where you have one individual who seeds that community and then the spread begins,” said Dr. Anna Lembke, an addiction-medicine specialist at the Stanford University School of Medicine and the author of Drug Dealer, MD. People whose parents or grandparents were drug- or alcohol-addicted have dramatically increased odds of becoming addicted themselves, with genetics accounting for 50 to 60 percent of that risk, Lembke explained; she noted that the correlation between family history and depression is much lower, 30 percent. Other risk factors for addiction include poverty, unemployment, multigenerational trauma, and access to drugs.
“It’s important to note, it’s really not just the unemployed and the poor who are vulnerable today; it’s really everybody, especially underchallenged youths or youths who aren’t engaged in school or other meaningful activities,” Lembke said.
At the age of thirteen, Spencer had stolen five bottles of painkillers more than halfway full—leftovers prescribed to different relatives in the aftermath of routine outpatient surgeries. By fourteen, he was taking pills regularly. Back then he used saved-up lunch money to buy weed, which he then traded for ADHD medications prescribed to his friends, or for OxyContin pilfered from their parents’ medicine chests.
“I did my first bag of heroin before I drank my first bottle of beer,” Spencer said.
In his Hidden Valley subdivision, full of sprawling ranches, trim colonial two-stories, and Arts and Crafts bungalows that were new but meant to look old, heroin was easier to get. “When we first started doing it, we didn’t worry about getting caught because cops didn’t know what heroin even looked like.
“One time I got pulled over, I had ten bags at my feet, and they didn’t know what it was so they didn’t look at it.”
*
In rural America, the opioid epidemic aged into a wily adolescence in the aughts. In the hinterlands of Virginia, it had tended to pool in families. “We’d sometimes have one overdose where the son would die, then the next day the father would die, then the next day the mother would die,” the Roanoke-based medical examiner said. “If it had been an infectious disease, there would have been widespread panic.”
Then–Virginia Tech researcher Martha Wunsch remembered the moment she went from studying overdose deaths in rural counties, funded by a National Institutes of Health grant, to hearing about it from her own teenagers, who went to high school with Spencer and Scott Roth. State health officials in Richmond had originally dismissed her research, telling her the same thing they’d said to Sue Cantrell, the rural health-department director: “This is a regional problem.”
“The issue is Interstate 81,” Wunsch told me. “The OxyContin epidemic spread from East Nowhere Jesus all up and down the Appalachian chain by way of the interstate, and suddenly my own kids were coming home from parties,” talking about pills being passed around in bowls.
Opioids infiltrated the toniest suburbs not by way of families but by peer groups. The new suburban users didn’t come to the attention of police until roughly around the time Purdue Pharma launched its 2010 abuse-resistant version of the drug, at the same time Spencer handed Scott Roth the heroin that led to his death—fourteen years after OxyContin was introduced.
*
In Roanoke, the urban hub for the western half of the state, I-81 perches at the edge of the northern suburbs. It rolls and undulates, connecting western Appalachian communities from Tennessee to Virginia as it travels northeast around Roanoke and up through the northern Shenandoah Valley, intersecting with other interstates leading to Baltimore and Washington, New Jersey and New York.
One of the most segregated cities in the South, Roanoke had long had a steady but largely quiet group of heroin users in its urban core, which positioned it to become an ideal transfer station for the region’s transition from dope to pills, then back to dope. It was the perfect incubator for the opioid epidemic—a cultural and geographic crossroads. It was big enough for users to easily forge drug connections and yet small enough for the drug dealers to hide out.
Some dealers, traditionally ensconced in the city’s poorest, northwest quadrant, were beginning to migrate to the more affluent neighborhoods of Hidden Valley and Cave Spring, one heroin task officer told me—to avoid robberies and home invasions.
“As long as it was in the lower economic classes and marginalized groups, like musicians and people of ethnic minorities, it was OK because it was with those people,” said Spencer’s counselor, Vinnie Dabney, an African American who took his first sniff from a bag of heroin his sophomore