by Beth Macy
Police Assisted Addiction and Recovery Initiative: Brian MacQuarrie, “‘Angel’ Opioid Initiative Thrives Despite Exit of Gloucester Police Chief,” Boston Globe, Feb. 21, 2017.
Janine had spent the previous seven years: Bobby’s story and the beginnings of the Hope Initiative outlined in multiple author interviews, Janine Underwood, beginning Aug. 3, 2016.
“It was like we had a Dementor from Harry Potter”: Author interview, Jamie Waldrop, Nov. 6, 2017.
a former pro baseball player who’d progressed: Author interviews, Terrence Engles, Jan. 4, 2016, and subsequent interviews.
“RomneyCare”: Kenneth Rapoza, “If ObamaCare Is So Bad, How Does RomneyCare Survive?,” Forbes, Jan. 20, 2012.
sacrificing $6.6 million a day in federal funds: “McAuliffe Pushes Virginia Medicaid expansion After GOP’s Failure to Repeal Obamacare,” CNN Wire, March 27, 2017. Republican House of Delegates speaker William Howell claimed an expansion would take state resources from education, transportation, and public safety, even though 90 percent of the bill would be footed by the federal government.
In states where Medicaid expansions were passed: Noam N. Levey, “Tens of Thousands Died Due to an Opioid Addiction Last Year. With an Obamacare Repeal, Some Fear the Number Will Rise,” Los Angeles Times, June 21, 2017.
It gave coverage to an additional 1.3 million: Sally Satel, “Taking On the Scourge of Opioids,” National Affairs, Summer 2017: 21.
political plot that seemed lifted from: Laura Vozzella, “Virginia Democratic Senator Puckett to Resign, Possibly Dooming Push to Expand Medicaid,” Washington Post, June 8, 2014. Political wrangling for favors: Jeff Schapiro, “McAuliffe, Others Pressed Puckett to Stay,” Richmond Times-Dispatch, June 10, 2014.
removed himself from consideration for the tobacco post: Puckett denied the quid pro quo, saying his talks with the Republican-controlled tobacco commission began only after he’d decided to leave. “At this point in my life, I feel that I cannot allow my political career to hamper my daughter’s future,” he said in a statement, according to Trip Gabriel, “State Senator’s Resignation Deepens Political Turmoil in Virginia,” New York Times, June 9, 2014.
while a six-month federal investigation: Andrew Cain, “U.S. Attorney’s Office Closes Puckett Probe, Will Not Seek Charges,” Richmond Times-Dispatch, Dec. 12, 2014.
a thousand more than died from AIDS in 1995: Centers for Disease Control and Prevention, as outlined in charts in German Lopez and Sarah Frostenson, “How the Opioid Epidemic Became America’s Worst Drug Crisis Ever, in 15 Maps and Charts,” Vox, March 29, 2017.
sixty-five new cases reported that year: NAS cases in Virginia had climbed from 88 in 1999 to 493 in 2013; in the Southwestern health district, there were 65 new HIV cases in 2015 and 46 in 2016, according to the Virginia Department of Health: http://www.vdh.virginia.gov/data/opioid-overdose/.
“My fear is that these are sentinel areas”: Dr. Art Van Zee’s letter to Purdue senior medical director Dr. Dan Spyker, Nov. 23, 2000.
Chapter Ten. Liminality
Interviews: Tess Henry, Patricia Mehrmann, Dr. Hughes Melton, Dr. Lisa Andruscavage, Kim Ramsey, Dr. Cheri Hartman, Kate Neuhausen, Missy Carter, Chief Mark Mitchell, Sarah Melton, Nancy D. Campbell, Dr. Steve Loyd, Judge Jack Hurley, Anne Giles, Don Flattery, Dr. Art Van Zee, Dr. Nora Volkow, Dr. Jennifer Wells, Jamie Waldrop
Suboxone is typically the preferred MAT: Standards shifted in 2017; Virginia Board of Medicine guidelines now recommended pregnant mothers use Subutex for no more than seven days before transitioning to Suboxone. Author interviews, Dr. Hughes Melton, March 31, July 1, Oct. 3, and Oct. 28, 2017.
