Dopesick

by Beth Macy

  Summer turned into fall as Tess bounced between the streets, jail, the battered women’s shelter, and the psychiatric wards of two local hospitals, the last of which she knew were prevented by federal law from turning suicidal patients away regardless of insurance status or ability to pay. “It’s so costly and ineffective,” said psychologist Cheri Hartman, another Hope volunteer. “If only [politicians] understood that getting access to Medicaid would actually save money and lives!”

  Tess wanted Jamie to find a long-term rehab program for her. “But we all know once her withdrawal gets bad enough she will want to be released and get her fix,” Jamie said in July. “Pray that this time we can get her somewhere before that happens.”

  The moment an addict is willing to leave for treatment is as critical as it is fleeting, Jamie said; she called it the liminal phase. “You only have a very small amount of time; you have to strike while the iron’s hot.”

  But Tess disappeared, again, before they could meet.

  The next time Patricia saw her daughter, she was nearly naked, posing for an ad on a prostitution website under the headline SWEET SULTRY SEXY 26. The baby’s father had discovered the ad through Tess’s cellphone number and told his mother, who alerted Patricia to it.

  A half hour for sixty bucks. There were pictures of Tess, crudely posed with her face cropped out, and a cellphone contact. “I looked at it as a way to contact her and let her know I still love her and support her. There’s nothing more I can do for her” until she’s ready to accept help, Patricia said.

  She was covertly tracking Tess via instant messenger now, a holdover from months earlier, when Tess signed onto Facebook using Patricia’s phone but forgot to sign out. She’d read heartbreaking exchanges between Tess, her drug dealers, and her friends, including another young woman from Hidden Valley, Jordan “Joey” Gilbert. Tess and Joey compared notes about dopesickness and black-market Subs (Suboxone or Subutex). They’d arranged to meet once to trade Xanax for crystal meth.

  Joey had had earlier success with the monthly naltrexone shot, Vivitrol, which is expensive but also impossible to abuse or to divert. Among the thirty-one states that had then expanded Medicaid under Obamacare, some improved access to naltrexone, even giving Vivitrol shots to people before they left prisons and jails, since they understood that addicted users were most vulnerable to overdose death just following a period of nonuse, when tolerance is low. But Joey lost access to the shot when she turned twenty-six and was no longer on her father’s insurance. “Without insurance, it would have cost us fifteen hundred dollars a month,” her father, Danny Gilbert, said.

  Joey eventually transitioned to buprenorphine, prescribed by Dr. David Hartman, the same Roanoke psychiatrist with the mile-long federally mandated waiting list that had stymied Tess. “Dr. Hartman would not write the prescription unless she passed her weekly drug test,” Danny Gilbert said. “And I held all her medication and gave it to her daily so there was control over it,” at an average price of around $700 a month.

  But there were still so many hurdles Joey faced in her quest for treatment, from the waiting lists that kept her from starting rehab to the byzantine rule that she had to be drug-free upon entry, not to mention her continued drug usage with people like Tess—all of which put her perilously close to relapse and death.

  In late October 2016, Jamie Waldrop and I visited Tess in the psych ward of a local hospital; she’d checked herself in, complaining of anxiety and suicidal thoughts. There was an outstanding arrest warrant out for her from a fraudulent seventy-eight-dollar credit-card charge earlier in the year. Her son was now fourteen months old, and Tess hadn’t seen him in eight months.

  She’d asked me to bring her a copy of my latest book, Truevine, which she’d read about in a People magazine at the psych ward. She thanked me for it and said it was OK when I asked to take notes. Her writer hero, David Sedaris, was about to publish a new book, and I promised to try to get her an autographed copy when it came out.

  Tess told us she was no longer using heroin, that she now favored crack cocaine. “I thought the cocaine would help me get off heroin,” she told us. “And it did, actually…but it’s very mentally addictive.”

