All tragedies have heroes. Obvious heroes, complicated heroes, reluctant heroes: The genre demands them. When grief does not belong to us, we sometimes struggle to see it clearly. A hero lets us empathize safely; we can even believe that our troubles are not as individually peculiar as they sometimes feel to us. Reporting can have the same virtues, and that is the case with Dopesick, author Beth Macy’s examination of the opioid crisis in southwest Virginia.

Dopesick is nonfiction, but it unfolds like a tragedy, in a place that receives little national attention outside of election years. Mostly Appalachian and often poor, southwest Virginia is a region Macy knows well. She’s based in Roanoke and formerly reported for The Roanoke Times; Dopesick is not, in other words, the work of a distant observer. Macy, also the author of Truevine, about two African-American albino kids forced to perform for the circus in Virginia at the turn of the last century, is reporting from within her own community, which makes for a sensitive and informed book. She even writes of having found her subjects by word of mouth, a reflection both of that insider status and of the respect she’s earned from her community throughout her career.

The result is a thoroughly clear-eyed and humane book. Dopesick sometimes feels like true crime; at one point, Macy picks apart a 2013 police investigation into a major drug ring. But she is most invested in addiction’s individual Armageddons, which creep through the hills of far southwest Virginia and then through the relatively affluent suburbs of Roanoke. Roanoke is a small city, but southwest Virginia is a mostly rural place. Lee County, where Macy starts her narrative, is coal country. Sparsely populated, conservative, and poor, it’s the sort of place that would form the backbone of a “Trump Country” piece in some national outlet.

If you grew up in rural southwest Virginia, as I did, you’re familiar with one particular resentment: Outsiders think Virginia stops at Roanoke. Hedged by mountains and ringed by coal to the west and the north, southwest Virginia can be beautiful or isolated or sometimes both in equal measure. The opioid crisis has focused some unwelcome new attention on the region. First came meth, which bloated the county jails and split families and blew up motel rooms all along Lee Highway. By the time I entered public high school in the early aughts, pills felt similarly omnipresent. The sickness spread everywhere.

Dopesick’s great revelation, in other words, is not that southwest Virginia has a pill problem. It is that despite the tragedy, despite the despair, there are also heroes in this story. This may be news to the casual observer, although it is no revelation to anyone from there. Macy introduces us to the area and to the crisis in the character of Art Van Zee, a Lee County doctor who quickly realizes that new pain-relieving drugs are more addictive than Purdue Pharmaceutical had originally admitted. With Purdue and other large pharmaceutical companies as villains, Dopesick initially seems like a straightforward iteration of David versus Goliath, and some of its most compelling moments do pit the people of southwest Virginia against conglomerates that possesses nearly unthinkable wealth and power.

Van Zee and his wife, Sue Ella, make up part of a local coalition that challenges Purdue on its misleading advertising in the early 2000s. When Oxycontin came on the market in the late 1990s, Purdue promised would-be prescribers that the drug did not pose a significant addiction risk. This is hardly the first time a corporation has lied about its product’s health risks; as we all know now, tobacco companies once insisted that there were no links between tobacco and lung cancer. On the ground, though, the extent of Purdue’s falsehoods was immediately obvious to Van Zee. Macy reports that within “two years” of Oxycontin’s release, “24 percent of Lee High School juniors reported trying Oxycontin, and so had 9 percent of the county’s seventh-graders.” In 2000, Van Zee wrote Purdue’s medical director to urge him to take action.

When local pressure began to mount in 2001, Purdue essentially shrugged. “The issue is drug abuse, not the drug,” one spokesman said in a meeting with community members. The corporation’s refusal to admit culpability or substantively alter its practices infuriated locals. “You have done more to hurt Appalachia than the coal industry has ever thought about doing,” Sue Ella told Purdue’s bewildered medical director. There are indeed a few passing similarities between Purdue and coal: Coal had its barons, and Purdue has the Sackler family, an art-loving clan reportedly worth a net $13 billion. Coal enriched its tycoons. Oxycontin enriched the Sacklers. Coal gave people work. Oxycontin allegedly gave them relief from pain. But while the coal industry extracted resources from the land and labor from the people who lived on the land, Purdue accomplished a particularly sinister feat. It extracted something essential from the people themselves: their will.

