by Beth Macy
John’s father hired an “interventionist,” a retired cop whose job was escorting, by force if necessary, reluctant patients into treatment. Another local agency offered a conference room, and everyone involved lied to John to get him there, saying it was outpatient counseling he was signing up for on his way home, not residential care.
“I played the Bobby card,” Janine admitted the next day on the phone.
And yet it had still taken four hours to persuade John to go, the volunteer angels sighing, finally, when he got on the plane.
As soon as one bureaucratic gap was stitched up—and that could take days—another rip appeared. Government help was on the way in many states, but the national treatment tapestry remained a hodgepodge, divided not only along geographical but also firm ideological lines.
In late 2016, Virginia State Health Commissioner Marissa J. Levine declared the state’s opioid crisis a public health emergency, noting that three Virginians were dying every day from drug overdose and that emergency departments across the state were seeing more than two dozen overdose cases a day. Levine also issued a standing order, or blanket prescription, allowing any resident to buy the opioid antagonist naloxone (brand name Narcan), the overdose-reversing drug.
Public health officials in Vancouver were miles ahead of most of America in so-called harm reduction, a social justice movement aimed at reducing the negative consequences of drug use—without necessarily ending the use—and, more broadly, treating users with dignity and respect. The basic theory being: Users can’t get sober if they’re dead, and it’s cheaper and more humane to give them clean syringes, say, than it is to pay for HIV and/or hepatitis C treatment. Vancouver officials launched supervised injection sites where nurses stood by to revive overdosed users, fostered the free exchange of used needles for clean ones, and distributed naloxone. Sites in Toronto and Ottawa were also approved.
Several liberal-leaning American states and cities have used Vancouver as a model, including Seattle, where officials in 2017 approved the nation’s first safe-injection program for users of heroin and other illegal drugs, even though it was still illegal under federal law. In Massachusetts, where the opioid death toll now claimed five lives a day, some Bostonians carried naloxone kits, signaling their ability to administer it by placing a purple ALLY patch on their backpacks. Prevention workers were piloting fentanyl test strips so users could gauge the potency of the drugs before they used them, then take smaller doses, avoid using alone, and have naloxone at the ready in case of overdose.
In San Francisco, Seattle, Philadelphia, and even Greensboro, North Carolina, drug-user unions were working to combat the stigma of addiction and advocate for harm reduction, pushing for wider naloxone distribution and needle exchanges, and even negotiating with drug dealers when batches of fentanyl entered the local supply. “Our goal is to end the drug war and to hold treatment providers accountable,” said Louise Vincent, who runs a Greensboro needle exchange paid for by state and private funds. “When you pay fifty thousand dollars for treatment and rehab, I believe you should get the gold standard of care,” including MAT, she said. She also argued for stricter regulations of “cash-cow Suboxone clinics.”
But there is still only one treatment bed available for every five people trying to get into rehab, and at a cost far beyond the financial reach of most heroin users. And for all the treatment money paid by people like Tess’s octogenarian grandfather, rehab isn’t standardized, nor does it often dovetail with what science says is the gold standard for opioid treatment: medication-assisted therapies. (Only about a third of all U.S. treatment centers allow MAT.)
“It’s really going to take doctors standing up for this, and it’s going to take going against the very vocal twelve-step recovery community, which is most at odds with the work the harm-reduction movement is trying to do,” said Vincent, a recovering heroin user who pays $480 a month, cash, for daily methadone maintenance.
In Baltimore, where the overdose death rate was six times the national average (and where much of Roanoke’s heroin supply originates), the health department has long deployed a needle-exchange RV to heroin hot spots six days a week, offering disease testing in addition to clean needles, naloxone training, wound care for injection abscesses, and prenatal care. The initiative is credited with reducing needle-injected HIV instances from 64 to 8 percent. Conservative then–Indiana governor Mike Pence responded, albeit reluctantly, to the 2015 Scott County HIV outbreak that infected 175 people with a limited needle exchange.