  Asked if it was a relief to be off the streets, Tess nodded. “When it starts getting cold out, I’m ready to come in for help.” She’d been beaten by a drug dealer, she said, but didn’t want to go into details. Jamie recommended an Asheville rehab that she had sent other people to, with good results, she said, but it would not accept patients on MAT or the antidepressant Cymbalta, which is sometimes not recommended for people with substance abuse disorder.

  “That’s the one I’m on,” Tess said. But Jamie remained relentlessly upbeat throughout our visit and promised to double-check on the Cymbalta, and Tess seemed brighter and more hopeful than she had in months. The Asheville rehab featured a regimen of horticultural work during the day and intensive group therapy at night.

  “It’s kinda hippie-ish,” Jamie said, knowing that would appeal to Tess.

  “Like Warren Wilson?” Tess said, hopefully, referring to the liberal-arts college nearby.

  She would not be allowed to talk to anyone back home for six months. It would drive her crazy not to see her son or hear about him, she said, “but my goal is, I want to get him back.”

  But the liminal window passed, as it usually did, when Tess checked herself out of the hospital before the Asheville rehab bed, or any others, could be secured. “She’s back out again,” her mother said. “All it takes is one contact, one blinging on the cellphone, and there they go, spiraling again.”

  The flood of street fentanyl had not slowed. From September to November 2016, Roanoke claimed the highest number of emergency-room overdose visits in the state, most fentanyl-driven. EMS workers reported having to give people as many as five doses of the anti-overdose drug, naloxone, to reverse its effects. One such call ended with a young mother dead in her bedroom, her baby beside her in the bed, cooing.

  A week before Christmas, Patricia showed me a card she was mailing to Tess, with pictures of her son tucked inside. She’d found what she believed to be her current address from a series of Facebook exchanges between Tess and her drug dealers, some angry (“Damn man. You stole shit from me”) and some matter-of-fact. She was staying in another apartment in southeast Roanoke, catty-cornered from the church where I’d first taken her to NA.

  Patricia wanted to tell her about a new Beck song that began:

  I met you at JC Penney

  I think your nametag said “Jenny”

  It was their favorite department store, the place where she bought Tess a new wardrobe every time she left a hospital or rehab stint—only to return home, months later, with just the clothes on her back.

  “It scares me now when she comes home,” Patricia admitted. She’d locked up her shotguns; a sport shooter, she was afraid they’d end up pawned the way her laptop did. All but two of her spoons were missing from the house, swiped for heroin mixing, she assumed. “It’s like there’s a demon inside her,” Patricia said. “I do get mad at her, and there are times I want to say, ‘I quit.’ But the truth is, and I want her to know this, I’ll never give up on her.”

  Tess had made her way home briefly at Thanksgiving and insisted on cooking for the entire family, never mind the bandage on her arm, an abscess from a dirty needle that required emergency-room care. But in spite of her efforts, Tess felt her contributions to the meal went unrecognized by her siblings, and she got high the following day on pills and alcohol Patricia had hidden in her shed.

  That weekend Patricia bought matching bracelets for the two of them with the inscription “Your heart is my heart.” The saying was inspired by an e. e. cummings poem Tess admired and adopted as a kind of mantra about her feelings for her son. Tess had won a national high school poetry competition in 2001; Patricia still kept her winning poem displayed in her kitchen. Over the next several months, whenever she texted me with updates, she referred to Tess as “ou
r poet.”

  They made an appointment to get Tess’s hair highlighted. They were supposed to pick her little boy up from his other grandmother’s North Carolina house. It would be his second Christmas, and Tess was eager to see her son. They’d already bought his Christmas presents along with clothes for his Santa picture, complete with a matching sweater and pop-a-collar shirt set, bought used from Once Upon a Child.

  “We had all these plans, and then suddenly the switch just goes,” Patricia said.

  On her way out, the week after Thanksgiving, Tess left a note on her mom’s kitchen counter:

  Gone to Carilion [psychiatric ward]. Mental Breakdown. I LOVE you so much Mom. You are my everything. I want to get better & I won’t stop trying.