Nancy Reagan’s old slogan, “Just Say No,” sounds simple enough to make a certain deceptive sense. Patients in pain could reject Oxycodone. Teenagers could refuse to try it for fun. And an addict could, in theory, just stop taking the drug. But like abstinence-only sex education, “Just Say No” fails because its believers adhere to a two-dimensional view of human nature. A patient will listen to her doctor if he recommends a drug. If they’re told a drug feels good, teenagers in every city and small town in America will try it, and so will plenty of adults. And if some communities are more predisposed to it than others, it’s not due to any inherent flaw in the people living here. In places like Lee County, Virginia, the prevalence of strenuous blue-collar work has meant worn-down bodies and chronic pain, dry tinder for substance abuse.

As Macy documents, the introduction of Oxycodone was a match to that tinder. Yet, once again, despite their economic disadvantages, a federal legal team that local advocates affectionately called the “hillbilly lawyers” filed a lawsuit against Purdue Pharmaceutical for false advertising practices in 2005. The case, which unfolded in an Abingdon, Virginia federal courthouse, did not end quite the way that Van Zee and other local advocates had hoped. A federal judge levied a fine of $634.5 million on Purdue itself and a fine of $34.5 million on three Purdue executives. The same executives each received three years of probation and 400 hours of community service. But not one person went to prison for essentially poisoning the residents of Lee County.

Despite the lawyers’ valiant efforts, the court’s verdict also did not stem the opioid crisis. It had already spread to the suburbs of Roanoke, where it ignited community panic, along with a good degree of shock. Addiction embedded into the student life at Hidden Valley High School in Roanoke, a phenomenon Macy also recounts in wrenching detail. Star athletes succumbed to temptation and friends sold drugs to friends, sometimes with life-ending consequences. In Macy’s telling, addiction grows into a tumor-like presence in the lives of her subjects, It reaches inward, and rearranges the furniture inside a person’s mind.

Addiction’s transformative qualities are particularly clear in the case of Tess Henry, whose story threads in and out of Macy’s narrative. The daughter of a surgeon and a nurse, she was a track star and aspiring poet. But after a doctor prescribes an opioid to treat a painful case of bronchitis, her life unspools. When Henry runs out of medically prescribed pills, she’s desperate for more, so she procures them illegally through the boyfriend of a friend. Macy writes that several months into Henry’s addiction, the DEA reclassified hydrocodone-based drugs, which according to Henry made the pills more difficult to access. She then turned to heroin. Though she remained functional at first, her addiction grew. Eventually, she became unable to care for her young son.

Henry found some relief through medication-assisted treatment (MAT), a controversial but often effective treatment for opioid addiction. Medications like methadone, buprenorphine, and naltrexone reduced the physiological symptoms of addiction like cravings, and helped blunt the feelings of euphoria provided by heroin and pain pills. But they’re often difficult to obtain, as Henry discovered. She struggled to afford the medication, and using it made her ineligible for some other treatment programs. She bounces from jail to psychiatric wards and then, as her life enters a particularly precarious phase, she is murdered. In a book that is as much about grief as it is about corporate greed, Henry stands out as its tragically doomed heroine.

As she documents Henry’s saga, Macy sometimes blurs lines between reporter and family friend, though never to a degree that violates an ethical standard. Henry reaches out to Macy frequently over the course of the latter’s reporting; throughout, Henry seems needy, often frightened, as she spirals downward into an abyss. It’s a difficult narrative that Macy plots with grace. Yet it also invokes a certain void, one that Macy did not create. She was perhaps simply unable to do it full justice in the course of just one book, in which so many other stories are also interwoven.

Stories of drug addiction are, as I’ve said, tragic by nature. But too rarely now do we truly frame them this way. We’re far removed from tales of graceful, white Victorian women succumbing to the temptations of laudanum. Drugs, and the wars we wage on them, are racialized: We blame addiction on culture, on broken families, on sloth. Presidential administrations from Reagan to Clinton have wrapped drug abuse into policies designed to make them look tough on crime; Republicans have now proposed drug-testing welfare recipients, reviving these old stereotypes, if they ever left to begin with. “Just Say No” is not a simple mantra we all have an equal chance to follow. It’s an excuse to punish individuals who fail to live up to its exacting standards. Both obvious heroes and villains rarely exist in the real world, but we’re often far too happy to lock addicts into the second box. Dopesick complicates these simplistic narratives.

