Beth Macy - Raising Lazarus

Tim Nolan initiates treatment outside a clients home, Icard, North Carolina.

The Secret of Patient Care

O n a chilly spring evening in 2021, nurse-practitioner Tim Nolan set up his portable exam room next to a McDonalds 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. Hes a practitioner on the move, delivering harm-reduction supplies, lifesaving prescriptions, and treatments for injection-related infections to patients who cant make it to his office because they dont have cars.

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

Because theyre not inclined.

Because the only thing they can think about is scoring drugs, so they wont end up on the toilet again, dopesick and in excruciating withdrawal.

A middle-aged factory worker named Sam, new to Tims 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.

Meanwhile, twenty minutes away, in a 1960s ranch that had morphed into a trap housea home dedicated to the selling and partaking of drugsa 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 housesomeones grandmotherhad recently moved to assisted living, and, for better or worse, the place was now all theirs.

Grandmas 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. Im trying to get me a car so I can live out of that, she said. It was Saint Patricks Day, so Jordan ordered green Krispy Kreme doughnuts via DoorDash, trying for a festive mood that was maybe a stretch for a hepatitis Ctesting party.

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

One: You can get better.

And two: Dont 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. In the past two decades, overdose deaths have quintupled. If life-expectancy declines persist, experts predict it will take more than a century to recover.

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, 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, and drug overdoses claiming the lives of more than 100,000 Americans in a yearmore than from car crashes and guns combined.

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 firsthandunless they know people like Tim and Samthe 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, not counting the calls for addiction-related domestic violence and child abandonment. In a small Tennessee town, a thirty-two-year-old told me shed 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.

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. The move was both cunning and literal, as it was preceded by a change of address that allowed the companys 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. Judge shopping, the practice is called.