Subutex babies, about half of whom require: Half of babies born in Roanoke to mothers on MAT require NICU care, usually involving methadone given twice a day, for an average in-hospital period of 7.7 days, according to author interviews with neonatologist Dr. Lisa Andruscavage, May 10 and 11, 2017, and clinical nurse specialist Kim Ramsey, May 11, 2017.
“If you two wake that baby up”: Author interview and NAS unit visit with Andruscavage, May 10, 2017.
the fifty-five babies born with NAS: Carilion NAS data from Ramsey and Andruscavage; statewide NAS data compiled from Virginia Department of Health: http://www.vdh.virginia.gov/data/opioid-overdose/.
dependent babies released from the NICU: Among the 55 NAS babies born between 2015 and 2016, 37 went home with a parent, 5 with another caregiver, and 13 went directly into foster care (though 2 of the 37 eventually landed in foster care); Andruscavage and Ramsey data. Babies typically wean off their low doses of methadone within three months.
Many have been stigmatized: Author interview, Ramsey.
Access to MAT in Virginia: Author interviews, Melton and Department of Medical Assistance Services director Kate Neuhausen, July 27, 2017.
As a work-around to the Republicans’ refusal: Author interview, Neuhausen.
“When calling facilities there is rarely”: Text to author from Patricia Mehrmann, Oct. 5, 2017.
most families to continue navigating: Author interview, psychologist and Hope Initiative volunteer Cheri Hartman, Aug. 8, 2017.
“Their treatment is a video playing”: Author interview, Missy Carter, June 20, 2017.
(Nationally, roughly half of drug courts): According to the National Drug Court Institute, 56 percent of drug courts allowed MAT, 2016: https://www.ndci.org/resources/training/medication-assisted-treatment/.
“abusing it every which way”: Author interview, Lebanon police chief Mark Mitchell, May 4, 2016.
“a wonderful medicine, but we were seeing”: Author interview, pharmacist and professor Sarah Melton, July 24, 2017.
several of the nation’s top buprenorphine prescribers: Using data from a ProPublica study of Medicaid reimbursements in 2013, John Ramsey, “Clinic Operators See Benefits of Careful Suboxone Use,” Richmond Times Dispatch, Aug. 6, 2016.
Buprenorphine is the third-most-diverted opioid: Sally Satel, “Taking On the Scourge of Opioids,” National Affairs, Summer 2017: 13.
She texted me: Author interview, Patricia Mehrmann, Sept. 3, 2017.
“no one wants to tell Prince”: Monthly meeting of NAS policy board, Roanoke Memorial Hospital, Kim Ramsey, May 11, 2017.
The FBN framed methadone: Multiple interviews about the history of addiction maintenance drugs with historian Nancy D. Campbell, August and September 2017. Campbell and Anne M. Lovell, “The History of the Development of Buprenorphine as an Addiction Therapeutic,” Annals of the New York Academy of Sciences, February 2012: 124–39.
“pharmacologically perfect solution”: Campbell and Lovell, “The History of the Development of Buprenorphine,” citing the researcher P. F. Renault from 1978. First use of Vivitrol in jails in Barnstable County, MA, according to Tina Rosenberg, “Medicines to Keep Addiction Away,” New York Times, Feb. 16, 2016. Aggressive marketing of Vivitrol, with sales going from $30 million in 2011 to $209 million in 2016: Jake Harper, “To Grow Market Share, a Drugmaker Pitches Its Product to Judges,” NPR, Aug. 3, 2017.
While methadone remained on the fringes: Campbell and Lovell, “The History of the Development of Buprenorphine.”
