John-Bryan “JB” Jarrett was supposed to be fishing on the Saturday morning of Labor Day weekend, September 2020. Over dinner the night before, he told his mom, Jessica, he wanted to be on the water by 7am.
Jessica and JB were unusually close. When her work brought her to Austin, she stayed in his spare room; when the pandemic hit, she moved in for good. Despite a full life – a girlfriend, a job, a side hustle running an online thrift store – he welcomed her. They planted vegetables, packed meals for homeless people, watched true crime, even shared their phone locations.
That morning, Jessica woke up eager to text him the same silly joke she always sent on his fishing trips: a screenshot of his coordinates – a dot in the water – captioned: “YOU’RE IN THE MIDDLE OF THE RIVER!”
But JB’s phone did not show up on the map. It was off.
Jessica started calling his friends, all of whom had lost track of him the previous night. Then she received a message on Instagram: “URGENT,” it said, next to a phone number. “Call now.”
JB had overdosed on fentanyl and had been found unresponsive in a friend’s apartment.
No one knew how long he had been without sufficient oxygen. He was transported to an Austin-area hospital, where the damage became clear: JB had sustained a brain injury and severe damage to his liver and kidneys.
By the standard measures of America’s opioid crisis, JB was one of the lucky ones. He did not get added to the nation’s tally of overdose opioids deaths – an estimated 55,000 in 2024, and more than 1m over the past 20 years.
But having survived, the 30-year-old now lives with life-changing injuries. Five years on, JB cannot walk or talk. After some recent medical setbacks, he also struggles to move, swallow or communicate in any way.
Jessica now provides him near round-the-clock care. She sleeps in his bedroom closet, her makeshift bed wedged between the wall and a rack of clothes, to be close enough to respond to every cry, call, shift of bedsheet, or other sign that JB is in distress. During the day, she works remotely as a social media manager and does her best to keep him engaged and comfortable.
JB’s story highlights a cruel irony: while overdose deaths have declined, thanks in part to the life-saving drug naloxone (better known by the brand name Narcan), more people are surviving with serious, sometimes devastating complications.
This is the epidemic within the epidemic – one we rarely count.
I knew JB’s story was not unique: my family had lived through something similar.
My cousin’s only son, Mason Bogert, overdosed on synthetic opioids and benzodiazepines when he was 18. He was a shy, kind, gifted kid who loved cats, guacamole and pulling a good prank. He was so adept with computers that he developed a popular weather app at age 16.
But he also struggled with anxiety and depression, and self-medicated. His tech skills became an accomplice to addiction: he bought the drugs that almost killed him on the dark web because they could evade detection in urine tests.
His parents found him without a pulse Mother’s Day morning, 2016. He lived the next five years in need of constant care, shuffling between ICUs, rehabilitation hospitals, and nursing homes across New England. The overdose left him blind and immobilized by spasticity, or very stiff muscles, a condition common with severe brain injury.
But, over time, Mason became increasingly aware. He began to communicate by spelling – opening his mouth to signal the correct letter – a method that allowed greater self-expression, and revealed he understood his circumstances and that he was deeply sad and frustrated by them.
Four years into his ordeal, we gathered to celebrate the fact that the earnings from his app had just broken the million-dollar mark – symbolic of a promising, even brilliant young life cut short. He died from pneumonia a few months later, two days after his 23rd birthday.
No one knows how many people survive opioid overdoses. The CDC’s best estimate is that for every fatal overdose, there are 15 non-fatal ones – which puts their number at well over 1m annually in recent years.
Dr Nora Volkow, the director of the National Institute on Drug Abuse, shared with me her “conservative” but staggering estimate that half a million Americans each year risk brain damage from opioid-induced hypoxia, which is when the body is not receiving an adequate amount of oxygen.
What effect these events have on people’s health, and how many are truly affected are burning questions. Volkow believes most injuries manifest in quiet but life-altering ways such as memory loss or diminished executive function. They can affect one’s ability to hold down a job, or fully participate in addiction recovery.
