Dopesick

Dopesick

by

Beth Macy

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Dopesick: Chapter 13 Summary & Analysis

Summary
Analysis
In 1925, a psychiatrist published some articles suggesting that addiction only affected people born with certain personality defects. He was forced to adapt his views, however, when colleagues showed him that 10 to 15 percent of “normal” patients, including healthcare professionals, could also become addicted when exposed to opioids.
Macy is a big believer in the idea that the past can help shape or even predict the future. In this case, she dives into the history of addiction research to see what can be learned from it. From the very beginning, it is clear that addiction is a contentious topic and that people’s innate biases may lead them to false conclusions.
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In the 1970s, the first MAT drugs were developed, but even today courts are more likely to send users to prison, where getting reliable treatment (particularly MAT) is difficult. While not all patients want or need MAT, Macy believes it is crucial that people have the option.
Macy has indirectly endorsed MAT earlier, by bringing up studies that show its benefits, but here she becomes more explicit in her argument. She has laid the groundwork for this more specific argument through stories like Tess’s, which vividly show the impact MAT can have on a person’s life.
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Macy asks why it took so long for the government to respond to the opioid crisis, with the CDC only issuing voluntary prescribing guidelines in 2016. These guidelines did not solve the issue of opioids being overprescribed, and they also occasionally led to patients with real chronic pain being treated like addicts. 
Since this is the final chapter, Macy recaps many of the themes she’s visited in previous chapters, including her criticism of the federal government’s slow response. She makes it clear that, even as recently as 2016, the issue has not improved.
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To finish her story, Macy looks back to Central Appalachia, where the modern opioid epidemic began. She speaks with nurse-practitioner Teresa Gardner Tyson, who hosts a major medical outreach event called Remote Area Medical (RAM) for the uninsured every year in far southwest Virginia. Macy sees Tyson’s makeshift health camp as proof of the benefits of a single-payer health care system with mental health and substance abuse coverage.
Because the story of the opioid epidemic is often grim, Macy looks to the story of Tyson to provide a somewhat more hopeful ending to her book. Tyson’s enthusiasm is an inspiration to Macy, and her proactive approach to treatment represents a constructive alternative to the stagnant federal government approach.
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Macy interviews Tyson before and after RAM. Macy and other reporters are often surprised by the scale of RAM, comparing it to natural disaster relief in Third-World countries. Though similar poverty and health problems exist in cities, in Appalachia, it’s impossible to conceal the scale of the problem.
Macy’s critiques of the media sometimes include herself; she admits to being guilty of ignoring the scale of the medical crisis in the rural U.S. She shows that this ignorance doesn’t have to be a stopping point—that once people learn about the problem, they can start to help with solutions.
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Macy finds hope while following the story of Tyson, her staff, and her patients. Tyson projects enthusiasm and confidence as she drives around the state in her old Winnebago. Macy watches her help a substitute teacher with a swollen wrist who has just suffered a pay cut due to school austerity measures.
Tyson has a very hands-on approach to treatment. Because the federal government is often reluctant to act, hands-on help like Tyson’s is often sorely needed, particularly in rural areas without the same medical resources as big cities.
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People like Tyson become crucial for filling in the gaps in Virginia’s increasingly frayed safety net. Even the typically optimistic Tyson occasionally finds herself crushed, however, by the news of a patient’s death.
No one is superhuman, and even Tyson faces setbacks and disappointments—what’s important is that these don’t discourage her from doing her work.
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Meanwhile, regional health department director Sue Cantrell is slowly making her own progress. Virginia has recently passed a law paving the way for needle exchange programs (although despite success in West Virginia with a similar program in 2015, the coalfield legislators across the border in Virginia all voted against the measure). Cantrell starts pitching even more ambitious ideas, like “clean living facilities” in subsidized housing, which would place recovering former users in areas with support groups. Other researchers have also noted that a person’s external environment plays a big role in whether they relapse, sometimes referring to a “geographic cure” where people leave the circumstances that cause them to use.
Cantrell advocates for change through more bureaucratic measures than Tyson, but Macy shows that Cantrell’s approach is also valuable. Cantrell has big ideas about how to fix the opioid crisis. While these may seem impractical, Macy has shown that the opioid crisis is so big that it requires big solutions and that sometimes when ambitious goals fall short, they can still lead to smaller, incremental changes.
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Macy contends that the current political response to the opioid epidemic is far from adequate. She proposes a “new New Deal for the Drug Addicted.” Despite bold proclamations about how to fix the opioid crisis from the Trump administration, little is accomplished, although his administration is far from the first to ignore the crisis.
By invoking the New Deal, one of the most ambitious political proposals of the 20th century, Macy is encouraging healthcare reformers to be similarly ambitious. Such a monumental response is the only way to deal with such a monumental problem, she argues.
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In Appalachia, the culture also remains a big barrier to treatment, with addiction still treated with a stigma. For example, a RAM event causes controversy when it’s alleged that a pharmacist gave Narcan training to a local Boy Scout troop without their parents’ permission, stoking fears that knowing how to use Narcan might encourage the Boy Scouts to party harder. Tyson’s mobile health service also faces close calls in dangerous neighborhoods and learns that they have to be careful about where they set up.
