by Beth Macy
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.
Epilogue
Soldier’s Disease
Back in my adopted hometown of Roanoke, where I’d been following families for going on six years, the addicted people I came to know were in widely ranging states of wellness, some far more fragile than others. Their relatives were worn out. Many seemed to age before my eyes, like a video on fast-forward.
The day his mother arrived to pick him up from the Petersburg, Virginia, penitentiary in February 2017, Spencer Mumpower was exuberant when he spotted her walking toward him. “I want to run to you, but I still have these prison clothes on, and I’m afraid they’ll shoot me!” he shouted, only half joking.
“That’s OK,” Ginger hollered back. “I’ll run to you.” There was almost no weekend since Spencer began his prison sentence, in 2012, when she hadn’t visited him in federal prison and/or put money on his commissary account, almost no month in which she had not tried to coax prosecutors, lawyers, politicians, probation officers, and even judges to grant her only son an early release.
That August, exactly a year after my prison interview with Ronnie Jones, Ginger left her Roanoke jewelry store, located on the fringes of Hidden Valley, and drove to a North Carolina halfway house to pick up Spencer, who had been living there for six months since his prison release. He was free to finally leave his confinement, all exquisitely toned 165 pounds of him, with a body that could deadlift five hundred pounds, in sets of five reps.
Sober for seven years, Spencer had replaced his heroin and methamphetamine addiction with martial arts even before he’d left for federal prison. The jujitsu practice had sustained him throughout his incarceration—even when his girlfriend dumped him and when his former martial-arts teacher and onetime father figure was arrested and jailed for taking indecent liberties with a teenage female student.
Spencer stuck to his recovery and to his prison workouts, ignoring the copious drugs that had been smuggled inside, and he read voraciously about mixed martial arts. Using the Bureau of Prisons’ limited email system, he had Ginger copy articles about various MMA fighters—laboriously pasting in one block of text at a time—so he could memorize pro tips and workout strategies and, eventually, through her, reach out directly to fighters and studio owners for advice.
If all goes well, Spencer will be taking the geographic cure when he moves to another Virginia city, which he doesn’t care to name, to work for one such studio—once his probation officer signs off. While he was enjoying his new freedom, the reality of life after prison was also settling in. Prison had given him post-traumatic stress disorder, he told me, and his transition to the outside world was proving to be far harder than he’d imagined. Sleeping in a room without the lights on or anyone else nearby made him nervous, as did driving a car. Ginger drove him to the gym most days, or he took an Uber, which didn’t exist in Roanoke when he left for prison in 2012. To help with his PTSD, he planned to get a service dog.
Scott Roth’s mom, Robin, still texted me regularly with pictures of sunflowers, along with images of Vanilla Rice pretending to cook with a sword, and another jokey one of him donning her fur coat the Christmas before he died. She texted a picture of an eighth-grade Scott, blond and bespectacled and wearing a classy black tux to his Catholic-school dance. He’d insisted she buy him a dozen roses for the dance, not just for his date but also for the girls who didn’t have one, she wrote; a trail of sunflower emojis decorated her note.
Still engulfed in her grief, Robin Roth had been mourning her son’s death now for eight years, and she was occasionally asked by his old friends for help getting into treatment, which she happily extended. She wanted me to convey both the depth of her grief and the ways in which she believed she had failed her son: “I wish I would have built him a stronger support system. I thought I could do it all as a single mom. I made a mistake. Find at least four adults your young adult can trust and turn to. Know their names and let them know that you are counting on them to help you assist your child to make good choices.
“Whatever rules you make, you better stick to them. Your son or daughter depends on it. They will call your bluff on everything. Don’t you budge. Changing the rules only confuses a young, developing mind.”
Two years earlier, Robin had moved into an apartment, downsizing from the suburban split-level where she’d raised her only child. It had been hard to leave the Hidden Valley home: the place where she’d removed all the bathroom doors, thinking that might keep Scott from shooting up; the yard where she’
d grown the massive sunflower field after his death.
