Heroin in the opioid crisis

Heroin in the opioid crisis is both a particular drug and a recurring answer to a market created by dependence: first marketed as a safer substitute for morphine, later driven underground by prohibition, and eventually positioned as an illicit alternative when prescription opioids became difficult to obtain. The book follows the substance across these reversals, from turn-of-the-century drugstores to contemporary rural and suburban communities, showing how a change in supply could move addiction into new places without resolving its underlying demand.

From Morphine Substitute to Commercial Product

In the late nineteenth century, the search for alternatives to morphine provided the opening for diacetylmorphine, later marketed as heroin. Bayer chemist Heinrich Dreser encountered earlier research by a British chemist who had synthesized the compound in 1874. The drug was more than twice as powerful as morphine, itself described as ten times stronger than opium. At a time when pneumonia and tuberculosis were major causes of death and antibiotics did not yet exist, Dreser saw the potential for a cough remedy that could match codeine without its familiar addictive properties.

The promise of safety shaped the drug’s early identity. After ordering a laboratory assistant to synthesize it, Dreser oversaw initial tests on rabbits and frogs, followed by tests on himself and Bayer dye-factory employees. He presented it to the German medical academy as a treatment for asthma, bronchitis, and tuberculosis, and as a broadly useful remedy for ailments including colds, influenza, joint pain, and infant colic. Bayer further promoted it as a treatment for alcoholism and morphine abuse. The book’s account makes the contradiction central: an opioid was sold as a remedy for dependence on another opioid, with its capacity to suppress breathing presented as a therapeutic benefit.

Drugstores, Domestic Use, and Prohibition

By 1899, Bayer was producing a ton of heroin annually and selling it in twenty-three countries. In the United States, it appeared in cough drops and baby-soothing syrups, and could be bought at drugstores without a prescription. Its customers were not limited to veterans or people already identified as addicted: the book describes a broad population that included barbers, teachers, shopkeepers, and housewives. Many could maintain ordinary lives and conceal their use while supplies remained steady and consumption did not exceed what they could manage. The drug’s place in everyday medicine thus made dependence less visible, not less consequential.

That commercial confidence persisted alongside warnings. Doctors criticized the practice of leaving morphine and syringes with patients, and some researchers questioned how well heroin’s toxic effects were understood. In 1906, the American Medical Association warned that the habit could form readily and lead to grave consequences. Hospital admissions involving heroin rose in New York and Philadelphia during the 1910s and 1920s, as officials recognized addiction among injured patients as well as recreational users. The Harrison Narcotics Act of 1914 sharply restricted the sale and possession of heroin and other narcotics; in 1924, its manufacture was outlawed in the United States.

Prohibition changed both access and social meaning. By the 1930s, the book describes typical heroin users as working-class people, including children of immigrants and a growing number of jazz musicians and other creative workers. Criminal networks now supplied the drug, and users depended on them to avoid withdrawal. Those left in the public picture were increasingly labeled junkies and treated as criminals rather than patients. The earlier presence of doctor-approved, middle-class opioid users faded from view. The legal boundary had altered the supply system and the public identity of addiction, but it had not removed the need that made an illicit market profitable.

The Modern Shift from Pills to Heroin

The book places this earlier history alongside the modern opioid epidemic. Its central continuity is the morphine molecule moving through different products and distribution systems: from OxyContin and other prescription painkillers, including Vicodin and Percocet, to heroin and later to stronger synthetic analogs. The modern shift did not occur in a fixed rural-to-urban sequence. The narrative begins in the coalfields, with the introduction of OxyContin in 1996, then traces heroin into suburban communities and along the northward corridor of Interstate 81. Heroin had reached subdivisions near Roanoke by the mid-2000s, even though its presence was not widely acknowledged at first.

Supply and dependence reinforce one another in this account. When prescription pills become too expensive or cumbersome to obtain, illicit sellers can meet the demand of people who fear running out and experiencing withdrawal. The book connects this mechanism to earlier eras, when criminal sellers stepped into markets after restrictions changed access to opium, morphine, and heroin. It also records how quickly a local market could grow: in 2012 and 2013, Ronnie Jones’s operation expanded from a handful of users to hundreds, spreading through northwestern Virginia and into communities west of Washington, D.C. When Jones was arrested in 2013, the disrupted supply left newly dependent users seeking drugs in larger cities, including Baltimore and Washington.

A Substance in a Wider Crisis

Heroin is not the final form of the epidemic in the book’s chronology. The account follows the shift from prescription painkillers to heroin and then to synthetic opioids, making the substance part of a changing drug supply rather than an isolated crisis. A later account of carfentanil—a synthetic opioid described as one hundred times stronger than fentanyl—records twenty-six people losing their breathing in Huntington, West Virginia, in a single day after one batch arrived. This episode marks the increased danger of a market in which a familiar drug can be displaced by a far more potent analog.

The scale of the crisis gives these local transitions national weight. The book reports that overdose had already killed 300,000 Americans over the preceding fifteen years, and that experts then projected another 300,000 deaths over the next five. These figures frame the drug’s history not as a sequence of disconnected episodes but as a long movement between medical availability, restriction, illicit supply, and renewed forms of exposure. The contemporary consequences also appear through individual histories: after the death of her nineteen-year-old son Jesse Bolstridge, Kristi Fernandez searched for the missing details of his rapid descent into addiction, including how he moved from high-school student and construction worker to a heroin-overdose statistic. Her search makes visible the personal cost that aggregate figures cannot explain.

The book’s account ultimately presents heroin as a substance whose meaning is made by more than its chemistry. A medicine once sold as nonaddictive became a prohibited commodity; a drug associated with urban illicit markets later appeared in rural towns and suburban neighborhoods; and, as prescription and illicit supplies changed, users were repeatedly pushed toward whatever market could meet dependence. The repeated pattern is not that every drug or community is identical, but that commercial assurance, access, restriction, and substitution can combine to carry the epidemic from one population and place to another.