In San Francisco, recovering heroin user and certified addiction specialist Tracey Helton Mitchell launched her own renegade harm-reduction movement in 2003 by mailing out free packages of clean needles and naloxone vials. In the opioid-minded Reddit forum where she became known as the Heroine of Heroin, Mitchell still shared counseling and intervention strategies, answering some fifty emails a day.
She continues to receive calls from frantic users in large swatches of the country eager for clean needles, information, and naloxone. “We’re in the absolute dark ages in most of this country for syringe exchange,” she told me, describing users with worn needles broken off in their arms, or people who reuse needles found in the gutters and then sharpened with matchbooks. “We’re years behind catching up, and the drug deaths haven’t even peaked yet.”
And yet the ideological gulf I witnessed between the criminal justice establishment and families like Tess’s seemed to grow wider by the day. Kevin Coffman, a drug task force member who’d worked the Ronnie Jones case, told me he firmly believed we could end the opioid epidemic with a single stroke of Trump’s pen: imprison heroin users for life the third time they got caught with the drug, and that would have a chilling effect on remaining users, who would logically, he believed, give up their drugs.
We were sitting in the same room where Coffman and Bill Metcalf had mapped out Jones’s heroin ring. It was next to the kitchen, where a TRUMP–PENCE sticker was pasted on the refrigerator door. Not only did the detective have zero empathy for the addicted, but he also lacked any scientific understanding of the morphine molecule’s pull.
Nor did some of my dear friends, longtime members of AA, who remain staunchly opposed to harm reduction and MAT for those working its twelve-step program. “There’s a reason why some people think NA and AA are cults,” said Mitchell, who used methadone, needle-exchange programs, and a secular support program called LifeRing to treat her heroin addiction. “They can’t take in any other information because it throws a different light on their own personal recovery.”
As Trump-appointed attorney general Jeff Sessions said in March 2017: “We need to say, as Nancy Reagan said, ‘Just say no.’ Don’t do it.”
Two months later, the Trump administration proposed gutting the office of the White House drug czar, reducing its budget by $364 million, despite Trump’s campaign vow to combat the nation’s growing opioid epidemic, and backed health care changes that would have put the most vulnerable users at risk. After a backlash, Trump rolled back his proposal to relatively modest trims. But more than a year after his inauguration, the office still lacked a permanent director, Trump remained more focused on law enforcement than public health strategies, and a comprehensive list of recommendations written by his own presidential commission remained a work in progress or unaddressed.
Harm reduction remained slow to catch on in most of the Bible Belt, including Roanoke. When I told Janine about an idea hatched at an opioid brainstorming session in Boston—to segregate users on a boat in international waters, where they could legally inject under medical supervision, ideally then transitioning to counseling and MAT—she was repulsed. “That’s crazy! We’ve created this problem, and now we decide we’re just going to continue to let it happen, and that’s the answer?”
And yet she was miles ahead of most leaders in her conservative community. She’d told her son’s story recently to the local school board and county officials, hoping to raise money for the county’s risk prevention c
ouncil, which was currently running on fumes and a few small federal grants. She’d explained how she’d pulled strings to get her kids into the Hidden Valley school zone because she considered it a superior place to raise children. But the affluence she believed would protect her family had instead allowed the festering of shame and inaction. Almost daily the Hope Initiative took a call about a heroin user from Hidden Valley or nearby Cave Spring, and police data showed that the problem was worse by far in those two communities than in other, less affluent areas of the county.
“I was just a mom trying to make them aware of what’s happening here, that they should be aware. But there was dead silence in the room,” Janine said. “Nobody asked me a question. I just spoke, and I sat down.”
The school board declined to support the program, and the county gave its usual $2,000.
Of the fifty-seven people who came seeking treatment in the Hope Initiative’s initial months, the volunteers had persuaded only two people to begin residential treatment. About fifteen were referred to MAT outpatient programs—seven of whom were still in recovery a year later. Neither Tess nor her friend Joey was among the successes, though both were regularly in touch with Hope volunteers.
