In early 2016, the Hope Initiative was getting started at right around the same time that Macy began following the story of Tess Henry and her infant son. After getting out of jail while seven months pregnant, Tess worries about giving birth to a child with neonatal abstinence syndrome (NAS), which is a painful state of withdrawal for the children of addicted mothers, and which often requires a long hospital stay. Babies with NAS look like miniature versions of adults with dopesickness.
Tess’s son is born two weeks early but very healthy, with no signs of NAS. He is lucky: many other babies in the hospital need to spend time in the neonatal intensive care unit (NICU) and about 27 percent of babies in the region’s NAS clinic end up in foster care.
Once again, Macy shows how luck and probability play a role in outcomes for addiction. There doesn’t appear to be any good reason why Tess’s son is healthy when so many others aren’t. In such cases, individual stories may be less helpful than the broader pattern, which in this case paints a troubling picture.
Tess’s goal in 2016 is to be a good mother. Her treatment with buprenorphine helps her to feel normal, but although much of her treatment is covered by insurance, the costs add up. In addition, medical-assisted treatment (MAT) clinics can have long waiting lists, and many used to take on more patients than they could handle until a new law passed that caps the number of patients a single doctor can see at 100.
Over the course of researching and writing Dopesick, Macy becomes an advocate for MAT, including buprenorphine, which she explores in more detail later. One of the downsides of MAT is that its effectiveness makes it very desirable and therefore hard to get. The expensiveness and scarcity of MAT form a central part of Macy’s larger critique of the U.S. healthcare system.
Many public health officials consider buprenorphine, a type of MAT, to be the gold standard treatment for opioid addiction, reducing the chance of overdose by more than half compared to just behavioral therapy. Researchers debate how long patients should stay on drugs like buprenorphine—some suggest for at least twice as long as the length of addiction, others suggest for the rest of the person’s life.
While Macy is sometimes skeptical of statements from public health officials (particularly the FDA), she trusts officials who have data to back their claims up, as is the case with MAT. The research about MAT, including the assertion that people should stay on it for life, may seem counterintuitive (since it might seem like the goal is to get people off drugs, not “addicted” to new ones), but Macy shows that sometimes the most logical response isn’t the most intuitive one.
Because of the high demand for buprenorphine and other MAT drugs, there’s also a lot of black market dealing of these drugs, with some even crushing the drugs up to snort or inject them for a high. Overprescribing among MAT doctors remains a problem, and only about half of drug courts nationally even permit the use of MAT.
Though Macy favors MAT, she is also honest about the risks, including the potential for abuse. Macy mentions these risks in order to anticipate criticism for her position (which is somewhat controversial, given the popularity of abstinence-only addiction treatment in the U.S.) and pre-emptively defend it.
Jamie Waldrop and Janine Underwood of the Hope Initiative are opposed to buprenorphine because, based on the experience of their sons, they felt that the drug was too easily diverted to be used for abuse. Tess’s mother Patricia discovers that Tess has figured out how to abuse the drug, having relapsed shortly after giving birth.
Macy shows how disagreement among activists doesn’t have to be a major stumbling block. In fact, Tess’s abuse of buprenorphine even helps justify Waldrop and Underwood’s skepticism for MAT. Importantly, however, Waldrop and Underwood don’t let their personal biases affect their own work too much, and they do keep open minds about MAT.
For many months in early 2016, Macy drives Tess and her baby to Narcotics Anonymous meetings. Though Narcotics Anonymous theoretically approves of MAT, many of the members at Tess’s chapter seem to shun her because of her involvement with the treatment.
Macy reveals that the divide between subject and journalist is not always rigid. Instead of simply observing Tess’s life from a distance, Macy becomes somewhat involved in her recovery. This does not mean that Macy is lax as a journalist (she keeps detailed notes about her sources in the Notes section at the end of the book), but it does show that she believes being an effective journalist might sometimes involve some flexibility.
Controversy over MAT goes back all the way to the birth of methadone, which was created as a synthetic painkiller in German laboratories shortly after World War II. Methadone’s ability to treat opioid addiction was discovered early, but regulatory agencies continued to restrict its use. Buprenorphine and naltrexone were part of a new generation of MAT that were formulated in an attempt to avoid some of the risks of methadone, like its depression of the respiratory system. Naltrexone was first approved in 1984 but didn’t start seeing wide use until a marketing push by its maker in 2012.
As with most things in the opioid epidemic, MAT is not a new concept—it has just recently gained new prominence. It’s unsurprising that regulatory agencies are slow to approve MAT, given the slowness of the federal response to other parts of the opioid epidemic. The popularity of abstinence-only addiction treatment and especially “Just Say No” in the 1980s (which Macy discusses in more depth later) are an important context when it comes to why MAT was (and is) controversial for some.
Research shows that buprenorphine is safer than methadone when taken in excess, but surprisingly, the drug still goes on to have significant value on the black market. Some doctors remain skeptical about all MAT, drawing parallels between the development of heroin in 1898. Macy believes, however, that hardline stances against MAT are the single greatest obstacle to reducing overdose deaths. Despite promises from both the Obama and Trump administrations to expand MAT funding, the treatment options available often depend on local drug courts.
Again, Macy considers the risks of MAT, which can be significant. Still, she looks at things from a utilitarian perspective and concludes that even if MAT has the potential for harm, it has even greater potential for good, and that banning MAT does the most harm. The importance of local drug courts once again highlights a downside of the United States’ disconnected healthcare system, where access to the best treatment options is uneven.
