by Beth Macy
But the long shadow of “the heroin mistake,” as researchers thought of Bayer’s 1898 development for most of the twentieth century, was not forgotten by the medical or criminal justice communities. They remained wary of the notion of treating opioid addiction with another opioid and sought opioid antagonists for that very reason.
Looking back, it was almost quaint how, for most of the last century, the underdeveloped pharmaceutical industry was dominated by governmental agencies like the National Research Council and the Committee on Drug Addiction. These organizations were composed of university researchers and regulatory gatekeepers who focused most of their energies on preventing new addictive compounds from coming to market in the first place.
As early as 1963, progressive researchers conceded that designing the perfect cure for addiction wasn’t scientifically possible, and that maintenance drugs would not “solve the addiction problem overnight,” considering the trenchant complexities of international drug trafficking and the psychosocial pain that for millennia has prompted many humans to crave the relief of drugs.
When complicated lives need repair, and even the best-intentioned doctors are rushed, it was as clear then as it is now: Medication can only do so much.
While methadone remained on the fringes of medical respectability for decades, the Nixon administration sought it out as a way to control crime and respond to concerns over the fact that 20 percent of Vietnam veterans (at a rate of fourteen hundred soldiers per month) were returning home addicted to opium or morphine. Doctors weren’t trusted, though, to both dispense the drugs and control for their illicit diversion in an office setting, so highly regulated, stand-alone methadone clinics became the norm.
Such skepticism toward the medical establishment seems extraordinary now, viewed through the more recent prism of hospital hallways dotted with PAIN AS THE FIFTH VITAL SIGN wall charts and embroidered OxyContin beach hats, hallmarks of an era when doctors were encouraged to prescribe high-powered opioids for months at a time. But as liberally as doctors could prescribe opioid painkillers up through 2016, they remained regulated as hell when it came to treating opioid addiction with methadone and buprenorphine—the latter of which only came to market in 2002, after a thirty-year quest for a new addiction-treatment drug.
The battle lines over MAT persist in today’s treatment landscape—from AA rooms where people on Suboxone are perceived as unclean and therefore unable to work its program, to the debate between pro-MAT public health professionals and most of Virginia’s drug-court prosecutors and judges, who staunchly prohibit its use. Those unyielding viewpoints remain, I believe, the single largest barrier to turning back overdose deaths. In 2016, not long after a Kentucky appeals court mandated its drug courts to allow MAT, President Obama’s Office of National Drug Control Policy announced it would deny funding to drug courts that cut off access to it.
The following spring, President Trump’s Health and Human Services Secretary Tom Price would release the first half of the $1 billion appropriated by Congress in the 21st Century Cures Act for treatment and prevention, including expanded access to MAT. But a month later, Price disappointed treatment advocates by publicly dismissing MAT as “substituting one opioid for another.” A Tennessee public health official told me Price changed his stance on MAT after NIDA director Nora Volkow showed him the scientific facts: “She worked on him in a hurry.” Price resigned a few months later amid a scandal over taxpayer-funded charter flights. In February of 2018, Price’s successor, Alex M. Azar II, signaled the administration would significantly expand access to MAT.
Drug courts remain among the country’s models for preventing recidivism and relapse, with intensive daily monitoring of participants—randomly, at all hours of the day and night—and swift consequences, such as being thrown in jail when they fail a drug test or commit another crime. Most of the country’s three thousand drug courts drop the charges when offenders complete the twelve- to eighteen-month program. Graduates are roughly a half to a third less likely to return to crime or drugs than regular probationers. Drug courts remain, then, an almost singular place where prosecutors, defense attorneys, judges, and mental health advocates gather around a table to coordinate care and punishment, and discuss the daily challenges of the addicted.
The success rate is so good in opioid-ravaged Russell County that Judge Michael Moore told me strangers approach him at the Food City, begging him to place their addicted children in his drug court, even when they haven’t been arrested for anything.