Tess seemed to be nowhere close to accepting help, Patricia told me, in early 2017. We sat next to each other at a drug-prevention forum put on at Tess’s alma mater, Cave Spring High, as judge after cop after grieving parent talked about rising overdose calls (thirty in the first six weeks of the year), more than a doubling of Narcan administrations, and increasingly potent seizures of fentanyl-spiked heroin.
Janine told Bobby’s story publicly for maybe the twelfth time. She finished by describing a recent visit to an urgent-care center with her teenage daughter, who’d sprained her thumb playing softball. After an X-ray and an exam to rule out a break, the doctor wrote her fifteen-year-old a prescription for a twenty-five-day supply of oxycodone.
“I tore it up,” Janine said. She also called clinic official Dr. John Burton, who said of the incident: “This was a provider who was still doing things the way we used to do them five years ago, and he didn’t get the memo.” A come-to-Jesus ensued, with Burton reminding the doctor of the hospital system’s ER policy of no more than three days’ worth of oxycodone or hydrocodone per prescription, sans refills.
During the Q&A at the end, Patricia stood in the audience and described Tess’s descent from Cave Spring honor-roll student and athlete to heroin addict and prostitute, preyed on by a growing network of drug dealers and pimps.
“I never saw it coming,” she told the crowd. “And I don’t know what the answer is, but I know it’s important we take heroin out from under a dirty rug. We should be talking about it the same way we talk about cancer.”
At the moment, Tess was back in the psych ward of a local hospital, Patricia said later. Hope volunteers Jamie and Terrence Engles were trying to coax her into a long-term rehab center in Nevada, but they were concerned, again, about the problem of the fleeting liminal phase—having a bed available the moment Tess was released from the hospital, not to mention coming up with the $12,000 she still needed for treatment, less the last bit of her college fund. She considered asking her eighty-five-year-old father for an early release of the inheritance he planned to leave for Tess, knowing the money would be no good to her dead.
Patricia had visited Tess at the hospital the night before, taking her grandson with her, and Tess beamed at the sight of her boy. It was the first time she had seen him in ten months.
But she had a methamphetamine rash on her face, and track marks extended from her biceps to her wrists. She was newly diagnosed, too, with hepatitis C, her weight down to ninety pounds. When Tess got on the hospital floor to crawl around with her son, Patricia saw abscesses on the back of her head. “She’s the sickest I’ve ever seen her, but she has no idea how sick she is!” Patricia told me.
After the forum, Tess’s onetime track coach walked up as we were talking and told Patricia he was stunned by her remarks. “She was such a good kid, I mean…Tess was just an awesome kid.”
The latest research on substance use disorder from Harvard Medical School shows it takes the typical opioid-addicted user eight years—and four to five treatment attempts—to achieve remission for just a single year. And yet only about 10 percent of the addicted population manages to get access to care and treatment for a disease that has roughly the same incidence rate as diabetes.
But Patricia wasn’t giving up on her father’s generosity, and she wasn’t giving up on Tess. Neither was Jamie. “We all knew that if we didn’t actually have a car waiting to take her to the airport from the hospital, she’d never go,” Jamie said.
Tess had lost her ID, and Patricia persuaded a kindly hospital employee who happened to be a notary public to create a new, makeshift one for her so she could get on the plane. Hope volunteer Terrence Engles, in recovery for five years, coordinated the transfer between the hospital and the cab that ferried Tess to the airport on February 26, 2017. The Nevada treatment center did not accept patients on MAT. Tess had quit Suboxone months earlier—she’d lost her Medicaid coverage when her son was removed from her care—and was mostly now using crack and heroin.
Tess would end up being the Hope Initiative’s fifth person to be funneled into residential treatment, though only time would tell if the Nevada attempt would be her last. “I feel like a spectator watching a movie and just hoping and praying it ends well,” Jamie said.
