“I’m walking around the methadone clinic parking lot for two hours with a four-day-old baby,” Patricia said. “And it was loaded with addicts. It was a place where Tess’s circle of addicts would become even bigger than it already was.” On days when Patricia had to work, her octogenarian father, who walks with a cane, drove Tess to the clinic.
“It’s a broken system,” said Ramsey, the nurse clinician. Too few obstetricians chose to become waivered to prescribe Suboxone, and very few drug-tested their pregnant moms, afraid of offending upper-middle-class patients and hiding behind their American Congress of Obstetricians and Gynecologists’ recommendation that a verbal screening suffices.
“We need to test all pregnant moms,” Ramsey said in a heated NAS-unit policy meeting I sat in on that pitted pediatric against obstetric staff. “We’re doing pregnant moms no favors by denying them the proper screening. It’s why movie stars and musicians get the crappiest health care—because no one wants to tell Prince he has an opioid problem.”
Tess relapsed not long after giving birth, Patricia discovered when she came home from a walk in the woods to find a man lurking around her mailbox. He told Patricia he’d come to return thirty dollars he owed Tess, but Patricia guessed, correctly, that he was a drug dealer. Tess went back to treatment in Galax for another month while the grandmothers kept the baby, then around six weeks old.
By the time I met Tess, she had just returned home and was hoping to transfer to a sober-living or halfway house—but the problem was, many didn’t allow MAT, and none of the available facilities would allow her to bring the baby. So she was back at her mom’s house and on MAT.
Though she didn’t agree with Tess’s MAT doctor’s protocols and cash-payment restrictions, Patricia was grateful she took Tess on as a patient when all the other area prescribers had long waiting lists.
Tess’s problems were growing worse by the minute, and the systems designed to address them were lagging further behind, mired in bureaucratic indifference.
*
For several months in early 2016, I drove Tess and her baby to Narcotics Anonymous meetings, recording our interviews (with Tess’s permission) on my phone as I drove and walking the baby around the back of the meeting room when he cried.
But Tess was edgy and distracted at the meetings, compulsively taking cigarette breaks and checking her phone. She was glad to leave her mother’s house but complained about the first meeting we attended, in white working-class southeast Roanoke, pointing out familiar drug dealers lingering outside the church where the group met. In the past, she’d preferred going to meetings in black neighborhoods because participants there were funnier, tended to have more clean time, and were “way more real,” she said.
She had been to twelve-step meetings before, both AA and NA, but felt stigmatized for being on buprenorphine, which many participants perceive as not being “clean,” or simply as replacing one opioid with another—a cultural gulf that only seemed to widen in the two years I followed Tess. Although NA’s official policy was accepting of MAT, longtime NA members who were asked by the meeting leader to sponsor or mentor Tess politely declined—a shunning that must have “felt like daggers” to her, a relative later said.
If you were drawing a Venn diagram comparing Suboxone attitudes among public health experts and criminal justice officials in the Appalachian Bible Belt communities where the painkiller epidemic initially took root, the spheres would just barely touch.
*
It had been that way since the birth of methadone, a synthetic painkiller developed for battlefield injuries that was discovered in—or rather, recovered from—German labs shortly after World War II. American researchers soon learned that methadone quelled opioid withdrawal, but the Federal Bureau of Narcotics (precursor to the DEA) was rabidly against using drugs to treat drug addiction. The FBN framed methadone as “unsafe”—read: and maybe even pleasurable—after studies revealed that morphine addicts liked it. The FBN also harassed the handful of doctors who used it in the 1960s to treat morphine and heroin addiction. Such controversies continue to this day and illustrate the blurry line between lethal and therapeutic, between the control of pain and suffering and the pleasure of a cozy high.
Over the next decade, into the 1970s, that criticism spurred researchers to improve on methadone and to develop compounds that would both block the euphoric feelings and the dangerous respiratory depression brought on by opioids, including methadone. Such compounds led to the development of next-level maintenance drugs: buprenorphine and naltrexone (now known by the brand name Vivitrol).
Vivitrol, an opiate blocker and anticraving drug given as a shot that lasts around a month, has no abuse potential or street value, and would therefore later become the favored MAT of law enforcement. While naltrexone was approved for treatment of opioid and alcohol addiction in 1984, it was slow to gain social acceptability among doctors or addicted patients despite one researcher’s belief that it was the “pharmacologically perfect solution.” It wasn’t widely used until its maker began aggressively marketing the injection to drug courts and jails, beginning around 2012.
Buprenorphine also blunts cravings, and it’s less dangerous than methadone if taken in excess, which is why regulators allowed physicians to prescribe it in an office-based setting rather than clinics that have to be visited on a near-daily basis. “I don’t think anyone thought the street value of bupe would be significant,” the historian Nancy D. Campbell told me. “That is generally thought of as quite a surprise.”
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.