Unlike Campanello’s Massachusetts, Virginia could not rely on anything close to RomneyCare, the 2006 initiative signed into law by then–Bay State governor Mitt Romney, guaranteeing insurance coverage to 99 percent of the state. Virginia’s legislature had repeatedly turned down attempts to pass Medicaid expansion in the wake of the Affordable Care Act, sacrificing $6.6 million a day in federal funds and insurance coverage for four hundred thousand low-income Virginians—a frequent source of frustration for opioid-affected families and health care advocates.
In states where Medicaid expansions were passed, the safety-net program had become the most important epidemic-fighting tool, paying for treatment, counseling, and addiction medications, and filling other long-standing gaps in care. It gave coverage to an additional 1.3 million addicted users who were not poor enough for Medicaid but too poor for private insurance.
But in Virginia in June 2014—one year before the first fentanyl spike—statehouse Republicans shut down the Democratic governor’s proposal to expand it in a political plot that seemed lifted from House of Cards: Democratic coalfields senator Phillip P. Puckett abruptly resigned to give the Republicans an expansion-quashing majority. Alleged motivations for his action included making his lawyer daughter eligible for a judgeship—the senate’s policy forbids judicial appointments of relatives—and also allowing him to nab a job with the commission that oversees economic-development investments from Virginia’s slice of the tobacco settlement.
The last Democratic legislator west of Roanoke, whose Russell County region in Appalachia remains among the state’s hardest hit by the epidemic, Puckett eventually removed himself from consideration for the tobacco post, citing “family matters,” while a six-month federal investigation into corruption claims went nowhere.
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Perkins hated political maneuvering. In his ideal world, the economics of securing help worked like this: Since addicts would be diverted from jail, the cost savings from their empty jail beds could be put toward treatment. “The problem is, it’s easier to give money to the corrections system—to the tune of one billion in the state of Virginia—than it is to take a couple of million dollars and provide inpatient treatment for our problem,” he railed, blaming politics and the tendency among jailers and sheriff’s departments to cling to bloated incarceration budgets championed during the War on Drugs, even though two hundred of the city jail’s eight hundred beds were typically empty.
But Frederick Douglass had it right when he said, “Power concedes nothing without a demand.”
Perkins pointed out that most addicted users return to the streets from jail with more drug contacts than they had when they arrived. “I said it all a thousand times, but I couldn’t get anybody to listen because the sheriffs are elected officials with powerful lobbyists, and a poor old appointed police chief doesn’t stand a chance,” he said.
At the first Hope Initiative meeting, stakeholders were so focused on hurdles to treatment that Jamie worried the project would die before it ever got under way. Privately, she reached out to Police Chief Campanello in Massachusetts and asked him to do a conference call with the working group. She even suggested exactly what he should say: that if they waited till they solved all the obstacles, the program would never begin; meanwhile, people were dying every day. By the end of 2015, fifty-one thousand more Americans were dead of drug overdose—a thousand more than died from AIDS in 1995, the peak year. And the epidemic displayed no signs of trending down. In fact, HIV, spurred by the sharing of dirty heroin needles, was on the rise again, with sixty-five new cases reported that year in rural southwestern Virginia alone.
It was exactly what Art Van Zee predicted in one of his first letters to Purdue. “My fear is that these are sentinel areas, just as San Francisco and New York were in the early years of HIV,” he had written of Lee County back in November 2000. Van Zee had no idea then that the OxyContin epidemic would become a heroin epidemic, which itself would lead to more deaths from HIV and hepatitis C.
From a distance of almost two decades, it was easier now to see that we had invited into our country our own demise.
Methadone dispensing room, Gray, Tennesse
Chapter Ten
Liminality
I watched the Hope Initiative take hold in early 2016 at the same time I began following Tess Henry and her cheerful five-month-old son. I hoped that one day their stories would converge. But as loved ones and advocates eager to help heroin users navigate treatment have shown me, threading a needle blindfolded over a hot bed of coals might have made for a less complicated odyssey.
Tess was nearly seven months pregnant when she left jail in June 2015. For a month, she lived with her mom and tried to make a go of it with her boyfriend, the baby’s father—“disastrous,” Patricia and Tess agreed—before they found a private treatment center two hours away that would take Tess during her final month of pregnancy. Private insurance covered most of the $20,000 bill while her dad paid the $6,500 deductible, using the remainder of Tess’s college-savings fund. The Life Center of Galax was one of the few Virginia facilities that accepted patients on medication-assisted treatment (methadone or buprenorphine). Tess was now taking Subutex, a form of buprenorphine then recommended for some pregnant mothers. (Suboxone is typically the preferred MAT for opioid users because it also contains naloxone, an opiate blocker; Subutex, which is buprenorphine with no added blocker, was then considered safer for the baby but more likely to be abused by the mom.)
After spending the first half of her pregnancy in the throes of heroin addiction and the second half on Subutex, Tess was nervous about the possibility of delivering a child with neonatal abstinence syndrome, a painful state of withdrawal that sometimes requires lengthy hospital stays. The syndrome is common even among so-called Subutex babies, about half of whom require neonatal intensive care and methadone treatment to facilitate their withdrawal from the medication.
An NAS baby is a portrait of dopesickness in miniature: Their limbs are typically clenched, as if in agony, their cries high-pitched and inconsolable. They have a hard time latching on to either breast or bottle, and many suffer from diarrhea and vomiting. When neonatologist Dr. Lisa Andruscavage showed me the hospital’s NAS services, nurses who had just spent the better part of an eight-hour shift coaxing an opioid-dependent baby girl born four weeks early to sleep greeted us, only half joking, with “If you two wake that baby up, we will kill you.”
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While Tess’s son was born two weeks early, he entered the world astonishingly healthy, showing zero signs of distress. He was not among the fifty-five babies born with NAS at Roanoke’s public hospital that year, a rate well above the state’s average. He was not among the children seen at the region’s NAS clinic, where dependent babies released from the NICU come back for weekly check-ins while being very slowly weaned from methadone under their mother’s or another family member’s watch; despite such attention, around 27 percent of the clinic babies end up in foster care.
In fact, Tess’s son was a calm baby, happy to sit on your lap looking at a board book or gumming a teething ring or playing peek-a-boo. He had his mother’s intense eyes, and his grin was captivating, bell-shaped and wide. Back then, Tess was fiercely protective, to the point of not letting strangers hold him, even for his first picture with Santa. She held him on her own lap instead, saying she was worried Santa might drop the baby or give him germs—a common reaction among drug-addicted new mothers, an NAS nurse told me. “These moms are so over the top after they deliver because they’re trying to show everybody how much they care,” Kim Ramsey, the hospital’s neonatology nurse specialist, explained. Many have been stigmatized by their friends and families, even by members of the hospital staff.