Occasionally, stray sunflowers still sprout up in the yard of her former home—eight feet tall, some of them, with a dozen or more blooms. They are not just memorials to Scott Roth but also to the epidemic’s intractability. The young woman who bought Robin’s house had not only been addicted to heroin herself (she’s been sober now for more than four years), but her sister, twenty-seven-year-old Joey Gilbert, is the one who relapsed and died in March 2017, despite the Hope Initiative angels’ herculean efforts to help her. Had Joey had access to Medicaid health insurance and a clear path forward for continuing her MAT, her family firmly believes, she’d be alive today.
In the early fall of 2017, I sat down again with the Hope Initiative director, Janine Underwood, Bobby’s mom, who grew more despairing by the day. All the overdoses and all the deaths—none of it seemed to inspire more awareness of the tragedy or its toll on families, many of whom were still cowering in shame.
Bobby’s old friends continued showing up to Hope every week. Some had been using for almost a decade, and “they are so, so very tired of the way they’re living,” Janine said, and yet they were so equally afraid to give it up.
One friend, a thirty-year-old man, had broken down when he realized Janine was Bobby’s mom. Though his mother had driven him to the Hope clinic from the suburban ranch-house-turned-meth-lab where he now lived, she was so ashamed that she waited outside in her car.
Betsy (not her real name), a young woman who had once babysat for Bobby’s sister, showed up recently at Hope, too, determined to get sober. But by the time Janine and Hope volunteer Nancy Hans went to her home to help arrange a transfer to detox, Betsy was nodding out. During a brief coherent moment, she pulled out her Hidden Valley High yearbook, pointing to a homecoming-dance picture of herself and her friends: Three of the five were now active heroin users, she said, her voice slurring as she spoke.
Then, abruptly, she pointed to the window. “Look, it’s raining,” she said. “That’s Bobby looking down on us.”
Nancy and Janine made dozens of phone calls to get Betsy into the community services board-run detox. Janine even drove her to the facility, but it wasn’t yet providing buprenorphine for detox, and Betsy left after just twelve hours, saying she couldn’t take the pain of being dopesick.
By the time the women lined up a facility that would allow her to be on MAT, Betsy had fled to New York, partly to avoid an upcoming court date for drug charges. A few days later, she overdosed on fentanyl-laced heroin in Central Park, where EMS workers revived her and let her go. The last Janine heard from Betsy, she had taken off for New Jersey, where she was now presumably trading sex for drugs.
Unlike the Tennessee Tri-Cities collaboration that had birthed Overmountain, Roanoke had not created a working group to transcend bureaucratic logjams, but perhaps in time it would. Nonfatal overdoses in 2017 had more than doubled the previous year’s count, and fatal overdoses had nearly tripled (and those figures were likely an undercount).
At a sparsely attended public forum at Tess’s alma mater, police recounted the August 2017 seizure of 4.4 pounds of fentanyl along I-81—enough for 1 million fatal overdoses. They’d also recently arrested a Cave Spring High graduate attempting to sell 700 “Xanax bars” at the local community college that contained fentanyl he’d mail-ordered via the dark web from Hong Kong.
Ronnie Jones was right again: Shit had not stopped at all, but with continued regional-media cutbacks—the Roanoke Times was down to just a single Roanoke Valley police reporter, and there were now sprawling heroin-ring prosecutions that received zero media attention—the public was left to believe that it had.
Warren Bickel, the world-class addiction researcher, had just nabbed a $1 million grant for his Virginia Tech Carilion Research Institute to pilot new MAT protocols for the streamlining of ER-to-outpatient transfers: Patients who overdosed would be directly connected to outpatient buprenorphine via a newly FDA-approved once-monthly injection called Sublocade. Bickel had recently lost a family friend to overdose. The young man had been taking Suboxone, but when he tested positive for additional opioids during a follow-up visit, his doctor cut his Suboxone dosage back as punishment. “What he needed was an increased dose, not less,” Bickel said. When I told Bickel that Tess was still living homeless on the streets of Las Vegas, paying for illicit drugs with sex work, he called up a study he’d coauthored in 1988, showing that buprenorphine definitively protects the addicted from overdose death and leads to reduced crime and better health. “Holy mackerel, this is such an old study, but people still aren’t aware,” he said.
The community services board in Roanoke had recently added MAT treatment for twenty-one patients, but only if they first engaged in counseling. Carilion still had a three-week wait for its outpatient MAT. When I floated the idea at a Carilion-sponsored forum that every doctor who’d accepted a Purdue Pharma freebie should feel morally compelled to become waivered to prescribe Suboxone as a way to beef up treatment capacity, the response among the doctors in the room was…crickets.