  Portrait of Bobby Baylis, held by his mother, Janine Underwood, Roanoke, Virginia

  Chapter Eleven

  Hope on a Spreadsheet

  Tess’s best chance for recovery, everyone thought, came down to a five-page spreadsheet. The volunteers at Roanoke’s new Hope Initiative had spent months crafting it—a list of thirty-six rehab and aftercare providers in the southeastern United States they could contact to arrange treatment, depending on the patient’s finances and the centers’ availability of beds. A few volunteers also helped arrange outpatient MAT, but the angels were divided on its effectiveness, many believing it was wrong to treat drug addiction with another drug, despite scientific evidence to the contrary. Users could drop in at the Bradley Free Clinic on the second Monday of every month and, if police officers found no outstanding warrants against them, pair them with trained volunteers who would troubleshoot their care. Social service workers would be on hand to help those who qualified apply for Medicaid.

  It was now early 2017, and fentanyl-overdose calls were coming in at a rate double that of the same period the previous year. In a region of three hundred thousand people, emergency-room doctors were now seeing drug overdoses daily—sometimes as many as three opioid-involved “gold alerts,” or severe trauma cases, at a time. In a single hour that April, three such patients would turn up in the ER of Roanoke Memorial Hospital, including a taxi driver found unconscious along the side of the road and a tree trimmer who’d been dropped off by a friend after injecting himself with two fentanyl-laced shots of heroin; he’d taken a second dose because he didn’t think the first one had worked. Emergency-room physician Karen Kuehl begged him not to leave the hospital after he was resuscitated: “I don’t want you climbing trees today.”

  Once revived, the man got up, politely thanked her, and left, saying, “I’ve got to go to work.” An older woman was expecting him to trim her trees that morning, he said, and she’d be disappointed if he didn’t show.

  In one weekend the following month, a local seventh-grader died of a probable overdose, the region’s youngest victim so far. The wife of Janine Underwood’s building manager at the clinic was getting her hair done only to be interrupted by the sound of a spectacular crash in the parking lot outside—a middle-aged professional man had passed out while driving, a heroin needle stuck in his arm, and crashed into her car.

  Kuehl was studying opioid-related hospital protocols in Ontario, where overdose patients are automatically referred from emergency rooms to outpatient medication-assisted treatment and counseling. “We need to do a smooth handoff here,” she said. She was helping local psychologist Cheri Hartman, one of the Hope Initiative coordinators, set up a similar transfer in Roanoke, but they were stymied by bureaucratic, financial, and legal hurdles, including a shortage of MAT providers and not enough opioid-detox and treatment beds.

  Both were hopeful about a grant they were applying for to make the handoff smoother. Until then, Kuehl said, hospital social workers were referring revived overdose cases to Hope—among them an increasing number of people who were passing out while driving.

  The state was concurrently working, through Carilion and other hospital networks in the state, to free up money to train peer recovery specialists who would facilitate the treatment handoff among overdose patients and others seeking treatment for both opioid-use disorder and mental illness, but the program wouldn’t be operational for many months. “Right now everyone is running around in crisis mode, trying anything they can, but there’s a lot of mismatched interventions, and no sense to it,” one health-system insider told me.

  “In the meantime,” Kuehl told me, sighing, “I’m definitely getting a bigger car.”

  Four months later, the women were crushed to learn they did not get the grant.

  Though she was still grieving her son’s fentanyl-overdose death—Bobby had been dead now for fourteen months—Janine Underwood thrust herself into the Hope project with vigor. She wasn’t a believer in harm-reduction strategies or MAT, but she was trying to keep an open mind. When users shot up in the parking lot at the clinic—“getting their last hurrah,” she called it—police declined to take action, knowing it would inhibit users from coming.

  Like most of the angels, Janine allowed participants to contact her on her personal cellphone. Texts and calls came by the scores, ranging from grieving mothers who wanted the ear of another mom who’d lost a child to a young heroin user named Matthew who’d heard about the program and just wanted to talk. He was suicidal, he said, and they spoke multiple times over the course of several days.

