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"Into the Sun 40, 2009." Varnished pigment inkjet print by Elijah Gowin. © The artist. Courtesy Robert Mann Gallery

Issue 118, Fall 2022

Hope After "Dopesick"

Last summer Beth Macy and I overlapped by a few days at the artist residency the Virginia Center for the Creative Arts. At least, her name was on the list of residents: I hadn’t seen any sign of her—not at dinner or lunch, or walking the grounds. I asked around. Maybe she’d left early? A painter told me, “Oh, I don’t think she comes to dinner much. She’s on a deadline.” An admirer of Macy’s investigative journalism on the opioid crisis, I was eager to meet her. Back at my studio, I messaged Macy on Facebook, and she immediately wrote back that she’d come to dinner tomorrow. She was on deadline, she explained.

Macy has been working on deadline for over thirty years. She was a staff writer for the Roanoke Times for twenty-five years, reporting on social issues and marginalized communities that led to writing 2014’s Factory Man, on economic dislocations caused by globalization, and the New York Times bestseller Dopesick: Dealers, Doctors, and the Drug Company that Addicted America, from 2018, on the opioid crisis. The Hulu TV adaptation of Dopesick, for which Macy was an executive producer and co-writer, premiered in 2021 and stars Michael Keaton and Rosario Dawson. The TV series captures the realities of Appalachia and opioid addiction with complexity and compassion, while also dramatizing the Sackler family’s role in flooding rural America with OxyContin. Macy is also the author of Truevine, which tells the story of a racially motivated kidnapping in nineteenth-century Virginia.

The next evening, the setting sun turning the sky shades of silver and pink, I sat at Macy’s table with several other writers and artists, and we talked about politics, COVID, and our creative work. Macy was easygoing and a nimble conversationalist—she drank a beer and talked about writing and researching her new book, the one she was on deadline for and which she described as more hopeful than Dopesick, but still dark. Macy was warm and quick-witted, and sparked with the restless energy of a curious mind. After dinner, she swiftly headed back to her studio. She wanted to spend more time hanging out, she said, but she had that deadline. I imagined that even without a deadline, Macy would be working—she had that kind of dogged energy, a commitment to telling the story she needed to tell and finding the right words. I didn’t see her again at the residency; she likely spent nearly every waking hour writing and editing her most recent book, Raising Lazarus: Hope, Justice, and the Future of America’s Overdose Crisis

In Raising Lazarus, the follow-up to Dopesick, Macy examines the opioid epidemic through multiple threads, following the legal trials of the Sackler family, and the efforts of the activists working to hold them accountable. Macy also reports on outreach workers across Appalachia and the rural South tackling the opioid crisis with innovation and action—and trying to stop overdose deaths. “I gravitated toward the people who weren’t waiting around for justice,” Macy writes. These are the doers who often work outside of typical bureaucracies, “regularly travers[ing] the backroads and under-the-bridge encampments of America’s Third World.” Many are former drug users who now do outreach to peers, or nurse practitioners delivering needles and hepatitis C testing kits out of the trunks of their cars to patients in parking lots and trap houses. They are recent college graduates who grew up with parents suffering from addiction, and are now convincing local law enforcement to offer jail-based treatment instead of perpetuating the endless cycle of arrest, probation, and relapse. They are volunteers sometimes risking their own arrests, and ex-DEA agents and lesbian ministers working to create ties across divided communities. 

In her reporting, Macy conveys with urgency the dire realities of the opioid epidemic: More than a million Americans have died from drug overdoses since 1996, and death from drug overdose is the largest factor in decreasing the overall life expectancy for Americans. Fentanyl, a potent synthetic found frequently in street drugs, has also caused a spike in overdose deaths. Opioid addiction also contributes to a rise in homelessness, domestic violence, and child neglect. It’s hard stuff. But running throughout the book is a shared belief that it is important to treat people with opioid use disorder (OUD) with humanity, to dismantle the web of stigma, and to understand addiction as a chronic illness.

