Powell Valley Overlook, Wise County, Virginia

Chapter Thirteen

Outcasts and Inroads

“If you want to treat an illness that has no easy cure, first of all treat it with hope.”

—Psychiatrist George Vaillant, Harvard Medical School

In 1925, the psychiatrist Lawrence Kolb Sr. published a set of groundbreaking articles arguing that addiction afflicted only people who were born with personality defects. He distinguished between “normal” users, who had been prescribed opiates by their doctors, and users who were “vicious” (a word deriving from “vice”), who had become addicted via illicit channels. The latter were much worse than the former, he initially believed, and this notion led him to categorize the addicted person as a criminal rather than a patient deserving of treatment and care.

In the mid to late 1930s, Kolb oversaw the opening of two U.S. Narcotics Farms, in Lexington, Kentucky, and Fort Worth, Texas, part of the federal government’s so-called New Deal for the Drug Addict. In bucolic rural settings, the government provided treatment both to the addicted who had arrived by court mandate and those who had volunteered, along with job training and medical care. Meanwhile, the government scientists were allowed to conduct research on the farms’ captive populations.

Kolb changed his beliefs about addiction after his colleagues proved to him that “normal” people, including the 10 to 15 percent of patients who were health care professionals, could become addicted, too, if they were opioid-exposed.

The work at the Narcotics Farm labs led to the field of addiction medicine. Both farms closed in the mid-1970s—due to an ethics scandal over experimentation on the addicted who were improperly exploited as research subjects. But their legacy includes the establishment of the National Institute on Drug Abuse and the scientific notion that addiction is a chronic, relapse-ridden disease.

Today, courts largely continue to send the addicted to prisons when reliable treatment is difficult to secure, and many drug courts controlled by elected prosecutors still refuse to allow MAT, even though every significant scientific study supports its use.

Not every patient wants or needs maintenance drugs, because every human experiences addiction differently, and what works for one might not work for another. Still, it is crucial to preserve treatments for people with addiction and help them obtain the means needed to get off drugs, rather than simply treat them as criminals who have no right to health care.

If my own child were turning tricks on the streets, enslaved not only by the drug but also criminal dealers and pimps, I would want her to have the benefit of maintenance drugs, even if she sometimes misused them or otherwise figured out how to glean a subtle high from the experience. If my child’s fear of dopesickness was so outsized that she refused even MAT, I would want her to have access to clean needles that prevented her from getting HIV and/or hepatitis C and potentially spreading them to others.

As the science historian Nancy D. Campbell, who documented Kolb’s work, has written: “Perhaps the day will come when more sensible views prevail—that relapse is the norm; that drug addiction should be treated as a chronic, relapsing problem that affects the public health; and that meeting people’s basic needs will dampen their enthusiasm for drugs.”

But there is so much more work to be done.

*

Why, in less than two decades, had the epidemic been allowed to fester and to gain such force? Why would it take until 2016 for the CDC to announce voluntary prescribing guidelines, strongly suggesting that doctors severely limit the use of opioids for chronic pain—recommendations that echoed, almost to the word, what Barbara Van Rooyan begged the FDA to enact a decade before? Why did the American Medical Association wait two decades before endorsing the removal of “pain as the fifth vital sign” from its standards of care? If three-fourths of all opioid prescriptions still go unused, becoming targets for medicine-chest thievery, why do surgeons still prescribe so many of the things?

While it is true that doctor junkets funded by Big Pharma are no longer the norm, and physicians no longer ask reps to sponsor their kids’ birthday parties, more than half of all patients taking OxyContin are still on dosages higher than the CDC suggests—and many patients in legitimate pain stabilized by the drugs believe the pendulum has swung too far the other way.

A journalist and former colleague of mine was so worried about the epidemic’s chilling effect on painkillers that she emailed me an X-ray of her back, showing a sixty-four-degree curve in her lumbar spine—from the front, it resembled a question mark—and slipped disks that caused severe arthritis pain. Painkillers had allowed her to work and actively pursue gardening, cooking, and beekeeping, and they precluded risky and potentially debilitating surgery.

