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Chapter 12
Themes
Key
LitCharts assigns a color and icon to each theme in Dopesick, which you can use to track the themes throughout the work.
Poverty as an Obstacle to Recovery
Cycles of History
Race, Healthcare, and Criminal Justice
Fighting the Medical Establishment
The Value of Science
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.
Themes
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.
Themes
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.
Themes
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.
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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.
Themes
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.
Themes
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.
Themes
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.
Themes
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.
Themes
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.
Themes
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.
Themes
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.
Themes
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.
Themes
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.
Themes
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.
Themes
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.
Themes
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.
Themes
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.”
