Book Review: “Raising Lazarus: Hope, Justice, and the Future of America’s Overdose Crisis” by Beth Macy

This book, published in 2022, is a follow up to her best-selling book and Hulu series “Dopesick.”

The author followed people on the front lines who are helping people with opioid use disorder. She chronicles their experiences and emotions. She follows the dedicated individuals doing the hard and often discouraging work of harm reduction, mostly located in the foothills of Appalachia. The areas she described are familiar to me: Hickory, NC; Mt. Airy in Surry County, NC; Charleston, West Virginia; and Batesville, Indiana.

In the opening scene, the author describes the life and work of Tim Nolan, a nurse practitioner in the Hickory area. She follows him as he makes “house calls” to patients in parking lots and fast-food joints. He delivers harm reduction supplies and life-saving prescription medications, along with treatment for the infections that can be associated with patients who use drugs intravenously.

I know Tim. We talk every month or so, because I am – or was – his physician supervisor for his buprenorphine patients. In North Carolina, physician extenders like nurse practitioners and physician assistants had to be supervised by physicians with a waiver to prescribe buprenorphine, called an “X” waiver. His supervising physician didn’t have an “X” waiver, and Tim asked if I could serve as his supervising physician just for his buprenorphine patients. I knew him from a Project Echo, a three-year program through University of North Carolina that taught new providers how to prescribe buprenorphine to treat patients with opioid use disorder. I knew Tim was knowledgeable and enthusiastic about helping his patients, so I was happy to help.

Now of course, since the “X” waiver was eliminated earlier this year, he no longer needs me to be a supervising physician but I’m always eager to help if needed. He’s doing important work.

Anyway, by reading Beth Macy’s book, I got a better idea of how far Tim goes to help patients. I didn’t know he routinely made these house calls, for example. Transportation to and from treatment providers can be a barrier to treatment and Tim has found ways to surmount the obstacles to care for opioid use disorders and for Hepatitis C.

The author also talks about Olive Branch Ministries, a harm reduction outreach program based in Hickory, NC that serves about ten counties in North Carolina. They do counseling and addiction treatment triage in these counties, as well as syringe exchange. They were also key in getting Hickory police to carry naloxone to reverse overdoses. The author does a great job of describing the challenges workers at Olive Branch Ministries face every day, trying to do a whole lot with a little bit of money.

The author talks about Surry County, which is one county to the north of Wilkes, where I work and live.

We know things are bad in Surry County. It has one of the highest overdose death rates in the state. The systems of medical care in that county have not embraced patients with opioid use disorder or provided care for them, until very recently. Finally, a physician extender who works at the county’s Health Department plans to start prescribing buprenorphine products for patients who need this medication. EMS workers just started doing buprenorphine inductions there.

For years, patients have told me horror stories about the Surry County jail. Since it is only one county away, some have had the misfortune of being incarcerated there. The author took a tour of this jail and after reading her description of what she witnessed I’d say the only word to describe the jail would be “squalid.” She describes inmates lying on urine-soaked mats on bare cement, and people in opioid withdrawal vomiting into buckets, crammed too close together. When she asked about providing methadone or buprenorphine, jailers said there was no room for such services, despite the presence of a nurse’s office that to the author’s eyes would be adequate for services.

The author researched and wrote much of this book during the pandemic and had a front row seat to the spectacle of everything going from bad…to worse. Care was harder to get, illicit drugs like fentanyl and methamphetamine more plentiful, and overdoses were more common. The COVID pandemic took the misery of the opioid epidemic crisis and amplified it.

During COVID, our opioid treatment program saw the same distressing problems in some of our existing patients and in our new patients. We admitted sicker people to treatment, with more severe mental health and physical health disorders. More of them had co-occurring stimulant use disorder, using methamphetamine.

 Many of them would have been appropriate for inpatient care, were it available. The Western half of North Carolina competes for beds at one government-run inpatient detox/residential site that will keep or start patients on methadone or buprenorphine while addressing co-occurring treatment issues. There’s a lot of competition for those beds. Often it takes weeks to get a bed for a patient in need, and they won’t take some patients with complex medical needs. When all the stars aligned and a patient goes there for treatment, they do well, and it’s a good program.

Nearly all the other inpatient programs STILL won’t permit patients to continue or start on methadone or buprenorphine, despite those medications being the gold standard. Understandably, patients admitted to these programs don’t stay. They get sick, crave opioids, and leave.

Much of this book describes the grass roots efforts of concerned citizens working in small towns in the U.S. to reduce the harm to people with opioid use disorder. The author talks about people who initiated Narcan distribution systems, people who deliver low-barrier buprenorphine treatment, people who make sure needle exchange is available for those who want it, and people who provide food and shelter to people who have neither.

After reading this book the reader will see just a few of the largely silent army of workers on the front lines trying to fix an overwhelmingly broken system. I appreciate all of them. They are truly doing God’s work.

Part of that work illustrates the basic theme of harm reduction treatment. As the author says in this book, “The idea that drug users are worthy human beings – that they are, in fact, equals – is harm reduction in a nutshell.” She talks about the need to stop judging people who use drugs as bad.

The author writes about the legal battles to bring harm reduction measures to communities, with the familiar NIMBY (Not In My Back Yard) attitudes. The opposition faced by well-intentioned harm reduction workers is heart-breaking. It’s due mainly to lack of information in people who still believe that tired old lie, “Once an addict, always and addict.”

To make the stories of the people with opioid use disorder and their front line helpers more poignant, the author juxtapositions their lives with descriptions of what was going on at the Purdue Pharma bankruptcy trial. The trial was covered more thoroughly in the book “Unsettled,” by Ryan Hampton, which I’ve also reviewed, but its placement in Beth Macy’s book was effective.

Reading about how the truly poor people of Appalachia’s opioid epidemic are trying to get by each day, and then reading how Purdue Pharma, claiming to be bankrupt, hired lawyers for $1,800 per hour to defend their interests was distressing and enraging.

I appreciate Beth Macy’s coverage of this whole issue. I love she spent space in this book discussing how medications for opioid use disorder are the standard of care for treatment. I love how she talked about how the stigma against patients with opioid use disorder and against MOUD is strong and gets in the way of more patients getting their lives back.

Her book also reports on the people who are in recovery from opioid use disorder, giving hope to the reader.

Unflinchingly, she points the way out of our public health nightmare and asks if we are ready to treat people with opioid use disorder as people deserving of help. She asks if we are ready to lay aside dogma and biases and adopt treatment strategies that are proven to work.

Here in 2023, we have plenty of evidence to show how to treat the opioid epidemic. That isn’t a mystery. The bigger story, which Beth Macy beautifully illustrates, is the question of why our country isn’t embracing the changes that are proven to help people and reduce morbidity and mortality?

The front-line workers she describes don’t have great funding. They don’t have much support at all, yet they carry on, trying to raise the dead through quiet little programs that are deeply evidence-based and undoubtedly doing a great deal of good. Yet why are these workers the exception? Why isn’t our country carpeted with these programs in every tiny neighborhood with a need?