And yet her scoliosis specialist had recently discontinued her pain management “without any notice and with no discussion during appointments to come up with a pain management strategy” because the new CDC guideline “frightened him into abandoning his patients,” she said. (For her arthritis, she takes the synthetic opioid Tramadol; for neuropathy, she takes the seizure medication gabapentin, which is increasingly sought on the black market for its sedative effects.) “My life is not less important than that of an addict,” my friend wrote, in bold letters, explaining that her new practitioner requires her to submit to pill counts, lower-dose prescriptions, and more frequent visits for refills, which increase her out-of-pocket expense.

“The system taking shape treats me like an addict, like a morally dubious person who must be treated with the utmost suspicion,” she said.

The CDC guideline had become so controversial among pain patients that the two employees charged with drafting it received death threats.

To follow the physician’s imperative of “Do no harm” in a landscape dominated by Big Pharma and its marketing priorities, the medical community only recently organized behind renewed efforts to limit opioid prescribing, teach new doctors about the nuances of managing pain, and treat the addicted left in the epidemic’s wake. The number of residency programs in the field of addiction medicine has grown in recent years from a dozen to eighteen.

“We live in an era where for a century now the pharmaceutical industry has invested enormous capital investments in new drugs, and there’s no turning back that clock,” said Caroline Jean Acker, an addiction historian. “So, as a society, we’re going to have to learn to live with possibly dangerous or at least risky new drugs—because Big Pharma’s going to keep churning them out.”

*

The birthplace of the modern opioid epidemic—central Appalachia—deserves the final word in this story. It is, after all, the place where I witnessed the holiest jumble of unmet needs, where I shadowed yet more angels, in the form of worn-out EMTs and preachers, probation officers and nurse-practitioners. Whether they were attending fiery public hearings to advocate for more public spending, serving suppers to the addicted in church basements, or driving creaky RVs-turned-mobile-clinics around hairpin curves, they were acting in accordance with the scripture that nurse-practitioner Teresa Gardner Tyson had embroidered on the back of her white coat:

Verily I say unto you, inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me. (Matthew 25:40)

One three-day weekend every summer in far southwest Virginia, Tyson plays host to the nation’s largest free medical outreach event. Held at the Wise County Fairgrounds, Remote Area Medical serves the uninsured, from children with undiagnosed diabetes to adults on walkers with infected teeth, some caused by lack of dental coverage and others by years of meth use. It’s where I crossed paths with people like Craig Adams, a construction worker and recovering opioid addict, who brought his wife, Crystal, to RAM so they could both get their teeth fixed: They’d used so many tubes of temporary dental repair glue, he told me, they’d lost count. Craig had spent eight years in the state prison system for breaking into Randy’s Gateway Pharmacy in nearby Richlands, trying to steal OxyContin. But he was taking Suboxone now—“responsibly,” he told me, “because my wife wouldn’t have it any other way.” Having lost scores of people to opioid overdose, including his mom and grandmother, he hadn’t used illicit drugs in more than three years. “I had put off going to RAM for years because I figured they’d make you feel like shit about yourself, like ninety percent of the social service people do,” he said. “But everyone was just…so…kind.”

If there’s an argument to be made for a single-payer health care system with mental health and substance abuse coverage, this is the lumpy ground on which to make it, a gravel lot in which upward of three thousand Appalachians camp out for days in 100-degree heat to be treated in exam rooms cobbled together from bedsheets and clothespins. Behind a banner for the virginia-kentucky district fair & horse show, patients wait in bleachers while volunteers pass out bottles of water as they triage them to pop-up clinics for medical, dental, and eye care.

I interviewed Tyson several times in the spring and summer of 2017, before and after the July RAM event that her organization helps plan and host. In the weeks leading up to it, she liaised with media from as far away as Holland and made frantic phone calls, once when her assistant struck out trying to secure enough bottled water for the RAM crowds. A nonprofit they usually counted on said this year’s pallets were already reserved for natural-disaster relief. “If this isn’t a disaster, I don’t know what is!” Tyson said, managing to sound both desperate and upbeat.

In rural America, where overdose rates are still 50 percent higher than in urban areas, the Third World disaster imagery is apt, although the state of health of RAM patients was actually far worse. “In Central America, they’re eating beans and rice and walking everywhere,” a volunteer doctor told the New York Times reporter sent to cover the event. “They’re not drinking Mountain Dew and eating candy. They’re not having an epidemic of obesity and diabetes and lung cancer.”

