Dopesick

by Beth Macy

  In 2017, two decades after OxyContin erupted in Lee County, Virginia’s Board of Medicine ordered that, to prevent doctor-shopping, all doctors were to check the drug-monitoring system every time they issued a prescription. This mandate arrived at the same time new CDC figures showed that residents of two rural Virginia towns had been prescribed more opioids per person than any other place in the country. (The top locality was Martinsville, and the fourth was Galax, the small cities where my book Factory Man was largely set.)

  As far behind as Virginia had been in its initial response, state health-department officials were now working hard to expand MAT as well as to crack down on its abuse. The expansion was mostly modeled after a Suboxone clinic in rural Lebanon, called Highpower, where a younger version of Art Van Zee, Dr. Hughes Melton, set up practice in 2000 because he wanted to treat the underserved. Melton was helping direct the state’s response to the opioid crisis; among his initiatives was a new statewide push for syringe exchange and some tighter controls on MAT prescribing. His wife, Sarah Melton, a pharmacy professor and naloxone trainer, hadn’t just given training sessions to more than four thousand doctors about the perils of opioids; she’d turned in a fair number for overprescribing them, too.

  The Meltons were so busy that often the only times I could interview them were at night or when they were in their cars. It was in their Highpower clinic that several patients had first explained the diversion and abuse of buprenorphine to me—a practice harm-reduction proponents elsewhere in the country dismissed every time I brought it up.

  Finding a balance between treating and perpetuating addiction had been pursued in the United States since the 1800s, when doctors used morphine to wean patients from laudanum, then later used heroin to get patients off morphine. Soldier’s disease had sparked a period of stern prohibition in the Harrison Act and, eventually, the War on Drugs. “Our wacky culture can’t seem to do anything in a nuanced way,” explained Dr. Marc Fishman, a Johns Hopkins researcher and MAT provider.

  While Fishman believed buprenorphine, methadone, and naltrexone were all imperfect solutions, they remain, scientifically speaking, the best death-prevention tools in the box. “I apologize for my white-coated, nerdy scientist colleagues who have not invented better yet, I get it!” he said. The naysayers would be more open to MAT if its proponents would more openly acknowledge the drawbacks of maintenance drugs—significant relapse rates when patients stop treatment, for instance—instead of portraying them as a kind of perfect chemical fix, Fishman argued.

  The explosive costs of addiction-related illness will eventually force health systems to integrate addiction treatment into general health care, he predicted, including a smoother transition of overdose patients from hospital ERs to outpatient MAT. “Too often, we’re still giving them Narcan, then sending them along with a tired old Xerox of AA meeting phone numbers, and telling them, ‘Have a nice life.’”

  In a treatment landscape long dominated by twelve-step philosophy, only a slim minority of opioid addicts achieve long-term sobriety without the help of MAT, Fishman reminded me. “AA is not a scalable solution in an epidemic like this, and most opioid addicts just can’t do it” without MAT, he said.

  In the Appalachian Bible Belt, a blend of MAT and twelve-step programs seemed to work best, which is why Art Van Zee and Sister Beth Davies still communicate daily about their patients, the nun letting the doctor know, for instance, when a shared patient suffers a personal setback, like a death in the family or a job loss. It had happened in the spring of 2017 with one of their longtime patients, Susan (not her real name), whose brother died of overdose. Then, a few months later, Sister Beth emailed me that it had happened again: Another of Susan’s brothers died of overdose, the youngest, whom she’d “practically raised. The loss is tremendous.”

  Among Susan’s ten siblings, only three had managed not to become opioid-addicted, although one of the three was a pill dealer who didn’t himself use, Susan had told me. She’d been in Van Zee’s Suboxone program for six years and was now transitioning off disability via a program called Ticket to Work. She was putting in twelve-hour shifts as a nursing-home licensed practical nurse and going to the local community college to earn her registered-nurse degree.