But in a place where illegal diversion of Suboxone dominates the court dockets as well as the landscape—I saw a billboard along I-81 for BRISTOL’S BEST SUBOXONE DOCTOR: MOST PATIENTS ARE IN AND OUT IN 30 MINUTES; CALL TO GET ON THE ROAD TO RECOVERY!—only a handful of Virginia’s rural drug-court judges permitted participants to be on MAT. “We’ve had thirteen babies born to mothers on MAT, and not one of those babies had NAS,” Tazewell County judge Jack Hurley told me.
“So tell me: How do you put a price tag on that?”
“The best research says counseling doesn’t help: ‘Just give ’em the pill. Give ’em the fucking pill,’” said a local addiction counselor, Anne Giles, who was furious about cultural biases against MAT. According to an analysis of international studies published in the Lancet, the best treatment for opioid addiction combines MAT with psychosocial support, “although some benefit is seen even with low dose and minimum support.”
Giles firmly believes that “courts should not be practicing medicine,” and yet, amid growing national consensus about MAT’s benefits, criminal justice too often trumps science, she fumed. People buying illicit Suboxone were self-medicating because federal regulators didn’t permit enough physicians to prescribe it, in her view, and privately operated clinics accepted only cash because Medicaid reimbursements were delayed and covered only a sliver of the costs.
“We should let doctors be doctors,” Giles said. “Because this crisis is a lot like Ebola, where we sent helicopters.” Given opioid-related spikes in deaths, HIV, and hepatitis C, she added, “we should be sending helicopters!”
Fury about the fundamental skepticism toward MAT is not restricted to the medical community. Don Flattery, a member of the Virginia Governor’s Task Force on Prescription Drug and Heroin Abuse, compared anti-MAT judges and police officers to climate-change deniers. He’d lost his twenty-six-year-old son, Kevin, to an opioid overdose and tortured himself for not insisting that Kevin stick with MAT. His son had been on Suboxone before but abandoned it prematurely, after feeling stigmatized for it, in favor of abstinence-only treatment, Flattery said.
Art Van Zee, too, struggled with law enforcement complaints about buprenorphine, though he conceded that too many Suboxone providers in rural America had lax practices that spawned diversion and abuse. To fix the problem, public policy makers should, in Van Zee’s opinion, incentivize more doctors to go into addiction medicine, and MAT should be predominantly expanded in the nonprofit realm of health departments, community service boards, and federally qualified health centers, where salaried doctors are less motivated to overprescribe.
“I think taking an opioid-addicted person and expecting them to do well in drug court [without Suboxone] is almost cruel and unusual punishment,” Van Zee said. “In the legal sphere, all the police and judges see is the worst, ugly part—the trafficking, the kids put into foster care because the mother’s found injecting Suboxone.” A patient had arrived at his St. Charles clinic recently on her sixteenth birthday, only to learn that she’d acquired hepatitis C from injecting black-market Subutex.
It was simple observation bias: MAT opponents failed to see the distinction between people who abused buprenorphine and those who took it responsibly. “They don’t see all the patients I have who are going through college, getting their master’s degrees, getting jobs and their kids back, some of them drug-free now for ten or twelve years,” Van Zee said.
A few of Van Zee’s long-term patients had tapered from 16 millig
rams of Suboxone to as little as a half-milligram a day, but he hesitated to wean them entirely because, in his experience, it often led to relapse. Though there was scant data about the efficacy of long-term Suboxone treatment, one study showed that 50 percent of users relapsed within a month of being weaned from the drug; the lower the dose at the time of weaning, the better the outcome. Another study, conducted over five years, showed that roughly a third of buprenorphine patients were drug-free after eighteen months, a third were still on MAT, and most of the remainder were back on heroin or illicit opioids.
