Raising Lazarus: Hope, Justice, and the Future of America’s Overdose Crisis

On a chilly spring evening in 2021, nurse-practitioner Tim Nolan set up his portable exam room next to a McDonald’s dumpster in Hickory, North Carolina, and he waited. His desk was the dusty dashboard of his gray Prius, his office this parking lot. It smelled like frying oil and fermented trash.

In the time it takes a drug user to pull up a shot of heroin, Tim can fashion a medical lab of test tubes and testing strips on the roof of his car. He’s a practitioner on the move, delivering harm-reduction supplies, lifesaving prescriptions, and treatments for injection-related infections to patients who can’t make it to his office because they don’t have cars.

Or because the transmission on the one they were borrowing just blew.

Because they’re not inclined.

Because the only thing they can think about is scoring drugs, so they won’t end up on the toilet again, dopesick and in excruciating withdrawal.

A middle-aged factory worker named Sam, new to Tim’s practice, was supposed to meet Tim in the parking lot at 5:30 p.m., but Sam had misplaced his cell phone and was running late. Also, he was super high.1

Meanwhile, twenty minutes away, in a 1960s ranch that had morphed into a trap house—a home dedicated to the selling and partaking of drugs—a cluster of young and middle-aged men and women gathered, playing darts while they awaited their own appointments with Tim. When Tim first began delivering clean needles to the group two years ago, they were living in the garage. But the owner of the house—someone’s grandmother—had recently moved to assisted living, and, for better or worse, the place was now all theirs.

Grandma’s fussy cut-glass pitchers and doilies still dotted the interior. Out of respect for Tim, thirty-two-year-old Jordan Hayes had spent hours that afternoon cleaning the place up. A hairdresser in another life, she was tired of being the de facto house mom. “I’m trying to get me a car so I can live out of that,” she said.2 It was Saint Patrick’s Day, so Jordan ordered green Krispy Kreme doughnuts via DoorDash, trying for a festive mood that was maybe a stretch for a hepatitis C–testing party.

Soon, Tim would arrive at the now-tidy house in the Appalachian foothills toting his usual array of clean needles, hepatitis C–testing kits, and a couple of pizzas.3 But first, he waited for Sam. He had two important messages for his new patient.

One: You can get better.

And two: Don’t disappear.

The Centers for Disease Control and Prevention estimates that more than a million Americans have died from drug overdose since 1996, the largest factor by far in decreasing life expectancy for Americans.4 In the past two decades, overdose deaths have quintupled.5 If life-expectancy declines persist, experts predict it will take more than a century to recover.6

Roughly six months into my reporting for this book, COVID-19 emerged in March 2020. Overdose deaths went up as the pandemic further isolated people with substance use disorders (SUDs). That community was already plagued by the poisoning of street drugs with fentanyl, a synthetic opioid 50 to 100 times more potent than heroin,7 and an environment that makes it far easier for people with addictions to use illicit drugs than to access treatment for addiction and their underlying mental health issues.

Within the first pandemic year, the overdose count was 29 percent higher than the year before, and the numbers kept climbing. By late 2021, it was clear that addiction had become the No. 1 destroyer of families in our time, with almost a third of Americans reporting it as a serious cause of family strife,8 and drug overdoses claiming the lives of more than 100,000 Americans in a year—more than from car crashes and guns combined.9

And yet, after reporting on the issue for more than a decade, I have learned that whatever most people believe they know about drug addiction, unless they understand the issue firsthand—unless they know people like Tim and Sam—the reality of addiction is hard to fathom. In one small Appalachian city, EMS workers have tended the overdose deaths of more than a dozen of their former classmates,10 not counting the calls for addiction-related domestic violence and child abandonment. In a small Tennessee town, a thirty-two-year-old told me she’d already lost 27 percent of her high-school class to overdose.

As Tim waited for Sam, the United States Congress debated how to hold to account the Sackler family, sole owners of Purdue Pharma, whose OxyContin painkiller was the taproot of the opioid crisis. The Sacklers are just one node in a vast network of opioid lawsuits broadly acknowledged to be the most complicated in American history.11

Under pressure from litigation against Purdue Pharma by 2,600 cities, counties, and Native American tribes, and to forestall further lawsuits against the Sackler family, the company filed for Chapter 11 bankruptcy in late 2019.12 The move was both cunning and literal, as it was preceded by a change of address that allowed the company’s legal reckoning to be determined in the sleepy suburb of White Plains, New York.