Severe cases can drain patients of their life potential, according to Dr Jennifer Stevens, the director of the Center for Healthcare Delivery Science at the Beth Israel Deaconess Medical Center. Young people in particular can become “incredibly financially toxic to themselves and their loved ones” when they are not able to work or require long-term support.
In other words, surviving an overdose can leave families fighting a different kind of crisis – one measured not in deaths, but in years of care.
An overdose occurs when opioids overwhelm receptors in the brain, leading to slower breathing and respiratory depression.
Experts believe brain injuries can occur after four or five minutes of inadequate respiration. The longer the brain and body go without sufficient oxygen, the worse injuries are likely to be – but outcomes remain a bit of a black box.
A few years ago, Ashley Six-Workman, a nurse with West Virginia University’s Rockefeller Neuroscience Institute, found a woman who had overdosed and been down for at least a few minutes in a parking lot. She did not have Narcan, so when she began doing CPR and waiting for emergency medical services, she feared the worst: she thought she was going to have an anoxic brain injury.
When the woman walked out of the hospital three days later, Six-Workman was both relieved and intrigued. “Clinically, in my head, it didn’t make sense,” she told me. “She should have some sort of impairment.”
Data from a rare study of overdose-related ICU admissions from 162 hospitals between 2009 and 2015 offers a sense of scale of the most extreme cases: of the 21,705 patients who required critical care, 8% suffered a catastrophic anoxic brain injury.
But this data predates the opioid epidemic’s “third wave”, when fentanyl drove overdoses to unprecedented levels – so today’s numbers are almost certainly higher.
Because fentanyl crosses the blood-brain barrier so easily, it can trigger an overdose within minutes, leading to respiratory depression and cardiac arrest. “You have a faster onset and a narrower window to intervene,” said Erin Winstanley, a professor of medicine at the University of Pittsburgh.
At the same time, naloxone has saved millions of lives: pharmacies sold 12.9m doses between October 2002 and September 2023. Yet each revived overdose also means another survivor left at risk of lasting complications.
It is also increasingly common for people to live through not just one, but multiple overdoses. Jon Zibbell, an epidemiologist who studies adverse health outcomes among people who inject and smoke street drugs, became concerned about the phenomenon as he witnessed people repeatedly overdosing on fentanyl and being revived by Narcan.
That survival is, on its face, a triumph of advocacy and harm-reduction policy. But Zibbell now worries about the cumulative toll. People he knew often felt “off-kilter” after a single overdose; what happens after a series of them?
He hypothesizes that the repeated injuries may be somewhat analogous to what happens with a cluster of mini-strokes – or to football players who, after multiple minor concussions, develop chronic traumatic encephalopathy (CTE), a devastating neurodegenerative disease. But it is going unnoticed, he adds, because non-fatal overdoses are perceived as harmless, and because their effects are often not obvious.
He and his co-authors flagged the issue in a federal report on the health consequences of non-fatal overdoses back in 2019. “I believe it’s a silent epidemic of many non-fatal overdoses,” he told me.
Early research supports this theory, and suggests repeated non-fatal overdoses may lead to Alzheimer’s-like brain pathologies. Postmortem studies show elevated tau levels, the protein found at high levels in Alzheimer’s and CTE patients, while imaging of survivors reveals reduced hippocampal volume.
The problem has only grown more urgent as the drug supply has become increasingly toxic and unpredictable, said Zibbell. Today, Americans are not exposed to fentanyl alone, but instead are consuming a cocktail of lesser-known synthetic substances, and these contaminants can limit the effectiveness of Narcan and prolong downtimes.
Recent CDC data appears to reflect his concern: between 2021 and 2023, ER visits for opioid overdoses declined, but related hospitalizations rose – suggesting patients now arrive in more serious condition.
For Zibbell, it marks a new phase in the opioid crisis: one that may be less likely to kill, but more likely to harm.
Almost from the moment Jessica arrived at the hospital after JB’s overdose, she sensed she and his medical team were on opposing sides. She was waiting for JB to wake up, she said, while they were waiting for JB to die.
Jessica remembers doctors aggressively urging them to withdraw life support on the second day of his hospitalization. “We were being literally harassed for his organs,” she said.