About ten months after the residency in Virginia, Macy and I met on Zoom—she was in her home office in Roanoke, Virginia, and I was at my house in Cincinnati. Macy spoke enthusiastically and quickly, spilling over with information about her research and stories about the people she writes about, the “outsiders and underdogs.” Communities and generations have been decimated by the epidemic, and Macy doesn’t soften the truth or paint over the grim outlook—without more robust, massive structural changes at the national level, it is difficult to create lasting, significant changes. However, Macy has also witnessed a change in attitudes, which can save lives. As we discussed the radical, inspiring, and innovative work she observed on the ground, Macy said she hopes that maybe Raising Lazarus can also be used as a “guidebook” for people who may feel hopeless about the crisis: “If you read it and you’re looking for techniques on how to make change in your community, even in a conservative community, you can get all kinds of ideas.” 

Carter Sickels: Raising Lazarus is a follow-up to Dopesick. What led you to write this book? Why did you want to continue telling the story of the opioid crisis?

Beth Macy: When I was finished with Dopesick, it was before Tess [Henry] died. [A central character in Dopesick, Tess was a young mother who was addicted to heroin and was murdered in 2017, her body discovered in a dumpster.] Then Tess died and I had to rewrite the end. I went to the funeral with Tess’s mother to be there when she said goodbye to the body. It was just so lacerating and painful, and I thought, I never want to write about this again. It was just so dark. I wanted to move on.

But then the response to the book was good, and I was able to go out and talk about it. As I was traveling and talking about it at bookstores and addiction conferences and reading groups, I was starting to learn about really cool things that were happening on the ground. I initially met Michelle [Mathis], who runs the Olive Branch Ministry [a harm-reduction ministry based in the Foothills of North Carolina that offers a number of services including syringe access and naloxone/Narcan distribution] because I was speaking at a panel and she was on the panel before me, and I heard her say, “We have to meet the other side—law enforcement—where they are too.” I’d never heard anybody say that before. [Divisions between harm reductionists and law enforcement are typically stark; through years of outreach, Mathis’s “biscuits and pragmaticism had won over the local cops,” Macy writes, and began to affect the way the police treated people with addiction.] I thought, wow, how can I figure out what her secret sauce is, in terms of doing harm reduction in a rural community where it’s very conservative and there is probably a lot of hesitancy to handing out needles. And yet she’s figured out how to do it. How did that happen?

I thought if I could shine a light on these little corners of inspiration and these beacons of innovation, then maybe that will help engender the political will necessary to bring harm reduction innovations to scale, to match the scale of the crisis.

Can you explain what harm reduction care is and why it is necessary for fighting the opioid epidemic?

BM: I have a slide on my presentation that’s a quote from Dan Bigg, who’s the father of harm reduction and started the Chicago Recovery Alliance in the ’90s: “Any positive change as a person defines it for him or herself is our definition of recovery.” So, it’s this idea of going to people and helping them, but not making the perfect the enemy of the good. We’re going to be okay if you’re still using drugs, but we want to help you improve your life beyond chaotic use, when and if you're ready to do that; and in the meantime, to stop the spread of HIV and hepatitis C, we’re going to give you clean needles and connections to care. Now we know that people who use needle exchanges are five times more likely to eventually go to treatment, but that’s not the goal. In fact, when I was going out [shadowing] Jessica Maloney [a peer recovery specialist at Olive Branch Ministry], who drives around to the little towns in North Carolina to check on clients, we’d meet somebody and then we’d get back in the car to rehash. I’d ask her, “So are they ready to go to treatment?” And Jessica kept saying, “No, Beth, that’s not the goal, the goal is to make them trust us because we know that the recovery can’t really happen until they buy into it. And that has to be on their timeline.” I think we’ve all been acculturated and brought up to think recovery is abstinence, and it’s not. I have been bumping on this for ten years.

The people you write about are often doing difficult work on the frontlines and socially progressive work in deep red states, which seems like such a paradox. Can you give another example of the innovative, harm-reductionist care you witnessed? 