  “Some of my family’s like, ‘Why don’t you just keep your [disability] check and stay home?’

  “And I’m like, ‘I’ve always wanted to go to school to be a nurse, and I can’t make it on seven hundred and forty dollars a month, and besides, you just feel so much better about yourself when you work.’”

  Asked how the epidemic had changed her community, Susan sighed and told me it was now just an ingrained part of the culture. Her fifteen-year-old son believes the only way to avoid its perils is to move away. “I can’t live here, Mom,” he told her. “There’s nothing here but drugs and nursing homes.”

  The first time Susan saw Van Zee, he spent two hours with her, learning her medical history, including the details of her addiction and childhood abuse. She’d recently had surgery for lung cancer, and he did not make her feel like crap for continuing to smoke (though he suggested she stop).

  The members of her twelve-step support group—the one led by Sister Beth—like to joke: “When you go to Van Zee’s office, you might as well take a pillow and a blanket and a book, because you’re going to wait there a long time.” They worry, though, about what they will do if something happens to the seventy-year-old doctor and the eighty-three-year-old nun. “There’s so many of us who would just be—lost,” Susan said.

  Van Zee was still working sixteen-hour days, much to Sue Ella’s chagrin. He was still conferring daily with Sister Beth over their growing roster of opioid-use-disorder patients (now the preferred term)—not counting the 150 people on his waiting list—either on the phone or via email multiple times a day.

  Van Zee told me his greatest fear now was of being hit by an intoxicated driver while he jogged the winding roads—not because he feared his own death but because where, then, would his patients go?

  Nationwide, attitudes about the drug-addicted were shifting, faster in urban settings than rural. At the edge of Boston’s South End, in a neighborhood some derisively called Methadone Mile, I stood in the low light of a homeless shelter clinic where users converged on a former conference room to be medically monitored as they rode out their heroin highs, often staggering in, propped between friends. In the facility’s public restrooms, a clever maintenance worker had rigged reverse-motion detectors that sounded visual and audible alarms to summon help if a person hadn’t moved for four minutes. The initiatives were the brainchild of the shelter’s medical director, who had sometimes tripped over bodies on her way to work, some of them having been fatally struck by cars. Dr. Jessie Gaeta’s goal in opening Supportive Place for Observation and Treatment inside the shelter was to keep users alive until they were ready to be funneled into treatment, as well as to separate them from those in the homeless community already in recovery (almost a third of the shelter’s clients have opioid-use disorder).

  But the brownstone-filled neighborhood was rapidly gentrifying, and the cultural obstacles, even in liberal Boston, were significant. Neighbors were worried that SPOT would just attract more heroin users, dirty needles, and crime. Many accused Gaeta and her staff of enabling continued drug use.

  The project got the neighbors’ reluctant blessing, but only after Gaeta invited community leaders and officials to the shelter and showed them what would happen in the small, ten-recliner room.

  Over the course of more than fifty neighborhood meetings, “I got my ass kicked, basically,” she said.

  But many skeptics were won over when they realized she was treating the problems that were already happening outside indoors. In a program that didn’t even keep patients’ names on file (a strategy called low threshold, to build trust), staffers monitored those who stumbled in on heroin combined with an increasing multiplicity of other drugs.

  The SPOT room was the first place where sk
ittish rape victims would let Gaeta administer proactive treatments for sexually transmitted illness as they tentatively told her their stories in an adjoining kitchenette. Only then would they allow her to stanch the bleeding brought on by forced sodomy with a gun or by duct tape ripped from their mouths.

  “Even in a mission-based organization, there’s still so much stigma around how we should treat addiction,” Gaeta said. “You have to constantly fight this notion that we shouldn’t wrap our arms around people who don’t want treatment.”

  Everywhere in America, it was painstaking to walk skeptics through the social, criminal, and medical benefits of helping the least of their brethren, but worth it—even if you had to get your ass kicked.