I had made a similar comparison two years before, when Art Van Zee drove me through the coal camps on my first visit to Lee County, just west of Wise. Though I’d covered immigration in rural Mexico and the cholera epidemic in northern Haiti, I told him, never before had I witnessed desolation at this scale, less than four hours from my house. Most of America would be shocked by the caved-in structures, with their cracked windows and Confederate flags, and burned-out houses that nobody bothered to board up or tear down. It felt completely out of scale with the rest of the nation I knew. But these conditions were hardly limited to St. Charles or Wise County, Van Zee pointed out. “On the other side of the cities [many Americans] live in, there’s poverty and poor health probably just as bad,” he said.

In Appalachia, he conceded, poverty and poor health were not only harder to camouflage; they were increasingly harder to recover from. For decades, black poverty had been concentrated in urban zones, a by-product of earlier inner-city deindustrialization, racial segregation, and urban renewal projects of the 1950s and 1960s that decimated black neighborhoods and made them natural markets for heroin and cocaine.

Whites had historically been more likely to live in spread-out settings that were less marred by social problems, but in much of rural America that was clearly no longer the case. These were the same counties where Donald Trump performed best in the 2016 election—the places with the most economic distress and the highest rates of drug, alcohol, and suicide mortality.

The national media’s collective jaw-dropping at the enormity of needs displayed at the RAM event underscored the fact that the outside world had zero clue. As the Appalachian writer and health care administrator Wendy Welch noted: “We’re not victims here, except for when it comes to Purdue Pharma. But when one of us makes a mistake, it tends to be a fatal one.”

*

I found hope in the stories of Tyson’s staff and patients as I set out, in multiple visits, to discern what happened after the volunteer doctors departed for their urban enclaves, and the politicians and pundits went home. I felt hope as I witnessed Tyson, a bubbly, every-curl-in-place blonde, manage her workaday free clinic as she seamlessly steered her rattling 2001 Winnebago through southwest Virginia’s serpentine roads, juggling phone calls from nurses, patients, and the media alike—in high-heeled, rhinestone-studded sandals. With her sorghum-thick accent, Tyson was camera-ready and thoroughly put together each time we met, except once, when mascara smudged her doctor’s coat.

I would find out soon enough why she’d been crying for days, and it wasn’t because the battery on her Winnebago had just conked out. (The nonprofit’s marketing manager was dispatched with the battery booster to give us a jump, while Tyson’s husband offered real-time jump-starting counsel via FaceTime.)

It was a fitting state of affairs for what happens after the out-of-state RAM do-gooders depart and Tyson’s grant-funded Health Wagon staff of twenty is left to tend to the health needs of the region’s uninsured. The program is called the Health Wagon because it was founded in 1980 by a Catholic nun and medical missionary named Sister Bernie Kenny, now retired, who first provided care out of the back of her red Volkswagen Beetle.

At our first stop, Tyson treated the swollen wrist of a substitute teacher whose pay had just been reduced from $70 to $56 a day. She was a casualty of school district depopulation and austerity, measures that included closing two schools in the town of Appalachia, one of which was now a food bank. In St. Paul, where our RV was presently stalled, the middle-school roof had become so tattered that buzzards had descended on it a few months earlier to eat the rotting tiles. With no money for repairs, school administrators resorted to temporary measures to divert the vultures, erecting giant inflatable tube men, the silly beacons you see waving from car dealerships.

The fifty-four-year-old teacher hadn’t had insurance in decades, not since she was pregnant and qualified for Medicaid; her husband, a former Walmart worker disabled by a series of strokes, was on Medicare. Because Virginia hadn’t approved the Affordable Care Act Medicaid expansion, she patched together free coverage at RAM events and occasional visits to Tyson’s mobile unit when it came to town. She had to be practically dying before she went to see her family doctor, who accepted cash at a discount rate of $63 per visit.

*

In a state with an increasingly flimsy safety net, people like Tyson had been left to clean up the politicians’ mess. As the health care debate over repeated attempts to repeal the ACA raged in Washington and opioid activists waited for President Trump to declare the epidemic an official national emergency—to free up immediate federal disaster relief funds for cities and states—between patients Tyson followed the machinations on her phone, fuming as she scrolled.