BM: The hair is standing up on the back of my neck just remembering this about Lill Prosperino [a thirty-year-old nonbinary harm-reductionist in Charleston, West Virginia] and what first made me want to write about Lill. People who use drugs in Charleston, West Virginia, don’t even feel entitled to go to the ER when they have a life-threatening abscess because they’ve been treated like shit so many times before. They’re stigmatized and just treated horribly. So Lill figures out a way that they can create these “drawing-out salves,” so [people who inject drugs] can heal their own abscesses. That’s a big key to harm reduction [to involve people in their own care and recovery]. When Lill creates this cream that helps somebody get better on their own, they’re doing it not just by their own ingenuity, but also with help from addicted folks who are out there helping and foraging for these herbs in the mountains. [When I learned about this], a part of me goes, Yeah, so now we’re using a treatment invented in the Middle Ages, is that what we're up to? But [what Lill is offering] is not unlike [the approach of] Tim Nolan [a nurse practitioner who drives all over the foothills of Western North Carolina to provide clean needles and testing, his street outreach coordinated by Olive Branch Ministry]. In Raising Lazarus, Tim, with clean needles and hepatitis C testing kits, goes out to the trap house in the holler where Jordan Hayes had assembled her friends for a hepatitis C testing party. The thing is, when you get people involved in their own care, that’s really empowering. As Michelle Mathis would say, that’s when you get to experience a miracle of raising Lazarus.

Can you walk me through your process? How do you balance the interviewing with writing the book? You also balance many storylines—how did you figure out the focus or how to start?

BM: Well, the hardest thing, especially with this subject, is getting people to trust you. The material is only as good as the amount that the person you’re interviewing trusts you. It took a long time to get to Michelle Mathis [and build up that trust] and then it took even longer to get to Tim Nolan. 

The beginning of the book isn’t the first beginning of the book that I wrote. But after my editor read [in an earlier draft] the first four chapters, she said, “You know you really do your best writing when you write about people you admire.” 

And I thought, Well, what is the biggest takeaway from the book? And, it really is this idea of don’t disappear. You can get better, and don’t disappear. And the scene that moved me the most was following Tim Nolan and just watching him work. [Raising Lazarus now begins with Nolan urging a new patient he meets in a McDonald’s parking lot to come back for another appointment, to not disappear.] Tim was so unflappable.…There’s something really joyful about Tim, and I think it’s because he does it out of a spiritual goodness. He is like a saint and never gets tired—his happy place is when he’s driving around after he’s worked all day long in the clinic. Then the thing with Tim was that he had discovered this little window and figured out how to reach these people, and that was really moving to me. I learned halfway into my career that I do my best writing when the values of the people I am writing about match my own. I’m writing about outsiders and underdogs. 

Publicity photo from Little, Brown and Company

You write about people and places with such care and empathy. Can you say more about how you get people to open up and trust you?

BM: Well, first, you have to find the story beacons, and those are the people who sort of get you the entrance into it. In Charleston, I started out with Joe Solomon, who runs the harm reduction group SOAR [Solutions Oriented Addiction Response], and then he got me to Brooke [Parker, also with SOAR], and Brooke got me to all these other people. I just met Michelle by accident, she got me to Mark, Mark got me to the people doing the harm reduction there. 

And, I just don’t go away. I follow up by phone, and I always have follow-up questions. I type up my own notes. I remember better what I have if I type it up myself. It’s very laborious, but it also makes me think better and see connections better if I’m actually touching every sentence. Then, I always have follow-up questions and I’ll call back and then I’ll make another appointment to come back. 

And, then if I’m writing about somebody who is marginalized, I always tell them, “Look, I’m going to read this back to you and want to make sure I got it right and I don’t want you to get in trouble.” A lot of reporters… I mean we’re taught not to do that. But I feel like if it’s somebody who’s never been interviewed before and they’re already in this position of feeling marginalized and stigmatized, we owe them that.