Compared to traumatic brain injuries, anoxic and hypoxic injuries caused by oxygen deficiency are barely studied, in part because outcomes have generally been considered very poor. (One neurologist, who wants to remain anonymous, told me that when his friend’s heart attack resulted in such an injury, his first impulse was “to put a pillow over his head”; that friend has fully recovered and remains alive decades later.)
When JB first opened his eyes five days in, the neurologist refused to watch Jessica’s video proof of it; it would not change his recommendation, he told her.
JB then moved to a long-term acute care facility that specialized in neuro-rehabilitation. It should have been an ideal place for him, but he languished there, heavily medicated and unable to actively “participate” – as required by insurance companies – in therapy. As a result, staff withheld those activities, including the stretching of limbs.
Four months after his overdose, JB still had not been out of a hospital bed.
At one point, he dislocated his hip, an excruciating injury that went unnoticed until Jessica pinpointed its source through the rudimentary communication system she had worked out: he would stick out his tongue to signal “yes”, which he did when she pointed to his hip. (The medical staff was skeptical, but a scan indeed showed it was dislocated.)
The facility transferred JB to a hospital for care, but because of his condition, no surgeon would operate on him.
It was at this point, over the Christmas holidays, that JB and Jessica experienced a sort of miracle. Through a series of increasingly desperate phone calls, she connected with a doctor who had trained at the Texas Institute for Rehabilitation and Recovery, better known as TIRR Memorial Hermann, one of the nation’s premier brain rehabilitation centers. The Houston-based hospital has a reputation for accepting patients with the most severe injuries and treating them as people with futures and potential.
On JB’s first day there, his physical therapist FaceTimed Jessica from the hospital’s outdoor courtyard. She had JB dressed in his own gym clothes, sitting in a wheelchair – a scene that had been unimaginable to her a day before. “That was just like everything, our whole world opening to possibilities,” she recalled.
Over the next three and a half months, as JB received three hours of physical, occupational and speech rehabilitation a day, he showed gradual signs of improvement. He smiled and reacted, gave thumbs ups, and even started to work on communicating with a laser-pointing headband and a letter board.
When he was discharged, his injuries were still profound, but each small sign of recovery validated Jessica: JB had already proven the doctors who predicted a permanent vegetative state wrong.
A half-dozen families I interviewed described the same experience: once hospitalized with overdose-related brain injuries, their loved ones were treated as lost causes.
Many felt judged harshly by medical staff for the role drugs played in the injuries, or for the decisions they made around their care. And a number shared the belief that young anoxic brain injury patients, often overdose survivors, are prematurely targeted for organ donation.
Put simply, trust is low, strained further by the complexity of these cases and the uncertainty among providers about how to treat them.
The families I spoke with often trusted the collective wisdom and lived experience of other caregivers online more than doctors, who see these cases rarely and usually not for long.
Dr Cindy Ivanhoe, a brain injury specialist at TIRR who treats JB, does not blame them. “It’s a very hard system to navigate,” she said. “It’s very hard to advocate.” She also sometimes wonders how much of her patients’ complications stem from the side effects of medications or medical care.
The experience can be isolating, too. Several parents told me they were shunned from support groups for families of opioid victims since their loved ones were still alive.
Kyle Harman was hooked up to a tangle of machines when his family reached the hospital. He had overdosed on what the doctors called a “scrambler” – a cocktail of benzodiazepines, opiates and cocaine – and been found by paramedics after an unknown period of time. Harman, then 24, was not breathing on his own, and an EEG showed little brain activity.
A restless, thrill-seeking kid who gravitated towards risky sports, Kyle had been battling addiction for years before the overdose that nearly killed him in 2016. He had begun experimenting with drugs in high school, and the following years had been a blur of stress and rock-bottom moments for the whole family.
Kyle estimates he overdosed 16 to 18 times, including once when his grandmother had to break the door down.
At the hospital, doctors did not expect Kyle to advance beyond a vegetative state. One offered frank advice: “Consider quality of life over quantity.”
Kyle’s parents decided to wait, and in the following days they glimpsed flickers of consciousness.