When a person is weaned too soon, his or her relapse feeds the perception that MAT is ineffective, reinforcing unfair and faulty notions about the treatment, said Nora Volkow, the NIDA official. “All studies—every single one of them—show superior outcomes when patients are treated” with maintenance medications such as buprenorphine or methadone, Volkow told me. She pointed out that most patients buying black-market Suboxone are really trying to avoid dopesickness—“and that is so much safer for them than going back to heroin.”
One Roanoke woman was so desperate to avoid relapse that she prepared for an upcoming two-week jail stint by stuffing a vial of Suboxone strips inside her vagina, knowing local jails didn’t allow MAT. “Then, in the middle of the night, she pulled the bottle out, took one, then quickly put it back,” said her Roanoke psychiatrist and MAT doctor, Jennifer Wells, who treats indigent pregnant women before and after delivery.
That patient’s continued recovery, Wells added, “speaks to the fact that MAT works. And that patients will go to any length not to relapse. They know what they need!”
But the divide between MAT opponents and proponents only deepened as I followed the travails of the Hope Initiative and users like Tess. While treatment providers, police, and family members were arguing about the best way forward, lives hung perilously in the balance.
It was hard being Tess. After four NA meetings, she stopped wanting to go, often texting me just as I was leaving to pick her up. The baby was sleeping, or she was too tired because he’d kept her awake the night before. His father was in jail after an alcohol-related arrest. And though his mother stepped in often to babysit, she was planning to move to North Carolina and hinted that she wanted to take her grandson with her.
Having grown up in an alcoholic household, I knew what it felt like to live on the periphery of addiction—the potential danger of being neglected, taken advantage of, or even raged against. And being with Tess sometimes brought up memories of a much darker time. I worried about her son and felt sorry for him. There were instances when journalistic boundaries blurred, such as the night Tess texted me from an unknown location:
Can yoi please come gwt me.
I was in the middle of organizing taxes, with the help of my spreadsheet-whiz niece, and didn’t see the text immediately. An hour later, I weighed what to do, talked to my husband, and ultimately forwarded Tess’s plea to both Patricia and Jamie Waldrop, who was Tess’s Hope volunteer. The next time I saw Tess, neither of us brought it up.
It was February 2016, and Patricia believed Tess was using again—items from the house started vanishing, including a laptop, and she discovered empty heroin baggies in her bathroom trash—but Tess vehemently denied it.
Family stress was high. Tess’s parents had different opinions about the best course of treatment, and Tess believed her siblings looked down on her as the black sheep. Her dad, Dr. Alan Henry, begged her to enroll in a twelve-month residential recovery program at the faith-based Roanoke rescue mission, but the mission banned stimulants of all kinds, from cigarettes to MAT, and Tess was not only still on buprenorphine and a heavy smoker, she was also a proud atheist. “The one thing that becomes clear is, there is misunderstanding with the siblings and with me on the distinction between helping and enabling that remains very murky,” Alan Henry told me later, suggesting that whereas he and Tess’s siblings preferred a tough-love approach, Patricia and her father were too easily manipulated by Tess, he thought.
Tess’s older sister, an AA proponent, begged Tess to adopt the Twelve Steps as she had done, arguing that the program emphasized spirituality over religion. “I told her, ‘Use Koda [Tess’s dog] as your higher power, for all it matters; just pray to something.’” But Tess laughed and said, “That’s ridiculous.” Soon after, a dopesick Tess asked her for money to buy buprenorphine, and her sister, believing Tess would spend it on heroin, offered her a ride to a meeting instead.
“I’m not trying to go sit in an AA meeting and listen to that bullshit,” Tess told her. “And you’re not my sister.” They stopped speaking.
When Patricia proposed that Tess consider other long-term treatment programs, MAT or not, she refused, turning argumentative and sharp. Her mom had a full-time hospital job with irregular hours; her shifts often ran longer than twelve hours, leaving Tess home alone with her son. Patricia had a security system installed in her home. But two cameras weren’t nearly enough.