A devoutly religious wife and mother from nearby Coeburn, she was finding it hard to remain optimistic. In our first interview, she’d been distraught over the recent death of a forty-two-year-old patient caused by untreated hepatitis C. Though he hadn’t used or injected drugs for eight years, he could not afford to see a specialist. And by the time treatment could be arranged, “the damage was already done, and he couldn’t overcome it,” said his father, who owns a twenty-seven-acre cemetery.

The man buried his son near his office so he could visit him daily, he said. He invited me to tour the Wise County graveyard, where he offered to point out the scores of people he’d personally buried thanks to “OxyCoffin,” as the pills are now known here.

Months later, Tyson found herself crushed by a repeat in the continuing tragedy: In spite of 24/7 news cycles and a dense web of interconnectedness, here was one more death that gained no media traction and inspired zero public action. She could give all the interviews she wanted during the month of RAM, but the truth was that the extent of the suffering here garnered very little attention outside the spectacle of the annual health care event.

Unremarked on were the slow-simmering and increasingly common stories of people for whom no treatment could be secured. This time Tyson was crying about Reggie Stanley, forty-five, who died in a Charlottesville hospital while awaiting a liver transplant, after twelve years of untreated hepatitis C. “This patient was such a good person. He did make the wrong decisions initially,” Tyson said of Stanley’s IV drug use, but he’d been sober for several years. She’d tried desperately to get him into treatment, but like 90 percent of her patients, he was uninsured, and Tyson could not persuade a gastroenterologist to take him on as charity care. (She has since had success dispensing free medication provided by the company that makes Harvoni, the expensive hepatitis-curing drug.) By the time Stanley made it to a liver-transplant list, his disease was too advanced.

“You can fix it upstream, when it’s affordable, or you can wait till they present back in the ER with stage-four cancer or cirrhosis, and they still need extended hospital stays,” Tyson said. “It’s a drain on the system no matter what, so why can’t we fix it upstream?”

Tyson kept looking at Stanley’s obituary on her phone, which included a photo of him beaming in his Clintwood High graduation gown. “He was a great guitar player, great singer, and a good soul who was loved by many,” one of the guest-book mourners wrote.

*

The region’s health-department director, Dr. Sue Cantrell—the same one who’d warned state supervisors about the epidemic two decades before, only to have her pleas dismissed as “a regional problem”—was slowly making inroads. With the Scott County, Indiana, HIV epidemic still in mind, Cantrell had been holding town-hall meetings in the coalfield counties throughout the summer of 2017 to sound the alarm. Though Virginia had recently passed legislation paving the way for syringe exchange programs, every legislator in the coalfields had voted against the bill, citing widespread local law enforcement concerns, even though crime historically has not risen in communities with access to clean needles. Across the border in West Virginia, a 2015 syringe exchange had resulted in lowered overdose deaths and five-times-greater access to treatment and disease prevention services. Cantrell was hoping to arrange a visit from a West Virginia police chief to talk to local authorities, and her staff was already teaching users to clean their syringes between injections, giving out Clorox packets and plastic cups. She sometimes offered free food to entice patients both to be tested and to return for their results.

The RAM clinic offered free hepatitis C testing for the first time—a pharmacy professor estimated that 75 percent of IV drug users in the region have contracted it “and have no idea”—and handed out take-home naloxone kits with training to almost four hundred people. “In a rural area like this, just trying to get people to their appointments is huge,” Cantrell told me. Two patients in the MAT clinic she runs in nearby Lee County, Virginia, either hitchhike or walk to their appointments, some from a distance of more than five miles.

She’d floated the idea of turning some of the area’s subsidized housing units into “clean living facilities,” with wraparound services and support group offerings, not unlike substance-free college dorms. “We need to support this as a chronic disease the same as we support cancer and other diseases,” Cantrell said. “Not just evidence-based treatment and drug prevention programs but broadening it to meaningful education that leads to jobs with a living wage so there are options to stay in the area—or to leave.”

At the Narcotics Farm in Lexington, Kentucky, researchers had once referred to the latter as “the geographic cure.”

The idea of moving away from the site of addiction’s onset appealed to younger people who grew up among addicted family members as well as to the recovering addicts themselves, and it had worked for some, like many of the returning Vietnam soldiers. But opioids are much more available today than they were then—summonable by text or via online cryptomarkets, aka the dark web—and vastly more potent.