As Philadelphia edged closer to launching the nation’s first supervised safe-injection facility, efforts to start a syringe-exchange program in Roanoke remained sluggish and mired in politics—even as the rural health department director Dr. Sue Cantrell finally won permission to open one in Wise, in the most conservative part of the state. The Virginia General Assembly seemed on the verge of passing a Medicaid expansion, finally, but with a provision that the “able-bodied” be required to work.
The changes weren’t trickling down fast enough for Tess. When I told her mom about the limited MAT expansions in the fall of 2017, paid for via state and federal grants, she called the community services board office and was told that only pregnant women were being accepted at the time. Soon after, Tess messaged me at 4 a.m. from someone else’s phone, saying she planned to enter another Nevada rehab and asking if I’d send her more books when she got there.
I texted back that I already had the new David Sedaris book ready to send.
“Oh, awesome!” she said, thanking me for my “positivity” and support. She didn’t have an address where she could receive the book, but she would let me know when she checked herself into a rehab. Her elderly grandfather had agreed to fund another round of treatment, even though Tess had recently talked him into wiring her $500, allegedly to pay a friend to drive her back to Roanoke. “He knew he was being played, but he loves her so much, and he was probably thinking, ‘What if she’s hungry?’” said Patricia, who learned about her dad’s cash transfer after the fact. Though the ploy was likely another con for drug money, Patricia was buoyed by Tess’s having reached out to her family and me, and updating her Facebook page with pictures of her son. Unknown to us at the time, Tess had applied for Medicaid in Nevada, which expanded access in 2014 under the ACA—another indication that she was actively seeking treatment and MAT.
“The problem is, we don’t even know where she is” or, worse, what pimp and/or drug dealer she was now beholden to. In a November 2017 phone call, Tess was hopped up on crystal meth, Patricia believed, and paranoid that “gang stalkers” were trying to kill her. As she walked down the streets of Las Vegas, she thought people in passing cars were flashing their lights at her. She thought strangers were shouting her son’s name.
“All Tess has to do is tell us where she is, and the treatment people will come and pick her up.”
Of the 132 addicted users who had come to the Hope Initiative in its first year, fewer than ten had gone to residential treatment and stayed sober.
But Patricia still slept with her cellphone every night, waiting and praying that Tess would one day be among them.
In early December, Tess seemed better, judging from sporadic text messages and calls to her mom. She’d decided to make her way home to Roanoke, though her plans for the journey were vague. Patricia lined up a bed at an abstinence-only treatment center fifteen minutes from her home, Tess’s grandfather agre
ed to cover the flight and rehab, and Patricia spent a week navigating the Department of Motor Vehicles bureaucracy to get Tess a temporary ID that would allow her to board an airplane.
But where to send the ID? Tess was still homeless, and another week passed before she called Patricia with an address via a borrowed phone, possibly belonging to a current or former pimp. “Are you in danger?” her mom asked, and Tess claimed she was not, repeating a line she often said: “I’m a soldier, Mom. I’ll be fine.”
“Yes, love,” Patricia responded. “But sometimes even soldiers fall.”
On December 9, Tess may have used that same borrowed phone to respond to one of my Facebook posts, about an early reading I’d given in a Richmond bookstore from the prologue of this book. “Yay,” she wrote. “I helped make it!”
I told her, via instant messenger, that her mother and I were eager to see her. She asked if she could read an advance copy of this book, I said she could, and later she texted that she really wanted to “work on it.” It was unclear whether she was referring generally to her recovery or to the trip back to Roanoke for her fourth rehab attempt.
Tess was walking the Las Vegas streets at night, I would later learn, often picking up johns, sometimes sleeping in corners of a casino. Her last known residence was an abandoned minivan in a parking lot. During one winter freeze, she turned up at a friend’s house wrapped in a blanket. “Some nights I’ve talked to her, and she’d just be up walking all night,” said Mark Sharp, who befriended Tess in rehab in the spring. “She missed her son a lot. She wanted her mom. She said she was all right, but I was like, ‘No, you’re not.’”