White Plains has only one bankruptcy judge, Robert Drain. And Drain is known for favoring settlement deals that make economic sense and for trusting big law firms to get the details right.13 Judge shopping, the practice is called.14

The Sackler family was nowhere near bankrupt—and had no meaningful connection to White Plains; it was simply piggybacking on Purdue’s bankruptcy, offering to swap out the company and a smallish portion of its wealth in exchange for blanket civil immunity.15 Nonconsensual third-party releases, that controversial practice is called, and Drain was known to favor those, too.16

If Drain confirmed the bankruptcy plan, the full extent of the Sacklers’ role in the overdose crisis would never be known. The Sacklers would not admit wrongdoing. And they would never be held to account for their role in helping addict people like Sam, one of an estimated 3 million Americans with opioid use disorder, or OUD.17

For a quarter century, the Sacklers masterminded and micromanaged a relentless marketing campaign for their killer drug, then surgically drained the company of $10 billion when they saw trouble on the horizon. The family socked much of that money away in family trusts and offshore accounts.18 But they needed a court’s help to shield this money—permanently—from the company’s creditors and other victims.

At the same time, any effort on the part of the government to rein in drug companies had long been dwarfed by the greed of private industry. Under Republican presidents before and after Barack Obama, career prosecutors who’d worked mightily to nail Purdue’s owners and executives for fraud were twice thwarted by politically appointed superiors at the Department of Justice, thanks largely to repeat influence peddlers.

During the Obama years, lobbyists pushed legislators to pass into law a bill called the Ensuring Patient Access and Effective Drug Enforcement Act. It sounded good, but in actuality the law severely limited the Drug Enforcement Administration’s ability to freeze suspicious narcotic shipments from drug distributors to pharmacies—setting the stage for more pills, more deaths, and more litigation.19 In recent years the opioid lobby has spent eight times more than the gun lobby to curry favor with lawmakers.20

By the spring of 2021, the naming of President Joe Biden’s new drug czar was bogged down in politics, as was the possibility of his appointing the acting commissioner of the Food and Drug Administration, Dr. Janet Woodcock, to the actual post. Earlier in her career, when OxyContin and many other potent painkillers were approved, Woodcock was supposed to have been the nation’s “top drug cop.” But for two decades, regulatory watchdogs stood by as pharmaceutical and health-products corporations plied lobbyists, political campaigns, and Capitol Hill politicians with $4.7 billion to smooth the pathway so they could sell, sell, sell.21

How did the Sacklers get away with so much for so long? They surrounded themselves with sycophants hired to shield them from the consequences of their faulty product. They bought influence. As OxyContin scion Richard Sackler put it, “We can get virtually every senator and congressman we want to talk to on the phone in the next seventy-two hours.”22

America’s 1 million overdose-death count is predicted to double by this decade’s end.23 It is already as if a city the size of San Jose has vanished, and, by 2029, those deaths will be Houston-sized.

But such disappearances are quiet and geographically dispersed as the epidemic remains hidden in plain sight, buried in a fierce, century-old battle between shaming drug users as criminals or treating them as patients worthy of medical care.

At this point, too much attention is focused on stemming the oversupply of prescription opioids. A quarter century into the crisis, many people with OUD have long since transitioned from painkillers to heroin, methamphetamine, and fentanyl, the ultra-potent synthetic opioid. And we now have a generation of drug users that started with heroin and fentanyl.

As President Biden faced pressure to make up for the drug war sins he’d committed in the 1980s and ’90s by championing punitive “tough on crime” laws that scapegoated Black and poor people, overdose deaths from fentanyl rose most among Black Americans, surging 38 percent in 2019.24 (Native Americans claimed the highest overdose-death rate in 2020,25 but no group has seen a larger increase than Black men.26)

In American cities being slammed by illicit fentanyl and in much of rural America where the crisis initially took root, a disparate group of people who work outside the realm of mainstream bureaucracies has begun tackling what officials have failed for decades to do: keep people alive. While many government-run programs were initially hobbled by pandemic rules designed to protect workers, people like Tim simply masked up and carried on. They worked long hours from the trunks of their cars, under bridges, and in fast-food parking lots. Some risked arrest to deliver sterile needles, lifesaving addiction medications, or treatments for injection-related hepatitis C and HIV/AIDS. The most passionate among them were former drug users who now do outreach and are officially called “peers” (short for peer recovery specialists or peer coaches).

