Intended for healthcare professionals


A novel that puts you inside the suffering from the opioid crisis

BMJ 2023; 381 doi: (Published 19 May 2023) Cite this as: BMJ 2023;381:p1148
  1. Richard Smith, chair
  1. UK Health Alliance on Climate Change

Barbara Kingsolver has been called an activist novelist. That phrase “activist novelist” worries me as novels where message comes before story invariably fail, but the four novels I’ve read by Kingsolver all seem to me great successes. She’s written about undocumented immigrants, feminism, climate change, and now the opioid crisis.

For Demon Copperhead, her novel on the opioid crisis, which has just won the Pulitzer Prize, Kingsolver has a “genius friend,” Charles Dickens.1 Her novel is based on David Copperfield, Dickens’ “impassioned critique of institutional poverty and its damaging effects on children in his society.” Kingsolver says her novel is “For the kids who wake up hungry in those dark places every day, who’ve lost their families to poverty and pain pills, whose caseworkers keep losing their files, who feel invisible, or wish they were.”

I’m a great believer that “the truth is in the fiction,” and Demon Copperhead brings you closer to the suffering from the opioid crisis than any account in a medical journal can manage. The novel is set in Lee County in the very west of Virginia, a poor, former coalmining county at the heart of the opioid epidemic. Kingsolver describes the county: “Everything that could be taken is gone. Mountains left with their heads blown off, rivers running black. My people are dead of trying, or headed that way, addicted as we are to keeping ourselves alive. There’s no more blood here to give, just war wounds. Madness. A world of pain, looking to be killed.”

Purdue, the company that developed the drugs that fuelled the opioid crisis, targeted places like Lee County. “Purdue looked at data and everything with their computers, and hand-picked targets like Lee County that were gold mines. They actually looked up which doctors had the most pain patients on disability, and sent out their drug reps for the full offensive.”

Kingsolver describes Kent, one of those drugs reps, whom she calls a “hired killer”: “A Burt Reynolds type, moustache, too dressed up for a Saturday, shoes like nobody from around here. Looking down on him, I could see a pink shine on top of his head with the dark hair pulled across it. Not a full Homer Simpson…just a little beginner’s hamburger helper up there. But do you trust a guy that cheats on his own head?” (Kingsolver’s novel is funny, albeit with serious intent, and is a joy as well as a horror to read).

Demon, the modern version of David Copperfield who tells his story, may not be impressed with Kent, but almost everybody else in the county is. Kent, armed with statistics and gifts from Purdue, is an evangelist. The medical establishment not taking pain seriously. “We know better than that now. Pain is the fifth vital sign. We invented the pain score so the patient can give an objective assessment.” Nobody needs to worry about becoming addicted: “There’s absolutely no chance of you getting dependent on this medication. The company did all kinds of studies. I can show you the package insert.” And to back up his evangelism, Kent has gifts for those who prescribe the company’s drugs: “This guy was Santa Claus Junior in a Ford Explorer, coming around to throw presents on all the receptions and nurses. Candy for the fat ones, coupons for Hair Affair if they were on diets. It was like Kent had spy elves telling him what they’d all want. The doctors got actual free vacations to Hawaii and such. Golf trips.” (An American doctor I met recently thinks that doctors are the unrecognised villains of the crisis.)

Demon’s young mother is addicted and eventually dies of her addiction. When older. Demon has a girlfriend Dori, later his wife, whose father takes opioids. His scrips are a source of income. The local pain clinic is a marketplace. Inside the clinic the doctor is asking $250 for a scrip plus $150 for “staff fees” that allow you to get the drugs more quickly. “Everybody gets the exact same thing, holy trinity. Oxy, Soma, Xanax.” Outside Dori sells her father’s pills. There are some 250 filled with addicted people needing drugs. She looks “for the ones that are seizing or puking.” The drugs sell for a dollar a milligram, and as her father gets 80 tablets month for $3 funded by Medicare she can make $2000 in a night.

People also get their drugs from June, a nurse practitioner, one of the heroines of the novel who after being hoodwinked initially realises the danger, tries to get people off the drugs, and organises a legal action against Purdue. The nurse’s daughter explains: “People come in every day just wanting her to write them. They’ll say anything to get their painkillers. Kidney stones. They take the cup in the bathroom and prick their finger to put blood in the urine sample. That’s the men….The women play it smart, they’ll go into their exam room and duck out with her prescription pad before Mom can get in there to see them….Mom says half these people don’t know they’re addicted. They took what some doctor told them to, and now they’re fiending and don’t really know what it is.”

Dori takes the drugs to assuage her grief after her father dies. Demon is prescribed them to keep him playing football after his knee is badly injured. They are soon both addicted. Demon tells June: “I don’t know a single person my age that’s not taking pills.” June answers: “It’s not just people your age. You know what I’m saying? If they’re old, sick, on disability? They need their scrip. If they’re employed, they get zero sick leave and can’t see me more than once a year, so there’s no follow-up. They need their scrip.” Other addicts include “the laid-off deep-hole man with his back and neck bones grinding like bags of gravel…the bent-over lady pulling double shifts at Dollar General with her shot knees and ADHD grandkids to raise by herself.”

Demon and Dori are soon injecting fentanyl. “The kit she took out of her purse. The spoon she used first, to scrape the patch. The lighter she held underneath. The cotton ball, the syringe, pulling the cap off the needle and holding it in her mouth like a nurse giving booster shots.” Demon describes the experience: “If you’ve not known the dragon we were chasing, words may not help. People talk of getting high, this blast you get, not so much what you feel as what you don’t: the sadness and dread in your gut, all the people that have judged you useless. The pain of an exploded leg. This tether that’s meant to attach you to something all your life, be it home or parents or safety, has been flailing around unfastened all this time, tearing at your brain’s roots, whipping around so hard it might take out an eye. All at once, that tether goes still on the floor, and you’re at rest. You start out trying to get back there, and pretty soon you’re just trying to get out of bed. It becomes your job, staving off the dopesickness for another day.”

Dori dies. Demon trying to end his addiction describes withdrawal symptoms: “What I’m discussing is a feeling up inside your blood and lungs, like you’ve been snakebit from the inside. Shivering, loose-boweled, a body you want nobody to get anywhere close to until you can get it fixed…I’d die before I asked for another prescription. But dying felt like an actual option here.”

Health insurance pays for the pills but it doesn’t pay for rehabilitation. Nevertheless, Demon finds a way into rehab, and this is how he describes it: “Rehab is like being married to sickness in a lot of ways, really. Disgust comes into it. You try to deny that, swapping it out for a kindness you may not feel. You fake it till you make it. You watch other people being smug, because they made better matches than you did. You let them say all the stupid things, God never gives you more than you can handle, etc. You get comfortable with vomit.” Demon, just like David Copperfield and Dickens, gets to a good place eventually.

Many non-fiction books have already been written about the opioid crisis with the best of them probably the Empire of Pain, the story of the Sackler family who invented pharmaceutical marketing, developed Oxycontin and other opioids, marketed them unscrupulously, made a fortune, and invested some of it in good causes.23 Other novels will be written about the opioid crisis–something that has killed hundreds of thousands, destroyed lives, and scarred America—but I doubt that many will be better than Demon Copperhead. The book works as a novel just as David Copperfield does—and may last as long.


  • Competing interests: none declared.

  • Provenance and peer review: not commissioned, not peer reviewed.