A major aspect of the novel is its exploration of the "opioid crisis," a drug epidemic in the United States that began in the 1990s and has since claimed the lives of hundreds of thousands of people. This public health disaster arose in the aftermath of a major influx of opioids, opiate-based pain medication, into the pharmaceutical markets. The book charts the progression of the crisis, as it shows the increasing presence of opioids in the Appalachia region of the American South. It then moves on to showing the wave of rampant, crippling drug addiction that this kicked off.
Demon first learns about the influx of painkillers in his hometown when he learns his mother overdoses on Oxycontin. Subsequently, he hears from June that her ex-boyfriend Kent was pushing opiate-based painkillers on patients in their county, in an effort to profit off people getting addicted to their drugs. He watches this turn into a full-blown epidemic, as everyone around him falls victim to addiction and becomes desperately dependent on opioids. It gets to the point, as he tells June, where not a single person he knows isn't on something. While keeping it grounded in Demon's narrative and its impact on his community, the book's examination of the opioid epidemic points to broader social issues. As June says to Demon, this didn't just happen: it was done to them by the drug companies.
In the late 1990s, drug companies estimated that approximately 100 million patients were experiencing chronic pain. This statistic, coupled with an increased focus on pain as the "fifth vital sign," lead to a major uptick in opioid prescriptions. This caused prescription numbers to rise from 79 million to 219 million in the period between 1991 and 2011. Subsequently, because of the known addictive properties of these drugs, abuse of and overdoses from painkillers skyrocketed. Oxycodone and hydrocodone were the most commonly prescribed opioids, both of which are stronger drugs than morphine. This epidemic of addiction, illness, and death swept through the U.S., particularly affecting low-income, rural areas. The public later learned that these areas were targeted by pharmaceutical companies, who used aggressive marketing and misleading information about addiction to turn a profit.
In 2017, a case was filed against Purdue Pharma by the state of Oklahoma. The state argued that Purdue knowingly started the opioid epidemic and used false information to get people to purchase their medication. In 2019, Purdue settled for $270 million. The case was viewed as a major victory for advocates who hope to pursue similar cases in the future. The state of California intends to pursue a similar line of argument against Purdue. In 2017, the U.S. Government declared the opioid crisis a public health emergency. Between 1999 to 2020, nearly 500,000 people died from opioid overdoses. While Demon's story has a bright conclusion, the aftershocks of this tragedy will be felt, as June says, for generations to come.