As the Reverend Michelle Mathis, who coordinates Tim’s street outreach, described it: Those who get close enough to people who use drugs may get to personally witness the miracle of wellness—but only if they first answer the call. As with the disciples who unwrapped a raised-from-the-dead Lazarus at Jesus’s command, Rev. Mathis explained, “it doesn’t always smell like flowers, and you might get a little something on you. But the people who are willing to work at the face-to-face level get to see the miracle and look it in the eye.”

As Tim worked nights visiting drug users, Judge Drain spent his days focused on buttoning up the bankruptcy. The Sackler family was on the verge of locking away most of its wealth even as overdose deaths kept breaking records.27

In a country that spends five times more to incarcerate people with SUD than it does to treat their medical condition,28 progress was stagnant. In 2019, an estimated 18.9 million Americans in need of treatment didn’t receive it. That’s a treatment gap of roughly 90 percent.29 Among the lucky few who do get treatment, Black patients were far less likely than Whites to have access to lifesaving buprenorphine (“bupe”), a medicine that blocks opioid cravings, for their OUD.30

When Americans fall into addiction, survival remains a luxury.

Just as it did when OxyContin first erupted in rural Virginia and Maine in the late 1990s, the national press mostly missed the out-of-the-way contours of the story. If you’re addicted in, say, Boston, you’re much more likely to access evidence-based care than if you live in one of the underserved areas where the crisis began. And even there, treatment is scattershot—“a drop of water in an ocean of misery,” as one Boston doctor put it.31

Death by drugs is now a national problem, but the crisis began as an epidemic of overprescribed painkillers in the distressed communities that were least likely to muster the resources to fight back. It erupted in rural fishing villages, coal communities, and mill towns—because Purdue’s sales strategy was to convince doctors that the nation’s injured miners and factory workers were better and more safely served by OxyContin than its weaker competitors. The company even maneuvered to convince the FDA to back this bogus claim.

As one early OxyContin user told me, puzzling over how Oxy had so quickly taken over her Virginia coal-mining town, “It was like the government was trying to get rid of the lowlifes.” Richard Sackler understood from the beginning that the shame felt by most families of the addicted would cloak his family’s role by blaming the very people OxyContin had helped to addict. “We have to hammer on the abusers in every way possible,” he famously strategized.32

From the stony patch of land next to a set of West Virginia railroad tracks to the smooth sidewalk in front of an LA Pottery Barn, the “lowlifes” and “abusers” were now everywhere. Many were neither voters nor campaign contributors, so the political apparatus felt free to look away from them.

In the Uneven States of America, stigma of one kind or another was always at the root.

The epidemic continues to shape-shift. When prescription pills grew harder to access in the aughts, drug cartels launched a second wave of the opioid crisis—heroin—understanding better than anyone that heroin and OxyContin are chemical cousins, and an opioid-addicted person’s fear of withdrawal guaranteed repeat customers. A few years later, they pivoted to hyper-potent fentanyl to boost profit margins; fentanyl was both easier to manufacture—no expansive poppy fields were required—and it was both tinier and more potent, making it easier to smuggle. A third wave commenced as dealers mixed fentanyl into almost every street drug, including fake pain pills and fake benzos, cocaine, and methamphetamine. What we now refer to as the “overdose crisis” is really an epidemic of death by polysubstance.

Given that the US government was also trying to recover the $12 billion that Juaquin “El Chapo” Guzman had made in illicit heroin sales, why shouldn’t it also redistribute the $12 billion made by the Sacklers to taxpayers harmed by OxyContin? “El Chapo got a life sentence, and he’s going to forfeit $12 billion. The Sackler family through Purdue has three felony convictions, but no one’s in jail, and it has its billion still,” Rep. Peter Welch (D-VT) argued during one heated congressional hearing.33

A theory began circulating among some public health experts and reporters that, to the extent that lawyers and politicians could convince the American people that it was Big Pharma’s job to fix the crisis—and not the US government’s—the Purdue bankruptcy and other opioid cases would let change-resistant bureaucracies off the hook.34 “The litigation probably sucks up more oxygen than it deserves,” one public health lawyer told me.35

Given the political fault lines rippling across the nation’s heartland, could litigation soothe the families’ pain and right the injustices and turn back an overdose crisis that only grew worse in the face of COVID-19? What was the real fix—not the easy hit or half measures that desperate users and wealthy companies alike had resorted to in place of real recovery?