20 percent of returning Vietnam veterans: Lee N. Robins, “The Sixth Thomas James Okey Memorial Lecture: Vietnam Veterans’ Rapid Recovery from Heroin Addiction: A Fluke or Normal Expectation?,” Addiction, August 1993.
The battle lines over MAT: My op-ed on the MAT controversy, “Addicted to a Treatment for Addiction,” New York Times, May 28, 2016.
In 2016, not long after a Kentucky appeals court: The shift of Kentucky drug courts to allow MAT was prompted by a Huffington Post investigation by journalist Jason Cherkis, “Kentucky Reforms Drug Court Rules to Let Heroin Addicts Take Prescribed Meds,” April 17, 2015.
Price disappointed treatment advocates: Harper, “Price’s Remarks on Opioid Treatment Were Unscientific and Damaging, Experts Say,” NPR, May 16, 2017.
“She worked on him in a hurry”: Author interview, Dr. Steve Lo
yd, Tennessee’s assistant commissioner for Substance Abuse Services, Aug. 25, 2017.
resigned a few months later: Juliet Eilperin, Amy Goldstein, and John Wagner, “HHS Secretary Tom Price Resigns Amid Criticism for Taking Charter Flights at Taxpayer Expense,” Washington Post, Sept. 29, 2017.
signaled the administration would significantly expand: Sheila Kaplan, “F.D.A. to Expand Medication-Assisted Therapy for Opioid Addicts,” New York Times, Feb. 25, 2018.
Graduates are roughly a half to a third less likely: National Association of Drug Court Professionals, as cited in Satel, “Taking On the Scourge,”17.
“We’ve had thirteen babies born”: Author interview, Tazewell County drug court judge Jack Hurley, April 20, 2016.
“The best research says counseling doesn’t help”: Author interview, counselor Anne Giles, Sept. 8, 2016. Giles was referring to a British study on 150,000 patients showing that people in abstinence-only care had double the death rate of those who received ongoing MAT, though that study doesn’t compare MAT-only with MAT with counseling: Matthias Pierce et al., “Impact of Treatment for Opioid Dependence on Fatal Drug-Related Poisoning: A National Cohort Study in England,” Addiction, February 2016.
“although some benefit is seen even with low dose and minimum support”: Research on opioid-substitution protocols: John Strang et al., “Drug Policy and the Public Good: Evidence for Effective Interventions,” Lancet, Jan. 7, 2012.
only cash because Medicaid reimbursements were: Author interview, Giles, Sept. 8, 2016. Reimbursements improved in Virginia in April 2017, under new regulations meant to nudge cash-only clinics toward adopting best practices; author interview, Dr. Hughes Melton.
He’d lost his twenty-six-year-old son: Author interview, Don Flattery, Dec. 30, 2015.
Art Van Zee, too, struggled with: Author interview, Dr. Art Van Zee, June 25, 2016.
he hesitated to wean them entirely because: “If tapered off buprenorphine-naloxone, even after twelve weeks of treatment, the likelihood of an unsuccessful outcome is high, even in patients receiving counseling in addition to standard medical management,” according to Roger D. Weiss et al., “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” Archives of General Psychiatry, December 2011.
one study showed that 50 percent of users: Brandon S. Bentzley et al., “Discontinuation of Buprenorphine Maintenance Therapy: Perspectives and Outcomes,” Journal of Substance Abuse Treatment, May 2015: 48–57.
roughly a third of buprenorphine patients: Roger D. Weiss et al., “Long-Term Outcomes from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study,” Drug and Alcohol Dependence, May 2015: 112–19.
his or her relapse feeds the perception: Author interview, Dr. Nora Volkow, April 22, 2016.
One Roanoke woman was so desperate to avoid: Author interview, Dr. Jennifer Wells, May 1, 2017.
“Can yoi please come gwt me”: Text to author from Tess Henry, Feb. 11, 2016.