“The biggest lesson of the science behind drug addiction is that alternate reinforcers are essential,” Nancy D. Campbell, the Narcotics Farm historian, told me. “If you want to keep people away from drugs and drug-related crime, you have to have rewarding activities. It’s work. It’s play. It’s an emphasis on the kinds of activities and relationships that people build their lives around. If we don’t do something to rebuild these communities, I don’t see this current drug configuration ebbing in the way that drug waves of the past historically have.”

The question echoed louder by the day in rural America: How do you inspire hope in a middle-school boy whose goal in life is to become a “draw-er,” like his parents before him and their parents before them? Did a president who bragged about winning a swing state—telling the president of Mexico, “I won New Hampshire because New Hampshire is a drug-infested den”—win because voters genuinely thought he could fix it, or because too many people were too numbed out to vote?

Voters should judge politicians at all levels on the literal health of their communities, lawyer Bryan Stevenson explained. And while most Americans support federal financing of health care and even a slim majority approves of single-payer, those reforms will likely remain political nonstarters until more voters begin defining themselves in contrast to the billionaire class holding sway in Washington. Also needed are more efforts to court nonwhite voters, including Hispanics (of whom 74 percent are currently registered to vote), African Americans (69 percent), and Asian Americans (57 percent).

“You’ve got too many leaders just not responding to problems,” Stevenson said. “Think about with HIV, with smoking, with Zika, you had this energetic leadership from people who were saying, ‘We’re going to win this.’ The mind-set of ‘This is unacceptable’ has to be brought into the way we think about addiction and the opioid epidemic. But part of the problem now is, we’re so hopeless…that we don’t try very hard.”

America’s approach to its opioid problem is to rely on Battle of Dunkirk strategies—leaving the fight to well-meaning citizens, in their fishing vessels and private boats—when what’s really needed to win the war is a full-on Normandy Invasion.

Rather than puritanical platitudes, we need a new New Deal for the Drug Addicted. But the recent response has been led not by visionaries but by campaigners spewing rally-style bunk about border walls and “Just Say No,” and the appointment of an attorney general who believes the failed War on Drugs should be amped up, not scaled back. Asked in August 2017 why he hadn’t taken his own commission’s recommendation to label the epidemic a national emergency, President Trump dodged the question. He said he believed the best way to keep people from getting addicted or overdosing was by “talking to youth and telling them: No good, really bad for you in every way.” A few days later, he seemed to change his mind, saying he would make the emergency official, even as he remained tethered to a law-and-order approach.

But months later, he still had not followed through. When the so-called emergency was retrumpeted in an October 2017 press conference, Trump sounded bold and even hopeful, but his ballyhoo fell short of an official declaration, and included no additional treatment funding. At the time, seven Americans were dying of overdose every hour.

To be fair, the crisis had been cruelly ignored by both sides of the political aisle. The Obama administration had also been slow to address the crisis and tepid when it did. Caroline Jean Acker, the historian who is also a harm-reduction activist, told me she was scolded during a 2014 NIDA meeting for championing needle exchange and naloxone distribution after a speaker attempted to separate “good” addicts, or people who became medically addicted, from the illicit, or “bad,” users—as if there were no fluidity between the two. “The worst thing for politicians, I was told, was for them to appear they were being soft on drugs. Even under Obama, federal [Substance Abuse and Mental Health Services Administration] employees were told not to use the term ‘harm reduction,’” she said, sighing.

*

No matter where I turned in central Appalachia, the biggest barriers to treatment remained cultural. Stigma pervaded the hills and hollows, repeating itself like an old-time ballad, each chorus featuring a slightly different riff.

At the RAM event in Wise, a kerfuffle erupted when a local judge volunteering at the event accused a pharmacist of giving Narcan training to a local Boy Scout troop without their parents’ permission; she claimed the kids would party harder knowing they had Narcan to revive them. “Just ridiculous,” one trainer told me.

But across the region, where it seemed every family had at least one soul crusher of a story, it would take more than one fairground debate to convince people that harm reduction was necessary to save lives, even as the region had the worst hepatitis C rate in the state. One-third of children in central Appalachia now lived with a nonparent adult, and 96 percent of the adopted kids weren’t orphaned—they’d been removed from their drug-addicted parents by social service workers.