While Tyson is celebrated both by Macy and by many in her community, Macy shows that even Tyson can be the subject of criticism. Tyson’s work may not seem particularly controversial, but the passionate responses she receives seem to indicate how controversial healthcare remains in many parts of the U.S.
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Opioids are currently on pace to kill as many Americans in one decade as HIV/AIDS has killed since its inception. Predictions about the end are vague, with some experts tentatively projecting a leveling off sometime after 2020. Meanwhile, 2.6 million Americans are currently addicted.
Most of the specific predictions in Dopesick have been totally thrown off by the COVID-19 epidemic, which drastically changed American healthcare. The statistics here do, however, accurately convey the sheer scope of the epidemic. Macy wants to emphasize that this is a problem all Americans must face eventually.
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In 2017, the Virginia Board of Medicine orders that all doctors must check into a drug monitoring system before giving prescriptions (in order to prevent doctor-shopping). Though Virginia was well behind in its initial response, state officials now begin expanding MAT. The costs of addiction-related illness are high, and they force health systems to integrate addiction treatment with general health.
Macy balances her criticism of the government response to the opioid crisis by noting some achievements that have already been accomplished. Though Virginia is not at the forefront of addiction treatment, it has made progress, perhaps due to the tireless efforts of activists.
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Sister Beth and Art Van Zee find that in the Appalachian Bible Belt, it helps to blend MAT with twelve-step programs (the latter of which are only rarely effective for opioid addiction on their own). They get to know patients who suffer with addiction in their families, some losing multiple relatives to overdoses. Van Zee keeps up a hectic patient load, working 16-hour days, and he carefully guards his own health because of the responsibility he feels to be there for his patients.
Beth and Van Zee demonstrate a flexible strategy of adapting treatment to the specific area where it’s needed. They take a personal approach to treatment, doing something that even an effective, responsive federal government would struggle to do. Macy admires Van Zee’s dedication to his patients, though she portrays him as an exceptional figure and doesn’t suggest that everyone needs to work 16-hour days to combat the opioid crisis.
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Across the U.S., attitudes about drug addiction begin to shift. Neighborhoods of Boston where people once had derisive attitudes toward addicts have now become the testing grounds for new treatment ideas, like reverse-motion detectors in public bathrooms that call for help if a person hasn’t moved in four minutes. Though some locals resist new programs, even in liberal neighborhoods, activists manage to win over some skeptical community leaders by explaining the benefits of treatment at public meetings.
Macy gives the example of Boston to show how people’s attitudes can change over time, particularly when they are presented with clear evidence of the effectiveness of new solutions. She doesn’t downplay the challenges faced by activists, but she does show how the challenges they face aren’t insurmountable, particularly if they have evidence on their side.
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Even in Appalachia, harm reduction begins to catch on as a method of drug treatment. Schools move away from the DARE model, which studies have proven is ineffective. Some addiction activists suggest that the real problem isn’t the individual choices people make but the social and economic conditions that make certain people more susceptible to opioid abuse.
DARE is a program founded in the 1980s that is used to teach children about drug abuse. It is often associated with hardline positions like “Just Say No” and zero tolerance enforcement. Macy disapproves of DARE, not because she disagrees with its stated intentions but because she believes the program is misleading and ineffective. Her disapproval of DARE shows that she believes it is important to clearly and correctly identify a problem before moving to the solution; for her, DARE does not adequately grapple with the nuance of drug addiction.
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Reflecting on what she’s learned over the course of her book that makes her feel hopeful, Macy thinks of people like Sue Ella, Tyson, and Cantrell, who use the strength of community to combat the epidemic.
Macy tries to move beyond negativity and pessimism—which can fatigue and discourage people—by giving a spotlight to people whose work she admires.
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Macy looks at the work of Dr. Steve Lloyd, a former opioid user who has become a charismatic leader against drug abuse. He credits his own recovery to a rigorous five-year model of intense monitoring, which is commonly used for addicted doctors and pilots. Though this method may not be feasible for widespread use—it cost Lloyd $40,000—it also has recovery rates of 70 to 90 percent.
Lloyd’s case shows that there are, in fact, already highly effective treatment programs out there—there problem is that the vast majority of people just can’t afford them. Macy leaves open a question: while offering this type of treatment more widely would be expensive, would it really be more expensive than dealing the effects of the opioid crisis?
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Lloyd repeatedly argues that MAT is an essential part of treatment, particularly since many patients are limited to 28 days of residential treatment, which has been proven to be far too short for most people who need treatment. One woman confronts him at a meeting to ask, “Just how many chances are we supposed to give somebody?” This attitude is fairly common, with many leaders bemoaning the taxpayer cost of treating people with addiction problems. Lloyd responds with a quote from the Bible: “Seventy times seven.” Macy concludes that if the federal government won’t step in to save Appalachia from the opioid epidemic, “Appalachia would have to save itself.”
In the Bible, when Jesus is asked about how many times a sinner should be forgiven, he replies seventy times seven times. (The number generally isn’t interpreted literally; it’s more often interpreted as some very large, uncertain number that suggests God is forgiving). Lloyd quotes this Bible passage to emphasize that, while people with addictions may not be perfect, Jesus advocated mercy for sinners and so anyone who believes in Jesus should offer a similar mercy. Macy ends the book proper by clearly restating one of her main arguments: since the federal government seems to be incapable (or at least unwilling) to fully address the opioid crisis, local community leaders will have to do the job on their own.
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