In March, Patricia arrived home to find Tess stumbling around the house, seemingly high, and clothes from one of the bedrooms vanished—pawned, presumably, for drugs. “I’m meeting with my attorney,” Patricia told me, shortly after this incident. “I can’t just kick her out because she’s been here awhile.” A guardian ad litem would be appointed by the court to weigh in on what was best for Tess’s son.
“Everything’s such a mess, and in the middle of it is this gorgeous, beautiful boy,” Patricia said. Now seven months old, he was ahead of developmental schedule and before long he would babble his first word: Mama.
Tess maintained she was not using, but evidence to the contrary kept presenting itself. Patricia sometimes arrived home from work to find her security cameras turned to the side. Once, awakened by the baby’s cry in the middle of the night, she found him on the couch, “only he could barely sit up, and he’s leaning over, and he’s crying. He had a piece of a bottle, a plastic tube, and he could have choked.”
And where was Tess? “She was in the bathroom putting on makeup! She was superhigh,” with her baby about to tip onto the floor. “It is so embarrassing and so painful, trying to make this work,” Patricia said. “Your giving starts to give out.”
The guardian ad litem saw what was happening, and by late March, Tess lost custody of her son. A judge awarded shared custody to the grandmothers, and Tess was no longer permitted to live at Patricia’s, though she could visit her son when Patricia was home.
That spring Tess moved into a cheap motel, a known haven for drug users and dealers, with no car. To regain custody, she had until July 18 to find a job and a place to live, and prove her sobriety. She was mad at her dad for not loaning her money for an apartment down payment and furious about being unfairly painted as an unfit mother in court. “Even if I did take a Xanax when I was with [my son], I’ve never been fucked up. I’ve never not changed his diaper,” Tess insisted. Asked if it was difficult to stay away from other heroin users, Tess said, “When I’m angry and I have nothing, it’s really hard.”
She was trying to switch to a Suboxone doctor who accepted Medicaid, which she was now enrolled in, but that physician had long ago reached his federally mandated cap (then a hundred patients). A hundred dollars in debt to her Blacksburg psychiatrist and cash-only MAT provider, Tess had to pay the balance before she could be seen again, and meanwhile she was down to just a week’s supply of MAT. She’d tested positive for marijuana on her last doctor’s visit: “I was having really bad anxiety, and I thought pot would be better because at least it’s herbal,” she said.
By May, Tess was couch-surfing in low-rent apartments in southeast Roanoke and using heroin daily. She posted a cry for help on her Facebook page, ending with a quote from a Lil Wayne/Eminem song: “Been to hell and back / I can show you vouchers.” She went by the street name Sweet T.
Though the Hope Initiative was still months from opening its doors, Jamie reached out to Tess on Facebook: “Call me if you need help. I might just know of something r
ight up your alley, Girl. Much love.”
Tess called immediately. She wanted to hear how Jamie’s older son, whom Tess had once dated, had gotten sober. They made plans to meet the next day, but Tess canceled at the last minute.
By early June her son’s dad was out of jail. They squabbled, it turned violent, and Tess went deeper underground.
Patricia and Jamie worked their contacts to find her. Jamie’s son showed her where they’d once done drugs together while Patricia, worried that Tess was seriously hurt, filed a missing-persons report.
They distributed flyers across the region and on Facebook with a smiling picture of Tess and her description: “Last seen June 11, 2016. Brownish/red hair, green eyes, 5' 7", 130 lbs. Tree of Life tattoo on left shoulder blade.” Two days later, police received a report that Tess had stolen a car and a credit card—she’d been sent out for groceries by a woman she was staying with and never returned. Police found and arrested Tess later that day.
Patricia texted Jamie the news: For the first time in months, she told her, she could go to sleep knowing that, at least for that night, her daughter would not die.
The baby was a toddler now, and Tess hadn’t witnessed a single one of his steps. He was living with his other grandmother in North Carolina, and Patricia made the twelve-hour round-trip trek to see him monthly, texting me pictures of their visits: her grandson playing on the beach, wearing a silly sock monkey hat.