At another Health Wagon event, a man overdosed on meth in the parking lot while his friends took off, running up the mountain, according to the responding EMT, who recognized a familiar unconscious face. “Repeats,” as Giles Sartin refers to many of his overdose calls, saying: “It’s rare you’ll get somebody who’s just now getting hold of it.” Sartin, twenty-one, has been an EMT since the tenth grade. He made the decision to train the day he was sitting in a freshman English class and heard the double thump of two classmates seated behind him hitting the floor.

They’d overdosed on OxyContin during a lesson on grammar and punctuation.

“Last week I Narcanned the same person for the fourth time,” Sartin said. When the man woke up, he punched Sartin’s EMT partner and broke his nose. He’d been speedballing painkillers with meth, which makes users paranoid and gives them “ridiculous strength.” It was such a problem that Sartin’s rescue squad had to adopt a new protocol: Even though people could die, they waited now for police to arrive before they went inside the patients’ homes.

“There’s communities where we’re like an ice cream truck,” Sartin said of the ambulance. “They’ll try to steal our needles, our gloves, everything,” especially in the Lee County hamlets of Keokee and St. Charles.

When I explained that my book began with OxyContin abuse in Lee County in the late nineties, Sartin cut me off with a warning: “Ma’am, there are spots in St. Charles where I would advise you not to be there at night. If they catch ya and don’t know ya, well…I don’t know.”

Tyson had revised the Health Wagon’s safety procedures, too. Whereas in Lebanon she tends to set her RV up outside a Food City grocery, or near the town square in St. Paul, she has learned to avoid residential neighborhoods in smaller communities. In the former coal camp of Clinchco, a close call had persuaded her to switch locales from a neighborhood to the police station parking lot.

Some neighbors had rushed to her RV, screaming and banging on the door for help. “We get to their trailer, and in the living room we get ready to work on the first person we see on the floor, but that wasn’t even who they were talking about,” Tyson recalled. The real patient was in the rear room, they were told, but her body was already growing cold. Meanwhile, others in the trailer were screaming at Health Wagon staffers “to get the f—outta here!”

“I still stand by what we did, trying to revive her, but the dynamics here are changing, and you can no longer just go blindly in,” said Tyson, who was genuinely afraid during the exchange.

Even law enforcement tightened up procedures. In June 2017, the DEA recommended that first responders wear safety goggles, masks, and even hazmat suits to avoid skin contact with fentanyl and other powerful synthetics after reports of officers having to be Narcanned when they inadvertently brushed up against them on calls.

But these guidelines came way too late for caregivers in the coalfields: Tyson’s life-and-death scare in Clincho took place more than a decade earlier—in 2006.

*

As a Lebanon prevention leader put it in a recent town-hall meeting called Taking Our Communities Back: “We are pioneers when it comes to this drug epidemic. We can tell people what will happen in their other communities in twenty years because it’s already happened here to us. We are the canaries in the coalfields.”

If it sounds like alarmist antidrug hyperbole—a version of Nixon’s speech identifying drug abuse as “public enemy number one”—it’s not. University of Pittsburgh public health dean Don Burke recently published a study forecasting the epidemic’s spread. Charting drug-overdose deaths going back to 1979, he added a new wrinkle to the work of Anne Case and Angus Deaton, the economists who pointed out the soaring “deaths of despair” among midlife white Americans.

Drug-overdose deaths had doubled every eight years over that time: Three hundred thousand Americans had died of overdose in the past fifteen years, and lacking dramatic interventions, the same number would die in just the next five.

“The numbers by themselves are disturbing, but more disturbing is the pattern—a continuous, exponential, upward-sloping graph,” Burke told me in 2017. A year before, more than a hundred Americans a day were dying from opioid overdose. Some epidemiologists were predicting the toll would spike to 250 a day as synthetic opioids became more pervasive.

Opioids are now on pace to kill as many Americans in a decade as HIV/AIDS has since it began, with leveling-off projections tenuously predicted in a nebulous, far-off future: sometime after 2020. In past epidemics, as the public perception of risk increased, experimentation declined, and awareness worked its way into the psyche of young people, who came to understand: “Don’t mess with this shit, not even a little bit,” as another public health professor put it. But that message has not yet infiltrated the public conscience.

