In Chris McGreal’s new book about the opioid epidemic, the veteran journalist likens health-care professionals to street-corner drug dealers. Two decades into North America’s overdose crisis, one often hears that comparison in a metaphorical sense. But in American Overdose: The Opioid Tragedy in Three Acts, the similarities are quite literal.

“The West Virginia police sergeant arrived at the clinic to find thirty people lined up outside waiting for prescriptions,” McGreal writes in the book.

“I’ve never been in an office like that,” his source recounts. “It was more messy than just about any crack house or drug house I’d ever been in. There was trash stacked in rooms to the ceiling. The exam table had a xylophone and a bunch of trash on top of it. The bathrooms weren’t working. Somebody had defecated in the sink.”

“When investigators opened the clinic’s files, they found dozens of presigned prescriptions,” McGreal continues. “They discovered records showing [Dr. Diane] Shafer had consultations with more than one hundred patients the previous day even though she wasn’t in Williamson. Then the police headed for the bank to get at the doctor’s safe-deposit box. It was stuffed with a half-million dollars in cash.”

McGreal has written a forensic autopsy on the role that prescription pills have played in the opioid epidemic. In American Overdose, he names names, and reports with unparalleled detail on the negligence of pharmaceutical corporations, on the doctors and distributors that move their products, and on the government agencies that let companies like Purdue Pharma get away with it.

In a telephone interview, McGreal says there is now little doubt that corporate executives should go to jail for their contributions to this health crisis, which killed some 52,300 people in 2015, roughly 63,600 the year after that, and an estimated 72,000 people in America in 2017.

“It wasn’t Purdue Pharma alone,” McGreal emphasizes. “The regulatory agencies, the U.S. government and Congress, they all played important roles. Purdue Pharma may have made it happen, but all of those other entities let it go on happening.”

There are some problems with the pharmaceutical narrative that North America applies to the overdose crisis. The singular emphasis that is often placed on prescription drugs like OxyContin and white populations living in rural areas does not tell the whole story. As the Straight has noted before, the prescription-pill narrative is not true to the same extent everywhere, and in some areas is not true at all. (In B.C., for example, health officials have said the overdose crisis is primarily an issue of illicit fentanyl.) But for where it is accurate, McGreal provides the most detailed account yet.

Speaking to the Straight, he expands on the story told in American Overdose and brings it up to the present.

“There is quite complex socioeconomic stuff going on,” McGreal says. “Some of the worst-hit areas in the country—places in Appalachia—are amongst the poorest [areas in the country].

“If you go to, say, East Kentucky or West Virginia, drugs become an economic opportunity. Some people who were very poor, they started dealing,” he continues.

McGreal argues that this combination of doctors and opportunists who weren’t using the drugs themselves but instead selling them on the black market created an abundance of prescription pills that primed the country for phase two of the epidemic: heroin.

“I think probably what it did was widen the group of people who had access to ‘heroin in pill form’, as the DEA put it, in a way that the cartels could never have hoped,” he explains.

“The cartels saw an opportunity because of the rising use of prescription opioids and the rising misuse of prescription opioids,” McGreal says. “They saw an opportunity, and so they started to push greater amounts of heroin into the country.”

At this point, McGreal says there was an “example of unintended consequences”.

About the same time that organized-crime syndicates made street heroin more widely available in America, regulatory agencies began to crack down on overprescribing. When patients could no longer rely on a doctor to supply the pills to which they were addicted, they went looking for similar narcotics on the streets. And there the cartels were waiting with heroin.

This new demand led to phase three of the epidemic: fentanyl.

“It’s no easy thing producing heroin,” McGreal says. “You’ve got to grow poppies, you’ve got to process it into heroin, and then you’ve got to smuggle it across the border and it is quite bulky.…So now you’re replacing the heroin with fentanyl, because it’s so much stronger.”

Whereas the production of heroin requires large tracts of farmland, fentanyl can be cooked in a laboratory. McGreal warns that this leaves authorities with a very difficult problem.

“There is definitely an unintended consequence here, and I don’t know what you do about that, because you do actually have to cut back on prescribing,” he says. “If you are going to cut back on prescribing, you really do have to make sure that treatment is in place. And we haven’t, because it costs money.”