“misunderstanding with the siblings and with me”: Author interview, Dr. Alan Henry, Dec. 30, 2017.
They stopped speaking: Author interview, April Henry, Jan. 3, 2018.
She was furious with the baby’s other grandmother: Author interview, Tess Henry, at her mom’s house during a visit to see her son, April 20, 2016.
“I’ve never been fucked up”: Author interview, Tess Henry and Mehrmann, April 20, 2016.
Jamie reached out to Tess: Tess Henry’s Facebook page, May 22, 2016.
“Last seen June 11, 2016”: Tess Henry’s missing poster, disseminated by Help Save the Next Girl.
“If only [politicians] understood that getting access”: The Emergency Medical Treatment and Labor Act (EMTALA) requires anyone coming to an emergency department to be stabilized and treated, regardless of his or her insurance status or ability to pay: author interview, Cheri Hartman, Oct. 13, 2017.
“Pray that this time”: Text to author from Jamie Waldrop, July 28, 2017.
Vivitrol shots to people before they left prisons: Sam Quinones, “Addicts Need Help. Jails Could Have the Answer,” New York Times, June 16, 2017. Maine became the thirty-second state to expand Medicaid and the first to do it via a ballot initiative: Michelle Hackman and Jennifer Levitz, “Maine Votes to Expand Medicaid Under the Health Law,” Wall Street Journal, Nov. 7, 2017.
Joey eventually transitioned to buprenorphine: Author interview with Joey’s father, Danny Gilbert, April 14, 2017.
Jamie Waldrop and I visited Tess in the psych ward: Author interview, Tess Henry, LewisGale Pavilion, Oct. 31, 2016.
Roanoke claimed the highest number of emergency-room: RAYSAC needs assessment summary, compiled using Virginia Department of Health data.
young mother dead in her bedroom: Author interview, Vinton EMS volunteer Jordan Fifer, May 1, 2017.
e. e. cummings poem: Tess had memorized the poem, “[I carry your heart with me (I carry it in)],” available here: https://www.poetryfoundation.org/poetrymagazine/poems/49493/i-carry-your-heart-with-mei-carry-it-in.
“Gone to Carilion”: Mehrmann texted me a photo of the note, Jan. 13, 2017.
Chapter Eleven. Hope on a Spreadsheet
Interviews: Janine Underwood, Dr. Karen Kuehl, Erin Casey, Cheri Hartman, Louise Vincent, Mark O’Brien, Tracey Helton Mitchell, Sgt. Kevin Coffman, Nancy Hans, Dr. John Burton, Dr. John Kelly, Jamie Waldrop, Emma Hurley, Danny Gilbert, Charles Cullen, Patricia Mehrmann, Wendy Gilbert, Britney Gilbert, Skyler Gilbert
Fentanyl-overdose calls were coming in: From the first six months of 2016, combined Roanoke city and county counted 85, compared with 38 during the same window the prior year: EMS data and author interview, Janine Underwood, Aug. 3, 2016.
Karen Kuehl begged him not to leave: Author interview, Carilion Clinic emergency-room doctor Karen Kuehl, May 9, 2017.
In one weekend: Author interview, Underwood, May 8, 2017.
the program wouldn’t be operational until 2018: Author interview, Erin Casey, Dec. 14, 2017. Casey led Carilion’s peer recovery specialist efforts.
the women were crushed to learn: Author interview, Cheri Hartman, Oct. 9, 2017.
a way to force users into treatment: Massachusetts and thirty-nine other states allow involuntary commitment for drug treatment: Karen Brown, “Some See Uptick in ‘Voluntary’ Addiction Treatment Commitments as Problematic,” WBUR, Oct. 25, 2016.
many experts believed coerced treatment: William L. White and William R. Miller, “The Use of Confrontation in Addiction Treatment: History, Science, and Time for Change,” Counselor, January 2007: 12–30. Maia Szalavitz outlines a host of reasons in “Attract Patients to Addiction Treatment, Don’t Force Them Into It,” New York Times, May 4, 2016.
