Ammad Butt is an FY2 doctor and writer commentating on the NHS and health policy based in Birmingham. His words can be found in national newspapers such as The Guardian, The Independent, and i Paper, as well as political magazines such as The Spectator and UnHerd. He is an awardee of the 2025 Wellcome Collection Non-Fiction prize for his book proposal, The International Health Service. He is on X: @ammadbutt_
I have always found the best books in life are those where the characters continue to live with you for months, even years after the fact. They become individuals who exist in the same universe as you, since their stories are so apt. There are many examples that come to mind like this — for better or worse Hanya Yanagihara’s A Little Life, Charlotte Bronte’s Jane Eyre, or more recently Sally Rooney’s critically acclaimed Intermezzo. When I saw the copy of Barbara Kingsolver’s Demon Copperhead sitting on the square stack of books in Waterstones, I was naturally skeptical; ‘No.1 reader’s pick for the book of the century’ and ‘Pulitzer Prize winning’ — quite the praise. In the months that have followed since finishing the novel, I can now see why — it is simply brilliant, and the characters in it have been a regular part of my thoughts since.
Broadly a retelling of Charles Dickens’ David Copperfield, Damon Fields is a child born into absolute poverty and heartache; even his journey from the womb to birth is a story of turmoil. He is referred to as Demon due to his attitude, and his bright ginger hair inherited from his late father, likened to the copperhead snake — hence the name Demon Copperhead. Set in Lee County in the Appalachian Mountains of Virginia, Demon navigates life surrounded by drug abuse. Kingsolver’s choice was not random however; as a resident of Appalachia herself she knew of the real-life stories places like Lee County face and it encapsulates the opioid crisis like few regions in the world.
“Opioid prescriptions doubled from 1998 to 2018 in the UK, and in 2019, the UK had the highest rate of opioid consumption in the world.”
Once a thriving coal-mining town, it was bustling with life and graft, a symbol of the American dream and getting by. Once the mines ran dry there was little left in the town and incomes began to struggle — deindustrialisation en masse seen across the West throughout decades gone by overseen by Ronald Reagan. Worn out labourers sickened with work-related disease sought ailments for their pain management. It was pharmaceutical companies like Purdue, who targeted areas like Lee County with their drug representatives to prescribe OxyContin and doctors followed on, blind to the potential harm it could bring.1
Kingsolver chooses the character Kent, who is a pharmaceutical representative and boyfriend of the heroic character Aunt June, a nurse who looks after Demon, to represent the pharmaceutical companies who predate on the vulnerable. Despite the whole town loving Kent, June soon falls out of love with the idea of Kent after realising the malignancy posed by him and the pharmaceutical companies that slowly seep through the youth of Lee County, describing him as a ‘hired killer’ for his company. It is the likes of Kent, who persuades, and Dr Watts, who prescribes painkillers for Demon after an injury playing football, that leads to his horrible addiction.
In an interview with the Financial Times,2 Kingsolver states: ‘Nobody chooses this life … Every single person I talked with started with a prescription from a doctor, with instructions; take this every four hours, set an alarm so you won’t forget’. This is true of Demon’s path to addiction, and by no fault of his own. We know as clinicians that often circumstance and social deprivation lead to adverse health circumstances, be it obesity, heart disease, and/or psychiatric disorders, and addiction is no different. Studies have shown children who have parents with substance-use disorder are at much higher risk themselves of developing one.3,4 Demon’s mother battles substance abuse from the beginning of the novel until her early death, and despite his upset at her, his treading down that path was an inevitability.
It is only when Demon is introduced to Dori that we really see the visceral impact of addiction. In true Dickensian fashion, Kingsolver’s descriptive elements bring the novel to life in ways academic textbooks or clinical articles cannot. One line describing Dori’s eyes as ‘shiny black like deep water’ where Demon ‘wanted to go skinny dipping in there’ is a personal favourite. But things turn sour quickly, and Kingsolver’s portrayal of opioid addiction is simultaneously terrifying and brutal.
We slowly watch Dori, who uses the pills prescribed to her dying father, become addicted and bring herself to a slow malaise injecting fentanyl with Demon before passing away unable to cope with grief; Demon’s difficulties managing car journeys, breaking out in nauseating sweats without a hit; and the many descriptions of her and Demon, watching themselves become thin, the constipation, and subsequent vomiting, are harrowing and provide an insight that clinicians often forget when treating patients who are suffering from addiction.
“… Kingsolver’s portrayal of opioid addiction is simultaneously terrifying and brutal.”
It is also a reminder of the benefits of the NHS compared to the American healthcare system, which incentivises profits of pharmaceutical companies. Dr Watts is later found to be running a dodgy pill clinic, something which would be virtually impossible to run in the NHS currently, which in fairness is a stark comparison of the issues private health care brings — especially in a time where the NHS as an institution is being doubted.
Financial incentive as a rationale for clinical decision-making lacks morality, which health care inherently is based on, and in a time where many doctors doubt the purpose of the NHS in achieving the best outcomes for patients (for many good reasons), this fundamental concept is still one of the greatest examples of just treatment for all.
This isn’t to say the NHS does not suffer from an opioid crisis, over our side of the pond we similarly face a problem with prescriptions for opioids. Opioid prescriptions doubled from 1998 to 2018 in the UK,5 and in 2019, the UK had the highest rate of opioid consumption in the world.6 Chronic pain remains common and yet poorly understood, hence many patients are offered opioid prescriptions. Characters like Dr Watt show the harm that clinical professionals can do, somewhat ironically from intended aim. Even within the NHS, how often are hard-hitting addictive drugs from opioids to zopiclone prescribed, without truly thinking of the long-term detriment it can cause to patients? We so often acquiesce and prescribe.
Demon goes on to describe his situation as the following:
‘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.’
These lines have stuck with me since finishing the book. Patients so often have to live with the health consequence of not only their predisposition, but of what other healthcare professionals have put them through. Whether it is mistakes in clinical practice or prescriptions that are made without knowledge of the full consequences of what regular use can do, we should all think twice when judging who comes through the front door of the practice, and try to operate within the aims of long-term benefit rather than convenience.
Featured book: Barbara Kingsolver, Demon Copperhead, Faber and Faber, 2023, PB, 560pp, £9.99, 978-0571376483
References
1. McGreal C. ‘I don’t see how it ends’: expert sounds alarm on new wave of US opioids crisis. The Guardian 2024; 28 Jan: https://www.theguardian.com/us-news/2024/jan/28/us-opioids-crisis-fentanyl-appalachia (accessed 5 Jun 2025).
2. Darbyshire M. Barbara Kingsolver: ‘Everyone has friends impacted by the opioid crisis’. Financial Times 2023; Jan: https://www.ft.com/content/9a0f18ca-2dd5-470a-a978-d7a7a166c999 (accessed 6 Jun 2025).
3. Yule AM, Wilens TE, Martelon MK, et al. Does exposure to parental substance use disorders increase substance use disorder risk in offspring? A 5-year follow-up study. Am J Addict 2013; 22(5): 460–465.
4. Parolin M, Simonelli A, Mapelli D, et al. Parental substance abuse as an early traumatic event. Preliminary findings on neuropsychological and personality functioning in young drug addicts exposed to drugs early. Front Psychol 2016; 7: 887.
5. NHS England. Opioid prescribing for chronic pain. https://www.england.nhs.uk/south/info-professional/safe-use-of-controlled-drugs/opioids (accessed 5 Jun 2025).
6. Roberts A-O, Richards GC. Is England facing an opioid epidemic? Br J Pain 2023; 17(3): 320–324.
Featured photo by Etactics Inc on Unsplash.
