Opioid diversion

Opioid diversion is the use or sale of prescription opioids for nonmedical purposes: medicines intended for treatment move into informal markets, where they may be taken or sold outside the prescribing relationship. In Dopesick, diversion is not presented as an isolated act of individual misconduct. It grows within a changing medical and commercial environment, takes hold in communities already facing economic strain, and prompts attempts at regulation that cannot by themselves resolve the dependence and treatment needs left behind.

Definition and Conditions

The book defines diversion broadly as using and/or selling prescriptions for nonmedical purposes. The term therefore covers more than a single route from pharmacy to street. It includes patients selling medicines obtained through legitimate prescriptions, people obtaining prescriptions from multiple doctors, and theft or forgery that brings pills into circulation without an appropriate prescription. These practices differ in how the medicine is acquired, but all involve a break between the prescription’s intended medical use and its subsequent use or exchange.

The surrounding conditions matter. In the coalfields, coal-mining employment had been in steep decline, while poverty persisted alongside high disability rates and drug diversion. The book’s image of pills becoming the new coal captures a double change: prescription opioids entered the local economy as powerful medicines and valuable commodities in places where work and household resources were under pressure. That setting helps explain why diversion could be both a source of drugs for nonmedical use and, for some residents, a way to supplement limited income.

Expanding Prescribing and Supply

The book places diversion within a period of changing beliefs and incentives around pain treatment. In 1996, the introduction of OxyContin coincided with the growing campaign to treat pain as the fifth vital sign. Hospitals and accreditation bodies adopted standards for pain assessment and treatment, while patient-satisfaction measures gave providers further incentives to address reported pain. Yet pain scores could make a subjective experience appear measurable without establishing what adequate relief meant. The book notes that reliance on pain scales did not correlate with improved outcomes and was associated with increased opioid prescribing and abuse.

Commercial promotion reinforced the expansion. Purdue Pharma presented OxyContin as safe and reliable for a wide range of chronic pain, and David Haddox promoted the claim that addiction among patients taking opioids as directed was rare. The company’s marketing materials and sales strategy encouraged physicians to treat pain broadly, not only in cancer care. Drug advertising also grew rapidly during this period, while detailed rules and guidance governing prescription-drug promotion remained limited.

Purdue Pharma targeted prescribing patterns rather than approaching every physician in the same way. Using data purchased from IMS Health, it identified doctors already prescribing competing painkillers and directed sales representatives toward those considered more likely to prescribe OxyContin. Representatives brought branded reminders, including clocks for examination rooms, and the company expected more than a million annual calls on physicians. Its rural sales efforts were especially successful: family doctors, rather than cancer specialists, had become the largest group of OxyContin prescribers by 2000. The book presents this widening availability as part of the context in which diverted medication could circulate; it does not reduce every instance of diversion to a single cause.

Routes into Informal Markets

In the communities described, diversion took forms that crossed the boundary between household survival, prescription access, and illicit sale. One account describes people who received OxyContin prescriptions through Medicaid selling their pills. A local woman explained that recipients could face a choice between food and an electric bill, while selling medication could supplement their income. The account connects diversion to economic need without treating financial pressure as an explanation for every seller or every transaction.

Other routes involved obtaining prescriptions through multiple physicians, stealing prescription pads, and check forgery. In a meeting about the problem, officials described people doctor-shopping to maintain a supply for their own use and, in some cases, to make money. Hypodermic needles were also appearing during routine traffic stops. The practices were linked to a broader local change: property crimes and other offenses associated with the pill market were becoming visible to law enforcement and county officials.

The pattern was not confined to one region or occupation. In a comparison with rural Maine, the book describes people taking prescription pads when a doctor was not looking and quietly seeking simultaneous prescriptions from multiple doctors. In an economically distressed county, selling pills obtained cheaply through insurance or Medicaid had become a perceived way to pay bills. The comparison underscores how similar forms of diversion could emerge in different rural economies, even where the principal industries and local settings differed.

Regulation and Its Limits

By 2001, concern about OxyContin diversion had prompted an unusual federal response. The Drug Enforcement Administration developed a national action plan asking Purdue Pharma to limit distribution, reconsider its marketing, and consider an abuse-resistant reformulation. The plan was notable because it targeted a specific drug and called on its manufacturer to help prevent diversion and abuse.

Purdue Pharma responded with a ten-point plan that included tamper-resistant prescription pads, a teen education program, and a grant to create a statewide prescription monitoring program intended to help halt doctor-shopping. The company also stopped distributing its 160-milligram OxyContin pill and reduced shipments to Mexico after reports that the drug was being smuggled back into the United States. In July 2001, the U.S. Food and Drug Administration announced a black-box warning developed with the company, intended to help prevent inappropriate prescribing, misuse, and diversion. These measures addressed access, prescribing practices, and warnings, but the book’s account also makes clear that they followed a wider expansion of opioid prescribing and did not erase dependence or its consequences.

From Supply Control to Treatment Access

The later response described in the book shows why diversion cannot be addressed only as a problem of controlling pills. In Roanoke, Virginia, Hope Initiative was conceived as a partnership to guide people toward treatment, with trained volunteers helping them navigate housing, mental-health, and employment resources as well as addiction services. Its approach represented a shift from treating opioid use solely as a policing matter toward building a route into care.

That route remained difficult to establish. A proposed hospital handoff from emergency overdose care to outpatient medication-assisted treatment and counseling faced bureaucratic, financial, and legal obstacles, including too few treatment providers and detoxification or treatment beds. In Hope Initiative’s first month, twenty-two people sought help, but none had entered residential treatment and only a handful had accessed outpatient medication-assisted treatment. When John was discharged from detox, arranging his onward transfer required coordination among a volunteer, his father, a treatment center, and local services; the detox facility would not host a family meeting, and an extra day had to be negotiated to make the transfer possible.

These later examples concern the consequences of opioid dependence and the practical work of reaching care, rather than diversion alone. They complete the concept’s place in the book’s account: medicines can move beyond their intended use through multiple channels, while the response must contend with both the supply that has circulated and the limited capacity to treat the people caught in its wake.