Opioid addiction

Opioid addiction is a chronic, often relapsing condition in which the need to avoid withdrawal can become more powerful than the original pursuit of intoxication. In the account of the epidemic across Virginia, dependence is not explained as a simple failure of will: it develops through interactions among opioid exposure, physical adaptation, drug markets, economic insecurity, stigma, and access to treatment. The same pattern can begin in a doctor’s office and continue through an illicit market, while the chances of sustained recovery depend partly on whether care is available and acceptable to the person seeking it.

Dependence, Craving, and Withdrawal

The book describes a cycle in which opioid use changes what a person is trying to obtain. As dependence deepens, users may take drugs less to feel high than to stave off the physical and psychological distress of withdrawal, or dopesickness. The need to prevent that distress can drive a person to buy drugs, sell part of a supply, or recruit others into the market in order to pay for the next purchase. The cycle can expand through successive customers and end in incarceration or premature death.

This shift is also presented as a change in the user’s relationship to time. Addiction researcher Warren Bickel compared the average nonaddicted person’s perceived future, calculated in his research as 4.7 years, with the addicted user’s horizon of nine days. The contrast gives a measurable form to the book’s account of narrowed priorities: long-term plans recede as the immediate problem of securing opioids takes precedence. It is not simply that future consequences are unknown; the time available for imagining and acting on them has contracted.

Routes into Addiction

The accounts trace more than one path into dependence, but repeatedly connect prescription opioids to later heroin use. In the northern Shenandoah Valley, some users began with prescriptions and turned to dealers when pills became difficult or costly to obtain. Jesse Bolstridge and Dennis Painter had used drugs together since adolescence. As their cravings grew in 2013, their parents paid for treatment at separate out-of-state facilities; after returning and reuniting, both resumed using. Jesse’s transition from injecting crushed prescription pills to intravenous heroin reflected the latter drug’s lower price and easier availability in the account of the local market.

Ashlyn Keikilani Kessler’s history shows a similar progression beginning with prescribed pain medication after childbirth. When prescriptions ended, she moved to illicit OxyContin, then to Roxicodone after OxyContin was reformulated to deter abuse, and later to heroin as the black-market pills became more expensive and difficult to obtain. Her account makes the change in supply consequential: a less accessible or more expensive drug did not necessarily end dependence; it could redirect it toward another opioid. The book presents this route as widespread, while also showing that each person’s circumstances and access to care differed.

Supply and Social Conditions

The epidemic’s reach beyond large cities is linked to the broadening of opioid supply. Historian David Courtwright describes an illicit opioid market that had been concentrated in major cities before OxyContin and other prescription opioids made the drugs available through doctors in small communities. In his analysis, economic decline mattered, but supply expansion came first: prescribing made opioids accessible in places where heroin had previously been scarce, and illicit sellers could later fill demand when prescription pills became harder to obtain.

The prescription environment was changing at the same time. OxyContin’s 1996 introduction coincided with the campaign to treat pain as the fifth vital sign and with new mandatory standards for pain assessment and treatment. Patient surveys and reimbursement competition gave health-care providers additional incentives to address pain liberally. Purdue Pharma promoted the drug as safe when used as prescribed and circulated a claim that addiction was rare. The book places those assurances alongside the wider system that encouraged opioid prescribing, without reducing the epidemic to a single cause.

Economic distress and unequal access to care form another part of the account. 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. The reporting connects the collapse of work and rising disability with the circulation of painkillers, describing economic hardship as kindling and opioids as the spark. In Virginia, rejection of Medicaid expansion meant that hundreds of thousands of low-income residents lacked coverage that could pay for treatment, counseling, and addiction medication. A rural teacher without insurance relied on free clinics and occasional visits from a mobile health unit, illustrating how the absence of coverage could make care intermittent and dependent on charitable services.

Stigma, Families, and Public Recognition

Stigma affects both disclosure and response. When reporting on heroin in Roanoke’s suburbs began in 2012, many families were too ashamed to speak publicly. By the time the book was completed five years later, far more agreed to be identified, although some still feared damage to their employment or safety. In 2012, parents also lacked the social-media groups that could connect families across the state to exchange treatment advice and practical support. Shame could isolate households just as addiction placed them in the gaps between health care and criminal justice.

Those gaps shaped public understanding. Laura Hadden argued at a community meeting in Woodstock that dependence altered the brain’s response to opioids and drove users to seek larger quantities to avoid becoming ill. Her explanation challenged the assumption that addiction was merely a freely chosen behavior. Yet recognition was uneven: Janine Underwood described telling local officials about heroin use in affluent communities and meeting silence; the school board declined to support her program, and the county contributed only its customary small grant. The contrast shows how family testimony could expose a problem without necessarily securing institutional action.

Treatment itself could carry stigma. Although Narcotics Anonymous officially accepted medication-assisted treatment, Tess Henry encountered members who declined to sponsor or mentor her because she was taking buprenorphine. Some participants treated the medication as incompatible with being clean, creating a divide between clinical evidence and recovery-group practice. The result was not only a disagreement over terminology: it limited the support available to someone trying to remain in treatment.

Treatment and the Possibility of Recovery

The account distinguishes short-term detoxification from continuing medication-assisted treatment. Suboxone, like methadone, can suppress withdrawal and reduce cravings; when appropriately prescribed and used, it does not produce the sought-after high described in the accounts. Jesse Bolstridge received buprenorphine briefly during a residential program, but was tapered off after three weeks. National Institute on Drug Abuse director Nora Volkow argued that evidence supported long-term maintenance alongside behavioral treatment and recovery support, rather than short detoxification intended to achieve abstinence. The book notes that leading health organizations and the federal drug-policy office supported indefinite, potentially lifelong maintenance, and that Hazelden Betty Ford Foundation began offering Suboxone to some patients in 2012.

The evidence cited for recovery emphasizes duration and continued care rather than a quick cure. In 2017, estimates indicated that 40 to 60 percent of people addicted to opioids could achieve remission with medication-assisted treatment, while sustained remission could take ten years or longer. About 4 percent of opioid-addicted people died of overdose each year. These figures make relapse and persistence central to the condition’s course: treatment can support remission, but a short intervention cannot be assumed to settle a chronic illness.

The book’s account therefore treats opioid addiction as both a bodily dependence and a public-health problem shaped by institutions. It follows the route from prescribing to illicit supply, and from family secrecy to public testimony, while showing how economic decline and restricted treatment access narrow the options available. Its recurring contrast is between the urgency of withdrawal and the long duration of recovery: the immediate demand for relief can be relentless, whereas remission requires sustained medical support, practical resources, and relationships that can outlast a return to use.