Tess’s loved ones create a five-page spreadsheet that they hope will guide her recovery. It’s early 2017 and fentanyl continues to lead to significantly more overdoses than usual.
The spreadsheet that Tess’s loved ones put together represents their attempt to control a situation that often feels out of their control.
Janine Underwood is still grieving the death of her son, Bobby, to fentanyl, but she puts a lot of energy into the Hope Initiative. She remains skeptical of MAT but tries to keep an open mind. She supports bills to involuntarily commit users, but these raise civil liberties concerns, and some experts think they may backfire.
Fentanyl is yet another step in the cycle of opioid history, just like morphine was stronger than opium and heroin was stronger than morphine. Underwood’s opinions show that she disagrees with Macy on some important points, but while Macy may not believe Underwood’s solutions are optimal, she still portrays Underwood’s commitment as admirable.
Twenty-two people walk into the Hope Initiative for treatment, but at first, none have entered residential treatment. The first big success for the initiative comes when they do finally set up their first residential patient, overcoming significant bureaucratic obstacles (for example, it is usually difficult to transfer a patient from the emergency room to detox without a waiting period in between).
Despite the Hope Initiative’s good intentions and the real need for better opioid treatment, progress is still slow. Still, slow progress is typical for opioid reformers and Macy shows how the initiative begins to help people in spite of all the obstacles.
In late 2016, Virginia’s state health commissioner declares the opioid crisis a public health emergency. This means anyone can now buy Narcan (a drug that can reverse the effects of an overdose). Other cities, however, like Vancouver, British Columbia, are even more proactive. They offer supervised injection sites and provide clean needles, on the theory that this is more humane and cost-effective. Some more progressive American cities begin using Vancouver as a model.
While Virginia’s recognition of the opioid crisis is important, Macy is quick to point out that other parts of the world have already taken much stronger action. Perkins got inspiration from Massachusetts, and here, Macy suggests similarly that eager reformers in the United States might look to methods that have been tested in Vancouver.
Harm reduction policies and movements to end the stigma against addiction pick up momentum across the U.S., from San Francisco to Philadelphia. Still, there are not enough resources to treat all the people who need it.
Similar to MAT, harm reduction often seems counterintuitive but is in fact arguably the best way to improve the lives of people dealing with addictions, at least based on the most recent data. People’s opinions on MAT and harm reduction tend to be linked, either favoring both or disapproving of both. (Macy favors them.)
Macy feels that the disagreements between the criminal justice establishment and the families of people struggling with opioids (like Tess) seem to only be getting more severe. Particularly during the Trump administration, government officials begin moving toward zero tolerance drug policies, prioritizing punishment over treatment.
While Macy sometimes avoids making political statements that could alienate parts of her audience, she is clearly taking a stand against zero-tolerance drug policies that put punishment over treatment.
Even among Hope Initiative members like Janine, the harm reduction approach to opioid treatment is controversial. Still, she tries to keep an open mind. Within the first few months of the Hope Initiative, they see 57 people, referring about 15 to outpatient MAT programs and admitting two to residential treatment.
Janine’s willingness to refer patients to MAT programs, even though she herself doesn’t support them, suggests that her intentions are in the right place: that she is willing to put the potential welfare of patients above her own beliefs when needed. (The situation is a little different for someone like Van Zee, who is a trained doctor, and who is therefore better qualified to make his own decisions about the health of patients.)
Tess remains in contact with the Hope Initiative but is not among its success stories. In early 2017, she doesn’t seem close to being ready to accept help, according to Patricia. She is back in a psych ward, weighing 90 pounds and with hepatitis C.
While Macy praises the Hope Initiative, she shows that even the best-intentioned organizations have their limits. In this case, Tess represents a case where even the Hope Initiative couldn’t help. Her poor health foreshadows an ominous future for her.
Patricia and Jamie arrange it so that Tess can go immediately from the hospital to treatment in Nevada, knowing that otherwise Tess will change her mind again. After being transferred to a new facility shortly after arriving, Tess seems to settle in. After a month, she seems to be doing very well, ready to transition to aftercare.
Like many people struggling with addiction, Tess cycles though healthier and less healthy phases. Sometimes a sudden shift helps start a new phase, and in this case, the trip to Nevada seems to do the trick. Macy again uses Tess’s story as a lens through which to view how treatment needs to be tailored to the individual patient, because different people will respond to treatments differently.
At the Hope Initiative, attention now turns from Tess to Tess’s friend Joey, who is in a similar situation. Joey tries to appear sober but continues to use and even invites a drug dealer and his girlfriend to live with her. In March 2017, Joey faces similar treatment barriers to Tess, with long wait lists for expensive treatment. Joey tries to wean herself off MAT, believing it will make it easier for her to get accepted for treatment.
Joey’s experience helps highlight both what is typical about Tess’s addiction experience and what is unique. In particular, Joey’s struggles to get treatment show that this is a much larger issue than the specific problems that Tess faced with getting treatment.
Joey is nearly through her weaning before rehab but she’s struggling. She calls her parents, who are traveling, and says she just had a major fight with her boyfriend. Later, she texts her father and asks for $4 to get a pack of cigarettes. The next morning, they get the news that Joey has died of a fatal overdose, after lying around for almost eight hours before anyone called 911.
The text asking for $4 for a pack of cigarettes represents a hyper-specific detail that makes Joey’s story feel more personal and wrenching. Tragically, however, Joey’s death and her lies to her parents are both a common feature of addiction stories.
At the memorial service, Patricia is moved by Joey’s family. She can’t help wondering how she would feel if it were Tess’s funeral instead of Joey’s. She already knows where she will sprinkle Tess’s ashes if she needs to.
Though parents are sometimes in the dark about the specifics of their children’s activities, Macy shows that Patricia is far from naïve. She is already prepared for the possibility of Tess’s death.
Six weeks later, Patricia intercepts a message between Tess and a drug dealer in Las Vegas. She sends her daughter a letter to express her disappointment. Tess texts her on Mother’s Day 2017: “I love you. But this [is] bullshit all of it.” She promises to find a way home.
Patricia is in a difficult situation—her choice to send a letter to Tess makes Tess angry, but there would also have been consequences to staying silent. Macy shows how one of the scariest aspects of addiction is that it causes people to lose control: people on opioids lose control of their lives, and their loved ones lose the ability to do much about it.