  In Appalachia, harm reduction was very slowly making inroads. In Lebanon, Virginia, where anti-MAT drug-court workers had once been castigated by harm-reduction proponents, Judge Michael Moore’s hair had turned from salt-and-pepper to white in the year since I’d first interviewed him.

  But the top Russell County prosecutor had recently signed off on allowing the drug court’s first Vivitrol participant, a thirty-year pill addict who admitted she could not stop abusing buprenorphine. Moore praised the prosecutor’s decision and viewed it as a harbinger of greater sensitivity in the criminal justice system to the realities of addiction. Half the probationers from his regular circuit-court docket were now on Suboxone, and “we do see good things with it,” he said. If his own kids were addicted, he told me, he, too, would want the option of MAT.

  “Last fall the governor declared opioids an epidemic and I was like, ‘Are you kidding me? We’ve had the epidemic since 2002!’” Moore said. One of his present drug-court participants, in fact, was born dependent on the drugs.

  “It’s really discouraging and scary because what kid, sixteen or seventeen, doesn’t know that opiates are addictive? They can see it in their family, so how can they not know, and yet they take them anyway. And there are parents out here just like me, or better, who have drug-addicted kids.”

  The local schools had recently adopted new prevention models, after studies showed kids were more likely to use drugs after DARE. (One advocate told me she remembered her classmates sharpening the DON’T off their DARE pencils so they actually read DO DRUGS.) A new school policy diverted first-time juvenile offenders into treatment instead of expulsion or jail.

  On Thursday nights, Judge Moore helps serve dinners to participants in a twelve-step program at a local church. He also persuades his friends in the community—from fast-food managers to local contractors—to hire his drug-court participants.

  At a recent jury orientation, Moore’s bailiff was approached by two boys, ages four and five. Neil Smith thought they were the grandchildren of a potential juror, but it turned out they were only temporarily with him as foster children, and they were looking for a permanent parent—a fact that became clear when the boys took one look at his bailiff’s uniform and asked him, “Will you be our daddy?”

  Smith is on the far end of middle-aged, a kindly-looking sort. Both his parents worked in the mines, and they grew a twelve-acre plot of tobacco on the side near the hamlet of Cleveland. His first memory of the judge was from when they were both kids: He remembered an adolescent Michael Moore getting on the same Russell County school bus that he rode, his face obscured by an armload of books, his bright future laid out before him.

  One of the truest things I heard in my reporting came from David Avruch, a Baltimore therapist who works with a largely homeless, heroin-addicted clientele. In his experience, the base problem wasn’t a dearth of harm reduction but an economic structure that created more foster kids and fewer Michael Moores.

  “The more we talk about the epidemic as an individual disease phenomenon or a moral failing, the easier it is to obfuscate and ignore the social and economic conditions that predispose certain individuals to addiction,” Avruch said. The fix isn’t more Suboxone or lectures on morality but rather a reinvigorated democracy that provides a pathway for meaningful work, with a living wage, for everybody.

  Judge Moore asked me, three times in one sitting, what I had learned from my reporting that he could feel hopeful about. He chuckled as he said, “I can’t wait to read your book, because then maybe we’ll know what to do”—but he seemed closer to tears than laughter.

  I told him what Sue Ella Kobak had said, more times than I could count: “The answer is always community.” I told him about Teresa Tyson’s Health Wagon and Sue Cantrell’s commitment to stopping the spread of hepatitis C. The elusive gap between law enforcement and health care seemed as if it were finally beginning to close, I explained, even in a few remote Appalachian towns.

  I described a faith-based treatment center in nearby Bristol that had just turned a donated former nursing home into a rehab with 240 beds. Geared to housing addicted people, veterans, aging-out foster kids, and ex-offenders getting out of jail, it had been brought to fruition by Bristol Recovery Center director Bob Garrett, who had spent three years forging collaborations with local courts, police, churches, and social service agencies. Participants would eventually pay to live in the center, nestled in a peaceful wooded compound, after they found jobs with the center’s help.