What about the more than 2.6 million Americans who are already addicted? Will the nation simply write them off as expendable “lowlifes,” as Van Zee’s patient still believed?

“My hope is that there is an end in sight,” Burke told me. “Some natural limit, or some policy where we deflect the curve downward.” But even in states where downturns have intermittently appeared—such as in Florida, following the crackdown on pill mills—“eventually those places snapped back to that curve, and we don’t know why,” he said.

In the carefully couched words of an academic, Burke suggested that the War on Drugs should be overhauled, with input gathered from other countries, including Portugal, that have decriminalized drugs and diverted public monies from incarceration to treatment and job creation.

He wondered whether drug cartels were the economy’s new invisible hand—a modern-day Adam Smith creeping around America’s suburbs, cities, and small towns, proffering stamped bags of dope. The economist had assumed the free-market economy would operate efficiently as long as everyone was able to work for his or her own self-interest, but he had not foreseen the elevation of rent-seeking behavior: the outsized greed of pharmaceutical companies and factory-closing CEOs, and the creation of a class of people who were unable to work.

*

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 skittish 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, they 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.

Though Loyd’s treatment was too expensive to be replicated to scale—he paid $40,000 cash up front (limited coverage is now available to those with insurance, but it would cost almost twice that today)—he believes the five-year treatment model, common for addicted doctors and airline pilots, is ideal. It’s why they tend to have opioid-recovery rates as high as 70 to 90 percent.

“There’s nothing scientific at all about twenty-eight days of [residential] treatment,” Loyd said of the kind heralded in movies and on reality TV. “It takes the frontal lobe, the insight and judgment part that’s been shut down by continued drug use, at least ninety days just to start to come back online and sometimes two years to be fully functioning.”

But most users don’t have access to ninety days of treatment, much less two years. Only one in ten addicted Americans gets any treatment at all for his or her substance use disorder—which is why there’s such a push for outpatient MAT and, increasingly, programs that divert the addicted from jail to treatment.

While drug courts rightly provide not only intensive monitoring but also the threat of a swift jail sentence, Loyd believes that all people in recovery, especially those who relapse, should be allowed MAT, even if they have to sue to get it. “The judges who don’t allow it are in violation of the Americans with Disabilities Act. They just are!” he said. Denying opioid-addicted participants medicine they have legitimately been prescribed is akin to denying diabetics their insulin on the grounds that they’re fat.

If 90 percent of people with diabetes were unable to access medical treatment, there would be rioting in the streets.

*

Loyd made his MAT argument repeatedly as he tried to sell the idea of Overmountain to the doubters in Gray, ten minutes down the road from his Boones Creek hometown. The crowd was tougher than he anticipated.

To intimidate him, they filmed him as he spoke. They yelled, “Put it in your neighborhood!” and placed condemning signs in the hands of their ten-year-old children as they marched.

At one meeting, Loyd tried to explain the science behind addiction—that it was a chronic brain disease, and relapses were to be expected—when a woman in the audience interrupted to ask, “Just how many chances are we supposed to give somebody?”

He tried to appeal to the group’s humanity, as Gaeta had done in Boston, pointing out that addiction already was in their neighborhood. Simply turning their heads away out of fear or sanctimonious denial was equivalent to enabling the spread of overdose deaths—quite possibly, even, in their own families.

From the community center where he stood, in the heart of the Bible Belt, Steve Loyd could make out four church steeples. He had played ball and gone to Sunday school with many of the people in the room.

There were leaders here and elsewhere who agreed with the woman, he knew, including an Ohio sheriff who’d recently proposed taking naloxone away from his deputies, claiming that repeated overdose reversals were “sucking the taxpayers dry.”

Loyd thought immediately of the answer Jesus gave when his disciple asked him to enumerate the concept of forgiveness. Should it be granted seven times, Peter wanted to know, or should a sinner be forgiven as many as seventy times?

In the shadow of the church steeples, Loyd let Jesus answer the woman’s question: “Seventy times seven,” he said.

*

If the federal government wouldn’t step in to save Appalachia, if it steadfastly refused to elevate methods of treatment, research, and harm reduction over punishment and jail, Appalachia would have to save itself.