“Our staff used to be really ugly to them,” Ramsey admitted. “They’d say, ‘This is ridiculous. These moms need to quit having babies and quit doing drugs,’ myself included. We had no understanding that these women’s brains have been altered, and what they need now more than anything, for the sake of the baby, is our support.”
*
Asked what her goal was in early 2016, Tess told me: “To be a good mom to my son. For right now it’s just to get some good sober time, and eventually go back to school and live a normal life. Luckily, I have a nice family, and I’m not dead or serving prison time. I’ve been given second and third chances, so…”
The buprenorphine made her “feel normal,” as Tess thought of it, with insurance covering 80 percent of the medication’s costs. Visits to her addiction doctor were cash only, though, requiring $700 up front and $90 to $100 per follow-up visit, as many as four a month, in order to be monitored and receive the buprenorphine, which prevents dopesickness and reduces cravings, theoretically without getting you high. “It’s a real racket,” Tess’s mom, Patricia, said of cash-only MAT practices. “And there are waiting lists just to get into most of these places.”
At the time, federal Health and Human Services rules prevented MAT-certified doctors from treating more than 100 patients at a time, a cap adjusted to 275 later that year in response to the opioid crisis. Access to MAT in Virginia would broaden greatly in 2017, thanks largely to the efforts of Dr. Hughes Melton, a Lebanon addiction specialist tapped to help lead the state’s Department of Health opioid response. Every week, piloting his own airplane, he would make the round trip between his Suboxone clinic, Highpower, in Lebanon, Virginia, and his office in Richmond. Melton also worked with state Medicaid officials to broaden reimbursements as well as to include payment for mandatory counseling and care coordination, partly as an incentive for cash-only clinics to begin accepting insurance, including Medicaid.
Some eventually did, but the vast human need for treatment was slow to be recognized, and even slower to trickle down to most communities.
As a work-around to the Republicans’ refusal to expand Medicaid in Virginia, the Governor’s Access Plan, initiated in January 2015, would provide additional addiction treatment and services to fourteen thousand Virginians—but only to a fraction of those in need, and not until 2017, leaving most families to continue navigating wide treatment gaps on their own. “When calling facilities there is rarely a sense of urgency for capturing the addict,” Patricia explained, in the middle of a subsequent crisis with Tess. “An application process has to be completed. How many addicts on the streets have insurance, Medicaid, or ability to fax lengthy applications, or access to large amounts of cash?”
For now, Tess and her mom had to pay cash, up front, at every visit.
*
Among public health officials, buprenorphine is considered the gold standard for opioid-use disorder because it reduces the risk of overdose death by half compared with behavioral therapy alone. It also helps addicts get their lives together before they very slowly taper off—if they do. One researcher recommended that MAT users stay on maintenance drugs at least twice as long as the length of their addiction, while others believe it’s too risky for long-term addicts to ever come off the drugs.
But black-market dealing of buprenorphine, especially Subutex, is rampant. And the drug can get you high if you inject or snort it, or take it in combination with benzodiazepines, a sometimes fatal blend.
Though I’d visited several Suboxone clinics considered to be best-practice beacons in addiction medicine—including Hughes Melton’s in Lebanon and Art Van Zee’s in St. Charles—a plethora of shoddy prescribers in rural Virginia and elsewhere in Appalachia had given the good clinics a bad name. Operating at clinics often located in strip malls and bearing generic-sounding names, some practitioners defy treatment protocols by not drug-testing their patients or mandating counseling, and by co-prescribing Xanax, Klonopin, and other benzodiazepines—the so-called Cadillac high.
“Their treatment is a video playing in the lobby as a hundred patients walk through to get their meds; it’s insane!” said Missy Carter, the Russell County drug-court coordinator who has dealt with widespread Suboxone abuse among her probationers as well as in her own family.
Overprescribing among doctors specializing in addiction treatment was rampant, according to several rural MAT patients I talked to who unpacked how Suboxone doctors prescribed them twice as much of the drug as they needed, fully knowing they would sell some on the black market so they could afford to return for the next visit. Others traded their prescribed Suboxone for illicit heroin or pills.
Almost every Virginia law enforcement official I interviewed for this book despised Suboxone, and most Virginia drug-court judges refused to allow its use among participants. (Nationally, roughly half of drug courts permit use of MAT, though the scales seemed to bend toward acceptance as the crisis deepened.) Critics compared the British makers of Suboxone with Purdue Pharma because of their zest for market saturation and noted that clinic operators have a financial incentive not to wean someone off the drug. “We have people shooting up Suboxone and abusing it every which way,” Mark Mitchell, the Lebanon police chief, told me. “For a town of just thirty-four hundred to have three Suboxone clinics—that’s absurd.”
“People [outside of Appalachia] don’t believe me,” said Sarah Melton, a pharmacy professor and statewide patient advocate who helps her husband, Hughes, run Highpower, their Suboxone clinic, which mandates strict urine-screening protocols, with on-site group and individual counseling. Suboxone, with its blocking agent naloxone, “is a wonderful medicine, but we were seeing actual deaths from Subutex here, where people are injecting very high doses of it. And it comes down to these physicians wanting to make so much money, just like they did with the opioid pills!” Subutex is the monoproduct version of buprenorphine; lacking the added naloxone blocker, it is therefore more coveted among some of the addicted, who like the option of being able to take additional opioids such as Percocet at night to get high, multiple users told me.
In Johnson City, Tennessee, just over the Virginia border—where several of the nation’s top buprenorphine prescribers have offices—one cash-only prescriber admitted as much in a public forum, saying, “We give ’em enough so they can sell it and stay in treatment,” Melton recalled.
Buprenorphine is the third-most-diverted opioid in the country, after oxycodone and hydrocodone.
*
Hope Initiative angels like Jamie Waldrop and Janine Underwood were opposed to buprenorphine because, based on their sons’ experience, it was too easily diverted and abused. Patricia wasn’t initially a fan either, because of the expense and the lack of accountability on the part of Tess’s doctor, whose drug-testing and counseling protocols seemed lax.
She texted me after taking care of a twenty-five-year-old IV Suboxone user at the hospital where she worked who claimed that 90 percent of all Suboxone was abused. To which I gently replied: “I know Suboxone abuse is awful, but at least no fentanyl is in it, so it’s somewhat safer than street heroin.”
Tess, too, had clearly figured out how to abuse the drug meant to keep her off heroin—Patricia found spoons and Subutex powder among her things, and Tess told me she doubled her dosage when stressed. Patricia fumed, too, because all but one of the treatment centers she’d called when Tess was pregnant refused to accept her until she’d been detoxed from all drugs, including buprenorphine. Even the hospital where she delivered the baby refused to give her a script for MAT. Instead they arranged for Tess to be seen at a local methadone clinic after Patricia refused for a day to take Tess and the baby home, complaining that it was an “unsafe discharge.” They landed at the clinic moments before it closed, with the newborn in tow.