Abstentionist drug policy creates gaping holes through which entire communities have been falling for decades. Applied to communities of color, it splits up families and leads to disproportionately high rates of imprisonment. In turn, it reinforces racist prejudices about sloth and hedonism and broken cultures. It ignores, too, the structures that can propel a community into a full-blown drug crisis. Poverty inflicts well-documented psychological burdens that influence individual decision-making, and policing can perpetuate the cycle. As Vox reported in 2015, drug-related arrests in Chicago correlate closely with the city’s poorest neighborhoods. The trend isn’t limited to Chicago, either. The same correlation occurs in San Francisco and Baltimore, among other major cities.

There are Tess Henrys in each of these places—bright young women trapped in webs they can’t escape from. If the daughter of a surgeon can’t access MAT regularly enough to save her life, then the odds aren’t good for anyone. Expanded, well-subsidized access to MAT would not end addiction, and neither would stricter federal penalties for the sort of deceptive advertising that Purdue practiced. But these changes would at least slow the current crisis, and create a deterrent for other pharmaceutical companies that may be eager to repeat Purdue’s financial success, to everyone’s peril.

A clear byproduct of the racism and insipid moralizing of the war on drugs, the emphasis on drug abstinence has become an excuse for voters and officials alike to block clean needle exchanges, methadone clinics, and other programs that provide addicts with the material help they need to recover. Dopesick, therefore, accomplishes something American drug policy hasn’t: It presents addicted persons as morally complex, fully formed human beings whose problems have medical and political solutions.

It should not have to be such a radical thing to assert the humanity of people who are addicted to drugs. It should not be shocking, either, to find out that people fight back when plagues like opioids hit their neighborhoods, whether they live in the coalfields, the inner-cities, or the suburbs. But while there is no monolithic “opioid story,” not in southwest Virginia or anywhere else, one common truth anchors this narrative: Stories about the opioid crisis are stories about power dynamics. There is no other way to explain why MAT remains so difficult to access, even though multiple peer-reviewed studies have proved its efficacy as a treatment for addiction. As Vox reported in 2017, the federal government caps the amount of buprenorphine a doctor can prescribe per year. And while some federal legislation has been proposed to lift the buprenorphine cap to increase the number of non-opioid painkillers on the market, as well as to bolster the DEA’s ability to review opioid shipments, StatNews reported in 2018 that drugmaker lobbyists had successfully convinced legislators to weaken or abandon these proposals.

The story of David versus Goliath does not become a tragedy unless Goliath survives and David dies. Unfortunately in this story, Goliath endures despite the efforts of advocates like Van Zee.

In the Brooklyn Museum’s Elizabeth A. Sackler Center for Feminist Art, Judy Chicago’s The Dinner Party squats low in a cavernous hall. It’s difficult, at first, to discern exactly what’s in front of you. Inch closer and you realize you’re looking at a table. At each empty setting sits a plate inscribed with the name of some famous female of a bygone era: Sappho, Christine de Pisan, Emily Dickinson. Underneath the table are 999 more names, etched in gold on tiles as white as Oxycontin pills.

Elizabeth Sackler, I later learned, claims that neither she nor her children have benefited from the sale of Oxycontin. But The Atlantic reported in April that Sackler’s claims are not entirely accurate. The estate of her father, Arthur Sackler, received a $20 million payment from Purdue one year after Oxycontin first hit the market. Elizabeth is not an heir to the estate, but her children are. It’s not completely clear if the Purdue money came from Oxycontin sales, as The Atlantic noted at the time, but the possibility is real. The Sacklers are known for their philanthropy in the arts, but it seems their definition of charity is a narrow one. Southwest Virginia has certainly seen little of it.

The Atlantic pulled the bulk of its reporting from court documents filed in Abingdon, Virginia; that long-ago, ill-fated court case still bore fruit. It is small justice. Judy Chicago will never put out a plate for Tess Henry. Tess is lost, a casualty of a crisis she didn’t start. How many others have we lost along with her? How many generations did Purdue take from our rolling country hills, our small towns, our cities? We call the opioid epidemic a public health crisis, and this is accurate, to a point. The health of the public does suffer. We are all dopesick, whether we are Sacklers, or whether we hail from Roanoke or Philadelphia or the hinterlands of Maine, all places where opioids have now rooted themselves deep into communities. We cannot cure ourselves until we see the dimensions of this tragedy for what they are. This is not an epidemic, but a theft. And theft is a crime.