The neurologist cautioned Kyle’s path would not be linear as his body detoxed, neuro-stormed, and battled multiple related complications including kidney failure, pneumonia and withdrawal. And it was true: some days, his mother, Lauren, could see signs of her son. One day, he surprised them by suddenly mouthing the words of a favorite Bob Marley song playing in the background; on others, he would stare blankly into space.
In total, he spent 17 days in the ICU, the first seven in a coma.
Experts are rethinking the conventional wisdom that patients who experience an anoxic event have little chance of recovery. The highly visible case of Buffalo Bills safety Damar Hamlin, who went into cardiac arrest on the field in 2023, is one example, but broader statistics suggest better outcomes are possible, particularly for overdose survivors.
Younger, healthier patients tend to do better, as do those who receive CPR quickly, and those who start rehabilitation soon after their injuries – but what sort of recovery a patient will make generally remains a mystery. (A common saying in the community is: if you’ve seen one brain injury, you’ve seen one brain injury.)
Kyle spent the next six months passing through various care centers, relearning basic skills: swallowing, then eating and drinking, whispering and speaking.
His recovery accelerated at Bryn Mawr rehabilitation hospital, a dedicated brain injury rehabilitation center near Philadelphia. Soon, he even developed a reputation for defying facility rules. He so disliked the food that he repeatedly used gift cards and Uber Eats to order in Philly cheesesteaks for himself and select staff.
By the time he was finally discharged, a couple of nursing home stays later, he was using a walker. Six months had passed since his overdose.
Does the fact that Kyle began rehabilitation on day three, whereas JB started on month five, explain their diverging trajectories? That is impossible to know.
“Some patients get better, some patients get worse,” said Ivanhoe, the brain specialist who treats JB. “We are not great at predicting who’s going to do what, and so I would just not like to take those opportunities away.”
But that is what insurance companies often do, she noted, adding that exasperating phone calls with medical directors over coverage of rehabilitation or other treatments are a routine part of her job.
The health system is ill-equipped to support the rising number of overdose-related injuries, experts say. “The system is set up for an elderly population,” said Winstanley, who adds that long-term care facilities lack expertise in caring for patients with substance use disorders.
Dr Brian Im, a brain rehabilitation medicine expert at NYU Langone, told me these patients often have longer hospital stays because his team struggles to find places that will accept them.
Meanwhile, in the field of addiction medicine, cognitive dysfunction is so common it often goes unremarked.
“I’m certain we’d find a ton of neurocognitive dysfunction if we screened everybody,” said Dr Joshua Blum, an addiction specialist in Colorado. “But we don’t screen, so we don’t know how big the problem is.”
Physicians told me these impairments – missed appointments, difficulty following instructions – are an underappreciated barrier to recovery.
“It’s maddening to ask someone to commit to recovery when that part of their brain isn’t working,” said Dr Lara Carson Weinstein, who runs a Philadelphia program for patients with substance use disorders. She argues for more screening and treatment, adding: “With rehabilitation and compassionate care, there’s every reason to think people will get better.”
When I visited JB and Jessica in their Houston-area home in mid-December, they were halfway through a chaotic week.
JB had spent the previous few days in the hospital, after his feeding tube had clogged – the latest in a series of complications. Doctors had hoped that switching to a J-tube, which bypasses the stomach, would ease his reflux. Instead, it brought more serious problems: repeated aspiration pneumonia, another trip to the ER and now, the decision to return to his original G-tube, which required surgery.
Jessica’s warmth filled the house. Amid boxes of medical supplies, a foil “happy birthday” banner hung above the mantle, next to a “PRAY4JB” license plate.
Jessica spoke to JB normally, and as we chatted in their living room, she got up every so often to adjust JB’s position, stretch his muscles and suction his throat. He expressed discomfort, but she could not figure out the source. (Later that afternoon, an occupational therapist stopped by. Using the movement of his shoulder to communicate with him – internal and external rotation for “yes” and “no” – she determined he was cold.)
“It’s a hard life,” Jessica acknowledged in one of our conversations. “Would JB want to live like this? I hold a lot of guilt around that. I don’t know.”
