“It’s really going to take doctors standing up for this, and it’s going to take going against the very vocal twelve-step recovery community, which is most at odds with the work the harm-reduction movement is trying to do,” said Vincent, a recovering heroin user who pays $480 a month, cash, for daily methadone maintenance.
In Baltimore, where the overdose death rate was six times the national average (and where much of Roanoke’s heroin supply originates), the health department has long deployed a needle-exchange RV to heroin hot spots six days a week, offering disease testing in addition to clean needles, naloxone training, wound care for injection abscesses, and prenatal care. The initiative is credited with reducing needle-injected HIV instances from 64 to 8 percent. Conservative then–Indiana governor Mike Pence responded, albeit reluctantly, to the 2015 Scott County HIV outbreak that infected 175 people with a limited needle exchange.
In San Francisco, recovering heroin user and certified addiction specialist Tracey Helton Mitchell launched her own renegade harm-reduction movement in 2003 by mailing out free packages of clean needles and naloxone vials. In the opioid-minded Reddit forum where she became known as the Heroine of Heroin, Mitchell still shared counseling and intervention strategies, answering some fifty emails a day.
She continues to receive calls from frantic users in large swatches of the country eager for clean needles, information, and naloxone. “We’re in the absolute dark ages in most of this country for syringe exchange,” she told me, describing users with worn needles broken off in their arms, or people who reuse needles found in the gutters and then sharpened with matchbooks. “We’re years behind catching up, and the drug deaths haven’t even peaked yet.”
*
And yet the ideological gulf I witnessed between the criminal justice establishment and families like Tess’s seemed to grow wider by the day. Kevin Coffman, a drug task force member who’d worked the Ronnie Jones case, told me he firmly believed we could end the opioid epidemic with a single stroke of Trump’s pen: imprison heroin users for life the third time they got caught with the drug, and that would have a chilling effect on remaining users, who would logically, he believed, give up their drugs.
We were sitting in the same room where Coffman and Bill Metcalf had mapped out Jones’s heroin ring. It was next to the kitchen, where a trump–pence sticker was pasted on the refrigerator door. Not only did the detective have zero empathy for the addicted, but he also lacked any scientific understanding of the morphine molecule’s pull.
Nor did some of my dear friends, longtime members of AA, who remain staunchly opposed to harm reduction and MAT for those working its twelve-step program. “There’s a reason why some people think NA and AA are cults,” said Mitchell, who used methadone, needle-exchange programs, and a secular support program called LifeRing to treat her heroin addiction. “They can’t take in any other information because it throws a different light on their own personal recovery.”
As Trump-appointed attorney general Jeff Sessions said in March 2017: “We need to say, as Nancy Reagan said, ‘Just say no.’ backed health care it.”
Two months later, the Trump administration proposed gutting the office of the White House drug czar, reducing its budget by $364 million, despite Trump’s campaign vow to combat the nation’s growing opioid epidemic, and backed health care changes that would have put the most vulnerable users at risk. After a backlash, Trump rolled back his proposal to relatively modest trims. But more than a year after his inauguration, the office still lacked a permanent director, Trump remained more focused on law enforcement than public health strategies, and a comprehensive list of recommendations written by his own presidential commission remained a work in progress or unaddressed.
*
Harm reduction remained slow to catch on in most of the Bible Belt, including Roanoke. When I told Janine about an idea hatched at an opioid brainstorming session in Boston—to segregate users on a boat in international waters, where they could legally inject under medical supervision, ideally then transitioning to counseling and MAT—she was repulsed. “That’s crazy! We’ve created this problem, and now we decide we’re just going to continue to let it happen, and that’s the answer?”
And yet she was miles ahead of most leaders in her conservative community. She’d told her son’s story recently to the local school board and county officials, hoping to raise money for the county’s risk prevention council, which was currently running on fumes and a few small federal grants. She’d explained how she’d pulled strings to get her kids into the Hidden Valley school zone because she considered it a superior place to raise children. But the affluence she believed would protect her family had instead allowed the festering of shame and inaction. Almost daily the Hope Initiative took a call about a heroin user from Hidden Valley or nearby Cave Spring, and police data showed that the problem was worse by far in those two communities than in other, less affluent areas of the county.
“I was just a mom trying to make them aware of what’s happening here, that they should be aware. But there was dead silence in the room,” Janine said. “Nobody asked me a question. I just spoke, and I sat down.”
The school board declined to support the program, and the county gave its usual $2,000.
*
Of the fifty-seven people who came seeking treatment in the Hope Initiative’s initial months, the volunteers had persuaded only two people to begin residential treatment. About fifteen were referred to MAT outpatient programs—seven of whom were still in recovery a year later. Neither Tess nor her friend Joey was among the successes, though both were regularly in touch with Hope volunteers.
Tess seemed to be nowhere close to accepting help, Patricia told me, in early 2017. We sat next to each other at a drug-prevention forum put on at Tess’s alma mater, Cave Spring High, as judge after cop after grieving parent talked about rising overdose calls (thirty in the first six weeks of the year), more than a doubling of Narcan administrations, and increasingly potent seizures of fentanyl-spiked heroin.
Janine told Bobby’s story publicly for maybe the twelfth time. She finished by describing a recent visit to an urgent-care center with her teenage daughter, who’d sprained her thumb playing softball. After an X-ray and an exam to rule out a break, the doctor wrote her fifteen-year-old a prescription for a twenty-five-day supply of oxycodone.
“I tore it up,” Janine said. She also called clinic official Dr. John Burton, who said of the incident: “This was a provider who was still doing things the way we used to do them five years ago, and he didn’t get the memo.” A come-to-Jesus ensued, with Burton reminding the doctor of the hospital system’s ER policy of no more than three days’ worth of oxycodone or hydrocodone per prescription, sans refills.
During the Q&A at the end, Patricia stood in the audience and described Tess’s descent from Cave Spring honor-roll student and athlete to heroin addict and prostitute, preyed on by a growing network of drug dealers and pimps.
“I never saw it coming,” she told the crowd. “And I don’t know what the answer is, but I know it’s important we take heroin out from under a dirty rug. We should be talking about it the same way we talk about cancer.”