  At first, Garrett told me, he wasn’t going to allow participants to be on MAT, but he changed his mind after serving on a community coalition spearheaded by East Tennessee State University public health professor Robert Pack. Since then, he’s preached the benefits of “evidence-based treatment” to churches across the state at dinners and presentations on addiction. “We want to show [the addicted] that they’re loved and cared about,” he told me. “And we’re trying to teach the lay folk, ‘They’re not really bad people,’ and ‘That’s a sin’ doesn’t really work.”

  I told Judge Moore, finally, that Pack’s coalition—an alliance of mental health and substance abuse administrators who call themselves the working group—had just scored another coup. Of all the upstart recovery programs I had surveyed in my reporting, this collaboration represented the strongest model for thwarting governmental rigidity and bureaucratic indifference to the crisis, and it had the potential to be replicated elsewhere.

  In a rural town between Johnson City and Kingsport, Tennessee, the alliance was about to open a treatment clinic called Overmountain Recovery. It was deliberately named: Overmountain, for the disparate group of local farmers and frontiersmen, called the Overmountain Men, who beat back the British in the Battle of Kings Mountain, turning the tide in the Revolutionary War; and Recovery, because the treatment is meant to go beyond MAT to include group and individual counseling, yoga, and other alternative therapies, plus job-training support. Though the outpatient clinic would eventually offer Suboxone, it would predominantly be a methadone clinic, because methadone is cheaper and harder to divert (participants drink the liquid daily in front of a nurse), and the nearest methadone facility in the region was over a mountain some sixty miles away.

  “We would not have pulled this off without the working group,” said Pack, who began his addiction research after losing a dear friend to opioid-related suicide in 2006. With the backing of his university, the region’s nonprofit hospital corporation, and the state’s mental health agency, Overmountain was the latest project of Pack’s working group, which had secured $2.5 million in grants, eight funded projects, twenty-five research proposals, and the opening of a Center for Prescription Drug Abuse geared toward research. And, maybe even more important, it was co-led by Dr. Steve Loyd, a charismatic physician with local roots who had been opioid-addicted himself.

  Located in Gray, Tennessee, a solidly middle-class community of farmers and suburbanites, with Daniel Boone High School just a mile and a half away, Overmountain fought a mighty resistance on its march to opening its doors, in September 2017. Headed by a respected area farmer, Citizens to Maintain Gray worried that patients taking methadone would be too high to drive safely. And, while the members of the group weren’t exactly against the idea of the center, t
hey didn’t want it anywhere near them, even as some admittedly privately to Loyd and Pack, “My son is dealing with this.” But the working group showed up and heard them out. They brought in outside police chiefs and methadone providers, giving decision makers examples and studies from other communities that overrode their safety concerns. To win near-unanimous approval from the city zoning board and the state, they willingly endured more than a year of public ass kicking. In a community of just 1,222 residents, more than 300 people had spoken out publicly against the project, some referring to Pack and Loyd as drug lords.

  In recovery for more than a decade, Loyd knew exactly how to explain himself to people in his hometown, to make them see the struggle anew: Before seeking treatment, he had doctor-shopped his own colleagues, stolen from relatives’ medicine cabinets, and even faked an ankle injury so he could have orthopedic surgery and get discharged with painkillers. His father called him out on his addiction in 2004 and forced him to get help, funneling him into ninety days of inpatient rehab, followed by five years of random drug screens, support services, and intensive monitoring.

  A key component of Loyd’s success was the threat of punishment; his medical license could be yanked if he relapsed and/or made a critical medical error while treating a patient. He still checks in daily for the possibility of a random drug screen, via an app on his cellphone, even though he’s now Tennessee’s assistant commissioner for Substance Abuse Services. The daily routines of his life as a recovering addict and physician keep him committed to recovery, just as the scar on his left ankle reminds him how desperately low the drug-addicted can go.