At the same time, she sees their lives as far richer than the picture doctors initially presented to her. She is relentlessly positive and certain his recovery has more chapters to come.
In the months since my visit, there has been evidence of that: JB’s health has stabilized, and he has begun to communicate more easily again by turning his head, and blinking and closing his eyes.
After years of effort, JB got approved for Medicaid in April, which means for the first time in four years, he now receives professional nursing support 24 hours a week. Jessica is hopeful JB will also start working with a speech therapist and that emerging technologies will help him communicate more fully soon.
At 34, Kyle lives with his mom and stepdad, Lauren and Matt McGinnis, in Salisbury, Maryland. On a quiet February afternoon, their tidy living room bore a framed sign: “It’s so good to be home.”
Little physical evidence of Kyle’s ordeal remains today, other than the scar left behind by his tracheostomy tube and the cane he uses to support his uneven gait. The residual cognitive and behavioral impact of his brain injury are harder to parse. Aside from his lost overdose memories, Kyle believes he is back to his old self: “My brain was injured, that has no bearing on me now,” he told me.
His parents seemed accustomed to this disagreement, which they navigated gently in my presence. “I love you to death, buddy,” Matt prefaced before pointing to changes they have observed, such as Kyle’s trouble focusing.
They reminded him of a conversation with his neurologist several years ago. Pointing to a cluster of dark spots on a scan of Kyle’s brain, she had compared it to a 70-year-old’s. Those damaged areas would not heal, but to give his brain the best shot at forming new pathways, she told him, he needed to embrace a life of routine and order.
For a time, Kyle followed through. He enrolled in the local community college, working toward an associate’s degree in counseling. He made the dean’s list, and even drafted a business plan for a rehab center he wanted to name after his dad, who had died of an overdose.
But just before finishing the program, he quit, thinking it was a waste to spend money just to get a piece of paper.
He tried jobs at call centers, which he did not care for, and in 2023, became certified as a life insurance broker, though he is not working as one as he sees a driver’s license as necessary for the job. (His was revoked a few years ago when Kyle was stopped for driving under the influence, an incident Kyle blames on his friend who refused to let him stay on his couch after a couple beers.)
When I visited, Kyle was spending his days in his bedroom trading crypto and aggressively pursuing the reinstatement of his driver’s license.
His actions may be hard to understand, but they reflect common struggles for brain injury patients, who can experience lower self-awareness and heightened impulsivity and risk-taking. Traumatic brain injury is linked to substance abuse – it is both a risk factor and can make addiction harder to overcome.
Kyle’s biggest setback came in 2018 when, two years into his remarkable recovery, he overdosed on fentanyl again. In an account his parents find dubious, he insists he found a bag of cocaine in the front yard and could not resist.
Whatever the case, his stepfather and paramedics used four doses of Narcan to revive him. After a week in the hospital, his family and their pastor – a recovering addict himself – staged an intervention and sent Kyle to Hazelden Betty Ford, the addiction rehabilitation clinic in Minnesota.
It did not go well – “I wasn’t having it,” Kyle told me. After a couple weeks, the center released him to a homeless shelter in Minneapolis. Kyle spent the next five months there, attending addiction counseling during the day and sleeping in the shelter at night.
After leaving in spring 2019, he stayed sober. His parents marvel both at the humane design of the city’s shelter system and at Kyle’s ability to thrive in it. “He did it on his own, with a brain injury and a cane,” Matt said.
When I visited earlier this year, Kyle insisted he would never touch drugs again. “My life is shit,” he told me – not as a complaint, but as a reason not to make it worse.
It’s not an easy path, though: as this story was going to press, Kyle was preparing to go to Florida for mental health counseling and a change of environment.
He hopes he will also get physical rehabilitation there. He is determined to walk completely unassisted one day and wants to move into his own place, get his driver’s license back, and sell life insurance or work in finance.
Not that he plans to forget his past. When he gets questions about his cane, he gives it to them straight.
“Drug overdose, 2016,” he tells strangers matter-of-factly. “Don’t do drugs.”
Reporting for this story was supported by a grant from the National Institute of Health Care Management Foundation