If money alone can’t swoop in to fill a leadership vacuum fueled by stigma and a racist War on Drugs that overrides the health of the most vulnerable Americans, what can?

Since the publication of my 2018 book, Dopesick: Dealers, Doctors, and the Drug Company That Addicted America, I have often been asked to explain why the crisis just keeps escalating.

A month before the COVID-19 pandemic broke out, a group of Indiana sheriffs invited me to address them. When I explained the benefits of treating addiction in their jails—or, better yet, connecting arrestees to treatment instead of jail—they scoffed. I cited the example of the city of Burlington, Vermont, where police and civic leaders cut overdose deaths in half after becoming the first in the nation to assiduously track the addicted they had previously arrested or those who had been identified by social workers as suffering from acute addiction, then diverting them to medication-assisted treatment and social supports instead of jail. At the end of my remarks, only one of the ninety-two sheriffs in attendance very slowly clapped.36

Reader, they stared nine-millimeter bullets at me.

In Charleston, West Virginia, complaints about vagrancy and needle litter outside the public health department’s needle exchange led to its closure in 2018, sparking a 1,500 percent increase in HIV.37 The national press, understandably busy with the pandemic, mostly looked the other way.38

There are confirmed health benefits to decriminalizing drugs, as Portugal did in 2001, and states like Oregon began to follow suit by decriminalizing all drugs in 2020. But most American states, with a patchwork of jurisdictions and overlapping agencies run by elected prosecutors and law enforcement officials who win votes by being “tough on crime,” were nowhere close to conceiving of legalization, to say nothing of making heroin available in government-run dispensaries, as Canada and some European countries have done successfully.39

Drug treatment doesn’t operate in a culturally homogenous bubble as much as some harm-reductionists wish it did. Oregon doesn’t get to tell West Virginia what to do, even when the science solidly backs Oregon.

Networks of underground activists who distribute clean needles in West Virginia blamed the vitriol they received for helping drug users on “assholes who think they get to weaponize trauma.” A local journalist believed the pushback was more about old-money forces refusing to loosen their clutch on power: “Rather than acknowledging that real problems exist and trying to solve them, they create new problems that they alone claim to have the solution to,”40 he said, referring to exaggerated complaints of needle litter. A Charleston peer summed it up best of all: “We all need therapy.”41

A trickle of settled lawsuits won’t “satisfy the populace because what people really thought they wanted was blood,” said Johns Hopkins University bioethicist Travis Rieder. “What we really need is a whole new public health infrastructure.”

If we’re going to reverse America’s declining life expectancy, we need to treat people with SUD the same way we treat other Americans with chronic illnesses. Medications for people with OUD should be as available as insulin is for diabetics or dialysis for people with kidney failure.

But in a nation whose leaders can’t even implement a watered-down form of universal health care—as of this writing, twelve states have yet to pass the Medicaid expansion—Rieder’s solution remains an empty wish, especially in the distressed communities first targeted by Purdue.

While the Sacklers’ lawyers battled it out—Marshall Huebner, their chief counsel, billed at a rate of $1,790 an hour—I gravitated toward the people who weren’t waiting around for justice. They were activists, volunteers, and outreach workers—people who regularly traversed the backroads and under-the-bridge encampments of America’s Third World.

I followed them as they innovated treatment regimens on manila envelopes, broke rules when they needed to, and butted heads with bureaucrats who refused to humanely treat those who had been most neglected, over the longest time, simply because of the stigma that adheres to drug use.

