Parent/Child Relationships
The instigating narrative device of the story is that of an adult child having to become the caretaker to a parent suffering from a debilitating medical condition. In this case, Emma Starling is a twentysomething whose adult life really hasn't even begun who finds herself back in her hometown caring for a father suffering from an especially debilitating condition which produces bizarre hallucinations and a propensity for showing up in public lacking the requisite expected clothing. Adding to the difficulty of struggling to be both child and parent to her father is the fact that despite his unquestioned mental deterioration, her father seems to be the only person in town seriously concerned with the mysterious disappearance of Emma's best friend. As his condition worsens, the load on Emma to keep the family unit functioning grows heavier.
The Opioid Crisis
The reason that nobody else in town is terribly concerned with the disappearance of Emma's friend, Crystal, is that the region has been hard hit by the consequences of opioid addiction. Crystal going missing is attributed to collateral damage from drug addiction. In addition, Emma's brother is also impacted. The thematic exploration of the crisis is not situated within a medical milieu or from a criminal perspective, but rather as a social critique on how apathy impacts social environments.
The Twentysomething Crisis
Emma is a medical school dropout who has decided to return to her hometown despite being an at age where so many others are already well on their way to what will become their life. Emma, by contrast, is left unmoored and feeling out of sync. Making this situation even worse is that Emma returns home having failed to meet the high expectations that launched her into college. Both Crystal and Emma had established reputations for having "healing powers" while still children. Before either has reached the age of thirty, one is a med school dropout working as a substitute elementary school teacher and the other is a missing and presumed dead drug addict.
Unreality
The story is punctuated and populated by elements which a great many readers may describe as disconnected from reality. The story is narrated by a dead man. Emma's dad seems ghosts which may or may not actually be there. Emma goes to college to become a doctor because she has supposedly had the ability to heal the people of her hometown all her life. Crystal is thought by some to be a witch. What all this unreality contributes to the novel thematically is simply the idea that there is probably a lot more to life than can be seen or known. The opiate of the masses is limited neither to religion nor actual opiates since everybody is looking for their own answer to make sense of the reality around them.