  When Janine learned that Matthew had hanged himself the day before he was scheduled to come in, she fell apart. “Before I knew it, I was becoming a crisis center,” she told me, a month into the program. “I was in over my head.”

  The following week, a young woman escorted to the clinic by police staggered indoors, then exhibited signs of overdose in the clinic foyer, necessitating a 911 call and several doses of naloxone to bring her back. And though Janine left follow-up messages with her, she never called or returned.

  A conservative Rotarian, Janine realized that barriers to treatment were more formidable than she’d understood, as was the epidemic’s scope. It wasn’t just the money and limited treatment capacity that waylaid people; it was the morphine-hijacked brain, the scrambled neurotransmitters that kept people from thinking clearly or regulating their pain with nonnarcotic substances, or imagining the possibility of feeling happy again.

  Janine wished for a way to force users into treatment, a detention order for the heroin-consumed brain. Bills to involuntarily commit users were increasingly being introduced in state legislatures from Kentucky to Massachusetts, but there were civil liberties concerns, and patients-rights groups and many experts believed coerced treatment backfired more often than not.

  Twenty-two people walked into the Hope Initiative in the first month, and the angels felt they were making progress with some, the ones who expressed repeated interest in getting help and continued to text and call. Still, exactly zero of them had entered residential treatment, and only a handful had been able to access outpatient MAT. Janine was so mentally exhausted that her colleagues had to call EMS after she passed out from stress-related vertigo at work one Saturday.

  Looking back now, the spreadsheet the angels had so carefully created seemed naive, akin to spraying citronella oil on a termite infestation and expecting your home’s crumbling foundation to magically reconstruct itself.

  The first Hope Initiative success came months into the program and took weeks of life-and-death negotiations—dozens of phone calls, days of hand-holding, and thousands of dollars, eventually, to arrange residential treatment placement for a single patient. Janine had personally spent eight straight hours in the emergency room with the family of “John” (not the person’s real name), a ten-year heroin user who had been a friend and fellow user with her son Bobby. John had tried detoxing at home, but his parents took him to the hospital when he became too sick, partly from needle-stick abscesses on his hands and arms, his temperature soaring to 103.

  Janine wiped the young man’s dopesick sweaty brow, rubbed his back when he writhed in pain, and comforted him when nurses could not find a vein receptive to a m
edication IV. His parents sat nearby, paralyzed in their fear and unable to help. “I want to get this out of me,” John told Janine, between screams. “It’s like a demon, and I want to get it out.”

  Janine had pulled strings to have John directly admitted from the hospital into detox, a rare handoff with no waiting—only to be slammed by the emotional wallop of visiting John the next day and walking the same corridor where she’d once delivered clothes to her son. “Because of his connection with Bobby, I feel like he’s listening to me, but the truth is, he could walk out any time,” Janine said. By day three of detox, John was already calling his parents and pleading over the phone, “Dad, come pick me up.”

  A Hidden Valley couple, his parents were unable to direct his care or even process what was happening to him. They’d been enabling John’s addiction for ten years, supporting him and allowing him to live in their home. “They were completely frozen,” Janine said.

  John’s dad, a retired law enforcement officer, told Janine he’d given many tough-love lectures to parents on the job, but when it came to his own son he was helpless, even denying that the constellation of scars on his son’s arms were track marks.

  “They couldn’t even call the detox center from the hospital; they needed someone to do it for them,” Janine said.

  And: “They have the disease, too.”

  When it came time to discharge John from detox, a Hope volunteer working with John’s father arranged for him to fly to an out-of-state treatment center, but it was up to Janine to make the transfer work. To do that, she coaxed the detox center to keep John an extra day, then arranged for an intervention between John and his family members off-site. (Detox managers would not allow the meeting to take place there, not even in their parking lot.) “I was starting to panic; I had that sick feeling in my stomach again,” Janine said. The liminal window was beginning to close.