable employment.

The opioid crisis did not begin in a vacuum of individual choices. Later analysis in the book places it alongside factory closures, unemployment, food insecurity, and rising disability claims. In Martinsville and surrounding Henry County, unemployment rose above 20 percent, food-stamp claims more than tripled, and disability rates increased by 60.4 percent. These figures describe developments with roots extending across the decade and beyond it; they help explain why communities entered the new century with fewer secure forms of work and heightened exposure to pain medication. The argument is structural rather than deterministic: economic distress formed part of the setting in which the drug supply expanded, not a claim that poverty alone caused addiction.

A medicine becomes a mass-market product

OxyContin’s arrival gave that changing setting a powerful new drug. The Food and Drug Administration approved it in late 1995, and Purdue introduced it in 1996. Purdue had developed the product as the patent on MS Contin approached expiration, adapting oxycodone into a formulation intended for a market broader than hospice and end-of-life care. The change was commercially consequential: a medicine associated with severe illness could now be promoted for a much wider range of pain.

In the late 1990s, Purdue’s promotion linked this expansion to claims that OxyContin was safe and reliable, with addiction rates below 1 percent. David Haddox, the company’s medical voice on the drug, presented it as suitable for chronic pain beyond cancer. Sales representatives carried the message to physicians and dentists across the country, including for conditions such as back injuries, dental surgery, bronchitis, and jaw disorders. The assurances mattered not only as advertising: they encouraged doctors to understand prescribing the drug as compassionate and responsible practice, even when the patients did not have terminal illnesses.

At the same time, the culture and administration of medical care were changing. In 1996, hospitals, doctors, and accreditation bodies were adopting pain as the fifth vital sign, giving it a place alongside blood pressure, heart rate, respiratory rate, and temperature. Patient satisfaction surveys made treatment experiences more visible to institutions, while reimbursement pressures encouraged clinicians to address reported pain. In 1999, the Joint Commission on Accreditation of Healthcare Organizations approved mandatory standards for pain assessment and treatment. Purdue recognized that these requirements created an opportunity to position itself as a source of pain-management materials for hospitals. The new standards and the company’s commercial strategy were not identical, but they converged around a growing emphasis on assessing and treating pain—and a market ready to supply medication.

The wider promotional environment amplified that convergence. After federal rules were loosened to permit detailed television advertising for nonnarcotic drugs, pharmaceutical advertising spending rose from $360 million in 1995 to $1.3 billion in 1998. Companies also increased the freebies and other inducements directed at physicians. Purdue used prescribing data to identify doctors already writing large numbers of competing painkiller prescriptions, then concentrated sales visits on those considered most likely to prescribe OxyContin. Branded reminders, including clocks for examination rooms, made the sales effort part of the everyday clinical environment. The decade’s expansion was therefore not simply a matter of one drug becoming available: prescribing expectations, marketing techniques, and institutional standards were shifting together.

Warnings before recognition

The first signs did not immediately register as evidence of a broad epidemic. Stallard’s 1997 encounter was an early, muffled warning from coal country, before residents had widely begun securing sheds and barns against theft associated with drug use. In Roanoke, heroin was still commonly imagined as an inner-city drug, used by a small and largely isolated population. Don Wolthuis, later a federal heroin prosecutor, recalled that in the 1980s and 1990s only a few dozen people in the city were believed to use it. That perception made the later spread into white suburban communities harder to anticipate; it also reflected a racialized map of who was assumed to use heroin and where.

The prescribing divide was consequential. Data discussed later in the book showed that doctors prescribed painkillers to people of color at much lower rates than to white patients, in part because clinicians distrusted people of color to use opioids safely. By 2014, overdose deaths among young white people had risen sharply compared with 2002, while rates among people of color had changed relatively little. These later figures do not make the 1990s a completed or uniformly experienced epidemic. They clarify how medical judgments during the decades of expanding opioid access distributed exposure unequally, while drug enforcement and imprisonment would also fall disproportionately on people of color.

The scale of the coming harm became visible only in retrospect. Research published by Anne Case and Angus Deaton in 2015 found that mortality among white Americans had risen by about half a percent annually from 1999 to 2013, even as midlife mortality continued to decline in other affluent countries. Their analysis encompassed more than overdose deaths, including suicide and alcohol-related liver disease, and described a wider pattern of diseases of despair. By then, the opioid epidemic was no longer an obscure local concern: a national poll found that 56 percent of Americans knew someone who had abused opioids, become addicted, or died of an overdose.

The decade’s afterlife

The 1990s established conditions whose effects unfolded across later decades. Prescription use could lead to heroin use, and some users sold portions of their supply to finance the next purchase; dependence made avoiding withdrawal an urgent force in that cycle. As people recruited others, the spread could multiply through social connections. Later, in Woodstock, the heroin network associated with Ronnie Jones demonstrated how a local market could draw in people who had begun with pills and extend through successive sellers and customers. The ensuing harms were not confined to drug use itself: the cycle could end in incarceration or premature death.

That trajectory also exposed the limits of treating the crisis chiefly as a policing problem. The book contrasts the public language that arrests could not end the epidemic with the harsher treatment of people prosecuted for heroin distribution, especially Black and Hispanic defendants. It also points to an alternative: reentry support and harm-reduction services that connect people to housing, work, and treatment, reducing both the barriers facing former prisoners and the pressure to return to drug dealing. Such later proposals belong to the response, not the origin, of the crisis. Their relevance to the 1990s is that the decade’s medical and commercial expansion proceeded amid persistent economic insecurity and unequal institutional treatment, leaving the next generation to confront problems that had been building before their full dimensions were recognized.