“They have the disease, too”: Author interview, Underwood, Jan. 6, 2017.
Levine also issued a standing order: Gregory S. Schneider, “Virginia Declares Opioid Emergency, Makes Antidote Available to All,” Washington Post, Nov. 21, 2016.
Vancouver officials launched supervised: Gordon Omand, “B.C. Naloxone Kits Flood Province to Reverse Overdoses Amid Fentanyl Crisis,” Canadian Press, Sept. 21, 2016.
Several liberal-leaning American states and cities: Katie Zezima, “Awash in Overdoses, Seattle Creates Safe Sites for Addicts to Inject Legal Drugs,” Washington Post, Jan. 27, 2017.
a purple ALLY patch: Martha Bebinger, “Hacking a Solution to Boston’s Opioid Crisis,” WBUR, Sept. 12, 2016.
piloting fentanyl test strips: Bebinger, “As Fentanyl Deaths Rise, an Off-Label Tool Becomes a Test for the Killer Opioid,” WBUR, May 11, 2017.
drug-user unions: Author interview, Louise Vincent, May 4, 2017, and http://ncurbansurvivorunion.org.
About a third of all U.S. treatment centers: National Survey of Substance Abuse Treatment Services (N-SSATS), Department of Health and Human Services, July 2017.
In Baltimore, where the overdose death rate was: Author interview, Mark O’Brien, Sept.
4, 2016.
reducing needle-injected HIV instances: Address by Dr. Leana Wen, Baltimore City Health Department director, Poynter Institute’s “Covering the Opioid Crisis,” Washington, D.C., Sept. 26, 2016.
Conservative then–Indiana governor Mike Pence responded: Alan Schwarz and Mitch Smith, “Needle Exchange Is Allowed After H.I.V. Outbreak in an Indiana County,” New York Times, March 26, 2015. A year later, HIV in the county had plateaued at around 210 cases.
Mitchell launched her own renegade: Andrew McMillon, “The Heroin Heroine of Reddit,” BackChannel.com (also published on Medium.com), July 21, 2015. Tracey Helton Mitchell would go on to author The Big Fix: Hope After Heroin (Berkeley: Seal Press, 2016).
“We’re in the absolute dark ages”: Author interview, Mitchell, May 8, 2017.
imprison heroin users for life: Author interview, Sgt. Kevin Coffman, July 10, 2017.
“Don’t do it”: Cameron Joseph, “AG Jeff Sessions Calls for Return to ‘Just Say No,’” New York Daily News, March 15, 2017.
backed health care changes that would have put: Andrew Taylor and Jonathan Lemire, “Trump Moving to Slash Budget for White House Drug Czar,” ABC News, May 5, 2017.
After a backlash, Trump rolled back: Andrew Joseph, “After Outcry, Trump Budget Largely Preserves ‘Drug Czar’ Funding,” STAT, May, 23, 2017.
the office still lacked a permanent director: Politico staff, “Trump to Nominate Jim Carroll for ‘Drug Czar,’” Politico, Feb. 9, 2018.
remained a work in progress or unaddressed: Tamara Keith, “Trump Says Administration Working on ‘Very Very Strong’ Policies to Combat Opioids,” NPR, March 1, 2018. The White House was criticized as viewing the drug czar position (and the opioid epidemic) as an afterthought, with Carroll nominated for it only after disappointing Trump as deputy chief of staff: Matthew Yglesias, “A Telling Anecdote About Trump and the Opioid Abuse Crisis,” Vox, March 1, 2018. White House counselor Kellyanne Conway was now Trump’s opioid point person, “quietly freezing out drug policy professionals and relying instead on political staff to address a crisis claiming about 175 lives a day,” according to Politico staff, “Trump to Nominate Jim Carroll for ‘Drug Czar,’” Politico, Feb. 9, 2018.