One rural syringe-services provider leveled a stare at me and begged: “Whatever you write, just tell it like it is, okay? Nobody [with the county] really wants to put a drug user in their car and give ’em a ride to treatment.”42

I was kvetching to my friend, the Kentucky novelist and activist Robert Gipe, who reminded me of Martin Luther King Jr.’s criticism of white moderates who are “more devoted to ‘order’ than to justice.”43 “It’s important to respect people who are out there on the leading edge trying to get change going,” Gipe said.44 “Those who are pushing less hard are probably better at getting people to accept moderate change, but it’s a balance, and you need both. Either way, somebody’s gonna get yelled at.”

I didn’t like getting yelled at, but I got better at it.

In 2018, I watched my friend Patricia Mehrmann, a key source from Dopesick, say goodbye to her heroin-addicted daughter. Twenty-eight-year-old Tess Henry was a young mother who’d flown from her home in Virginia to Las Vegas for her third rehab attempt. Months after Tess relapsed and fled the facility, her body was found at the bottom of a dumpster on Christmas Eve. The week of her murder, she had been trying to secure the paperwork necessary to fly back home to try treatment again. She had already applied for Medicaid and researched methadone clinic options in her hometown.

I spent much of the next year helping Patricia retrace Tess’s final steps.45 It was sad and frustrating, as dark as the underground homeless encampments through which we walked, showing Tess’s picture, looking for clues. But, ultimately, Tess Henry’s saga of patient abandonment led to real change in her Virginia hometown—a small step toward what Tess imagined as “urgent care for the addicted.”

Whether we realize it or not, most of us continue blaming the victims rather than the corporations, politicians, and impotent regulators who allowed the wealthy to poison our nation.46 Though half of Americans report believing addiction is a disease, 80 percent still say they’d prefer not to be friends, neighbors, coworkers, or in-laws with someone who has SUD.

People blame victims rather than corporations, but they’re also more willing to blame corporations than do the hard work of moving forward and allocating the resources needed to actually fix this thing.

The Sacklers should be punished, but identifying the initial bad actors will only take the nation so far. Like all crises that persist rather than get resolved, the overdose crisis has created crises of its own.

In a nation where the treatment gap barely budges, many Americans who use drugs resort to theft, sex work, and selling drugs to avoid the pain of becoming dopesick. Many also use methamphetamine on top of heroin, for the same reasons my friend Tess did—so she could stay awake all night to avoid being robbed and raped, so she could muster enough hustle to get up and do it all over again.

Many get trapped in an endless cycle of jail, probation, and relapse—caught in a roughly $50 billion bureaucracy47 that employs millions and reelects tough-on-crime sheriffs but does little to help the victims of Big Pharma’s crimes. When you peer into the country’s most intractable problems—homelessness, disability, domestic violence, child neglect—you see the persistence of dopesickness everywhere.

“If we fix the opioid crisis, we fix America,” one reader e-mailed me, envisioning a country where meaningful work, health care, and social supports become not only embedded into treatment protocols; they might one day serve as prevention strategies, too.

When my displaced factory-worker mom in Ohio asked me what my new book was about, I told her the overdose crisis. She was in her nineties, with advancing dementia, and so she asked me this question approximately eight times a day. Having spent much of her life surrounded by addiction, she always had the same response:

“I think you should write a love story instead,” she said.

Shadowing Tim Nolan, the sixty-two-year-old nurse-practitioner, reminded me of a quote I’d first heard from an addiction doctor in Massachusetts. He said the solution to the epidemic could be summed up in a single quote from a Harvard physician in 1926: “The secret of the care of the patient is in caring for the patient.”48

Recently, Apple announced it would create three thousand jobs and a new East Coast campus in nearby Raleigh-Durham, part of North Carolina’s so-called Research Triangle, about two hours east of where Tim works.49 But outside the Whole Foods–rich triangle (four and counting), little opportunity beckoned for Tim’s patients, most of whom were thirsty, hungry, unhoused, and divorced from mainstream health care.

Tim’s patients aren’t well enough to make it to the clinic where he works during the day, let alone apply for Apple’s jobs in machine learning, artificial intelligence, and software engineering. They have lived off-grid and in the shadows for too long. The state pledged $845 million in tax incentives, and the county $20 million. But for the people in Tim’s practice, no such investment is being made.

Street medicine is low-tech and high-touch, the antithesis of Apple. But more than most of the programs I’ve witnessed in my decade of reporting on the overdose crisis, Tim’s low-barrier approach works—not always the first time, and not for everyone, but, eventually, for many.