Many in the medical community, including Art Van Zee, express frustration over anti-MAT skepticism, claiming that it prevents doctors from being able to use one of their most effective tools. Van Zee notices with his patients that rushing to wean patients off MAT can lead to relapse, which only furthers the narrative that MAT is ineffective.
Doctors like Van Zee are perhaps among those most likely to trust studies, so it makes sense that he would be an early adopter. The fact that his personal experience matches up with the studies only helps to solidify his position.
Tess goes to a few more Narcotics Anonymous meetings, driven by Macy, but after four, she stops wanting to attend. The journalistic boundary between Tess and Macy blurs, particularly during a moment when Tess sends garbled text messages late at night asking Macy to come get her. Macy ultimately decides to forward the texts to Patricia and Jamie Waldrop, and the subject doesn’t come up again.
While earlier Macy was willing to bend journalistic boundaries for Tess’s sake, the late-night text seems to cross a line for her. Still, rather than ignoring the message, she turns it over to Patricia and Jamie, suggesting that she still feels a moral obligation to do what’s best for Tess, regardless of what a rigid interpretation of journalistic ethics might dictate.
In February 2016, Patricia believes Tess is using again, but her family disagrees about the best treatment methods. Eventually, Tess’s relapse becomes too clear to hide, and Patricia meets with her attorney about the best way to kick Tess out without harming Tess’s seven-month-old son.
The situation with Patricia and her attorney attempting to kick Tess out highlights one specifically heartbreaking moment in Tess’s story. In some ways it recalls the earlier moment when Kristi Fernandez had to put a lock on her bedroom door. In both cases, parents find themselves forced to make painful decisions about what’s best for their kids—often in a situation where there are no good answers. These choices represent part of the human toll of the opioid epidemic.
Tess starts neglecting her son and eventually loses custody, with a judge awarding shared custody to the boy’s grandmothers. Tess moves into a cheap motel with a reputation as a drug haven. To regain custody, she must find a job and a place to live, then prove her sobriety. She struggles to find a doctor for MAT that will accept Medicaid, which she’s currently on.
While Macy is sympathetic to Tess’s situation, she also shows that Patricia isn’t over-reacting and that Tess has become a potential danger to her son. Tess is caught in a vicious cycle where she needs a job to pay for MAT, but the best way to get a job would be to get treatment with MAT. The absurdity of her situation represents the difficulties that many opioid users faced as well.
By May 2016, Tess is couch-surfing and using heroin daily. Her son’s father gets out of jail in early June. They argue violently, and Tess disappears, prompting Patricia and Jamie to worry and file a missing-persons report. It turns out Tess stole a car and credit card, and she is arrested later that day.
As is often the case when an addiction worsens, Tess becomes more estranged from her family to the point that they don’t know whether or not she’s gone missing. Macy doesn’t assign blame; she is trying to portray the tragedy from a perspective that is sympathetic to all sides.
Tess’s son grows to be a toddler without her there to witness his milestones. By fall, Tess is still alternating between the streets, jail, and a women’s shelter. Tess tells Jamie she wants long-term treatment. Jamie knows this period is a critical window: many opioid users only want treatment for a limited period of time. But Tess disappears again before they can meet.
Tess’s absence from her son’s life also shows a growing disconnect from her old self, particularly her old goal of wanting to be a better mother. The critical window of treatment for addiction is yet more evidence for why a slow federal response to opioids is doomed to be ineffective. What people like Tess really need is people like Jamie who can be there to act and respond immediately, although sometimes even this isn’t enough.
The next time Patricia sees Tess is in an ad on a prostitution website. She has been able to covertly track Tess by following her messages on a social media account that Tess forgot to sign out of. One of Tess’s friends, Jordan “Joey” Gilbert, talks about success with naltrexone, before switching to buprenorphine because of naltrexone’s high cost.
Addiction has caused Tess to lose control over her body, and her prostitution ad seems to represent a new stage in this. Patricia’s spying on Tess might be problematic under different circumstances, but given what Macy has revealed so far about their relationship, Patricia’s concern for Tess seems more than justified.
In October 2016, Jamie and Macy visit Tess in a psych ward, where she has checked herself in due to suicidal thoughts. Tess hasn’t seen her son in eight months and has a warrant out for her arrest over a fraudulent credit card charge. She tells Macy, however, that she isn’t using heroin. Jamie recommends an Asheville treatment center for Tess, and Tess seems interested and even hopeful.
Tess’s suicidal thoughts confirm that she is no longer getting pleasure out of her addiction—in fact, it’s the very opposite. It might seem paradoxical that Tess would keep using when she’s so unhappy, but as Macy has shown many times before, dopesickness is a powerful force, motivating people to keep using in order to avoid its painful effects.
But when Tess gets out of the ward, her moment of wanting treatment seems to have passed again. A week before Christmas that year, Patricia plans to mail a card to Tess with pictures of her son in it. She wants to tell Tess about the Beck song “Debra” because it mentions J.C. Penney, and that’s where Patricia and Tess used to go to buy Tess new clothes after a stay in the hospital or rehab. Tess was home for Thanksgiving, but Patricia has mixed feelings about Tess being home because she has to watch out for theft. A week after that Thanksgiving, Tess leaves a note saying she’s had another mental breakdown and checked into a psych ward.
Macy uses this passage to look at some of the specific details of Tess and Patricia’s relationship, showing that they are both far more than statistics, even if their story does follow the same broad patterns as other addiction stories. Patricia’s misgivings about having Tess home for Thanksgiving are particularly heartbreaking because they show how addiction can turn a family celebration into a potential disaster. While sometimes the “geographic” cure can help addicts, for Tess, it doesn’t seem to be enough, since shortly after coming home, she checks into a psych ward again.