Then I just try to sort out [my material] and I always just go with what moves me. That’s the only way I can make a story out of it. I figure the biggest problem [facing people with addiction] still is stigma, and we’re not going to put a dent in that until we get people to see people with OUD as human beings with a medical condition. So, I try to figure out, what are the stories? Of all the scores of stories that I have gathered for this book, what are the ones that move me the most? And, if I can tell them movingly and accurately, then I can help move the reader and that will help get rid of the stigma.

That issue around stigma and shame certainly comes up in the series Dopesick. I’d love to hear you talk about Dopesick being adapted into a TV series. How did it feel to be a part of that experience?

BM: I was nervous going in because it’s Hollywood and they were throwing so much money at this and I didn’t know Danny Strong [the series showrunner] at the beginning. What is so different about writing a book is that I’m just here [in my office] with all my notes, my phone, my computer. But in a writers’ room for a TV show there are several people [writing and collaborating]. We had six people [in our writers’ room]…all with great experience, and then Danny Strong was our leader. Danny had a real vision for the story and great energy, and whenever we didn’t know something, he would hire consultants. He let me weigh in on that too. I suggested we hire Robert Gipe [Appalachian author of Trampoline] to make sure we had the language right and the parts about Appalachia exactly right. Danny would send Robert an email [with a question about the script], and Robert would give us five possible answers to the question, and the answers were all just so creative…and helpful. 

Danny and I would have conversations on the phone with [the people who inspired characters in the TV show] and we would interview them together. In the show, the Michael Keaton character is based loosely on Dr. Steve Loyd, who’s from Tennessee and had gotten addicted to Oxy himself. We brought Dr. Loyd into the writers’ room one day, and we just asked him everything. We asked him how he initially got addicted, we asked him all the tricks [and how he got away with it]. [There is a scene in the show] when Michael Keaton takes the forty milligrams from his patient and then writes his patient a script for eighty, and puts the extra pills in the drawer so that he can take them himself, and that scene was coming directly from Dr. Loyd. 

My two goals going in for the project were, one, that we not stereotype Appalachia. We’ve all seen it. You know, Hillbilly Elegy. And I just didn’t want somebody like Robert to see it and be ashamed. I didn’t want Dr. Van Zee [a primary character in the book Dopesick who was a doctor in Lee County, Virginia, and one of the first to question Purdue about OxyContin’s addictive qualities] to see the show and be ashamed. I didn’t want any of the folks I interviewed to be ashamed.

And the second goal, and I think we nailed it, is to show that while abstinence might work for alcohol, it doesn’t work for OUD. And so, you see Keaton, an A-list actor, get on methadone and then Suboxone, and you see him in counseling. 

I really appreciated that the TV show was clear about showing why medical treatment for opioid addiction is critical for recovery. That rarely gets presented. It goes back to what we were talking about earlier, about these misunderstandings about addiction and recovery that are so ingrained in our society. Something that I’ve always heard, for example, is that people struggling with addiction have to hit rock bottom before they can ever go into treatment, and I’ve learned that is a misconception. 

BM: Totally a misconception. Especially in the era of fentanyl, which is in almost every drug now… Just assume if you’re buying an illicit drug, it has fentanyl in it. Everybody says that, from harm reductionists to law enforcement folks. Tess’s mom now says, “I used to believe in rock-bottom thinking too, but rock bottom has a basement and the basement has a trap door.” We can’t wait for rock bottom because it’s too often just death. 

Carter Sickels

Carter Sickels is the author of the novel The Prettiest Star (Hub City Press), winner of the 2021 Southern Book Prize and the Weatherford Award for Appalachian fiction. His debut novel The Evening Hour was adapted into a feature film that premiered at the Sundance Film Festival in 2020 and is now streaming. His writing appears in the Atlantic, Poets & Writers, BuzzFeed, Guernica, Joyland, and Catapult. Carter teaches at Eastern Kentucky University.