Patricia compared the precariousness of the situation to a balloon with a pin poised a millimeter from the edge. “It’s like, dear God, please please do not pop this balloon,” she said. “Because there is no love you can throw on them, no hug big enough that will change the power of that drug; it is just beyond imagination how controlling and destructive it is.”
After an initial hiccup—Tess transferred in her second week to a smaller women’s facility nearby called the We Care House, saying the first place wasn’t a good fit—Patricia said she was “doing great” a month in, and would soon transition to aftercare. Her granddad had stepped in with her early inheritance, putting $12,000 toward her treatment.
Jamie Waldrop and I both sent cards of encouragement, and I included a copy of Mitchell’s Big Fix: Hope After Heroin because it offered the clearest framework for getting sober that I had read. The author, in recovery for nearly two decades, was not opposed to MAT (even though replacement medication had not been her ultimate path), and her book was full of hopeful data like this:
If Tess could remain sober for a year, she had a 50 percent chance of relapsing. If she stayed sober five years, her chance of relapse was less than 15 percent.
At the Hope Initiative, triaging Tess now shifted to triaging her friend Joey Gilbert. The two had couch-surfed together in southeast Roanoke, trading intermittent texts about dopesickness, Xanax, and crystal meth. Joey had arrived at Hope with her mom in early 2017. She tried going cold turkey during a brief stint at the abstinence-only rescue mission program—and didn’t last twenty-four hours before fleeing, telling Jamie she was too sick and couldn’t handle it. “She told me, ‘As long as I can use the Suboxone, I can wean myself down,’” Jamie said. Her goal was to become someone who helps other people get off drugs.
“I know I can do it,” she’d tell Jamie.
“I know you can, too,” Jamie said.
A beautiful young woman, with long blond hair and blue eyes like crystal orbs, Joey had graduated from Hidden Valley High in 2007, the same year as Tess. She excelled in art and music, and once had a three-year string of near-daily Goodwill shopping fueled by a personal style rule that every accessory or piece of clothing had to match the color she’d chosen that day—if her outfit was green, then her earrings, shoes, and tights had to all match, down to her rings. Joey liked to share her opinions on everything from Freddie Mercury to eye makeup to the best dance moves when making a Facebook workout video to the Prince song “When Doves Cry.”
“She’s the funniest
person I’ve ever known; she’s literally a ball of fire,” said her best friend, Emma Hurley. A boyfriend had introduced Joey to pills in high school, then heroin shortly after that. They were part of the Hidden Valley group of early opioid users that included the late Scott Roth and Janine’s son Bobby. Over the next decade, Emma would lose three close friends and ten acquaintances to opioid overdose. A friend of many of the Hidden Valley users told me he no longer asks what happened when people phone him to say that another friend has passed. “I already know,” he tells them.
“Hidden Valley was where it all started with my friends,” Emma said. “I just happened to say no to the harder stuff. You’d be at a party, and it was, ‘Hey, try this, have a beer, pills, cocaine, anything you could use to get a little bit higher.’” She separated herself from the group when IV heroin became part of the mix, she said.
“It was just overwhelming, the ups and downs of clean Joey and relapsed Joey,” Emma said, recalling that supposedly sober Joey had talked her into sharing an apartment in 2013, and swore that she no longer used heroin. “I wouldn’t have let her move in with me if I had known,” Emma said. “Eventually, she’d do it [heroin] right in front of me; it was tough.” They parted ways over a missing six dollars, and for six months they didn’t speak.
“This too shall pass,” Joey had written around that time on her Facebook page. “It might pass like a kidney stone, but it will pass.”
Joey was not only still using, but she had also allowed an abusive drug dealer and the dealer’s girlfriend to move in with her in exchange for drugs, unbeknownst to her dad. “She was ashamed of how low she’d gotten herself in her own eyes,” Jamie said. She and Cheri Hartman, a Hope volunteer, worked to find Joey a residential-treatment bed, according to the new Hope policy of volunteers working only in pairs, which allowed them to share the heartache as well as the tasks.
