*
In the Appalachian Bible Belt, a blend of MAT and twelve-step programs seemed to work best, which is why Art Van Zee and Sister Beth Davies still communicate daily about their patients, the nun letting the doctor know, for instance, when a shared patient suffers a personal setback, like a death in the family or a job loss. It had happened in the spring of 2017 with one of their longtime patients, Susan (not her real name), whose brother died of overdose. Then, a few months later, Sister Beth emailed me that it had happened again: Another of Susan’s brothers died of overdose, the youngest, whom she’d “practically raised. The loss is tremendous.”
Among Susan’s ten siblings, only three had managed not to become opioid-addicted, although one of the three was a pill dealer who didn’t himself use, Susan had told me. She’d been in Van Zee’s Suboxone program for six years and was now transitioning off disability via a program called Ticket to Work. She was putting in twelve-hour shifts as a nursing-home licensed practical nurse and going to the local community college to earn her registered-nurse degree.
“Some of my family’s like, ‘Why don’t you just keep your [disability] check and stay home?’
“And I’m like, ‘I’ve always wanted to go to school to be a nurse, and I can’t make it on seven hundred and forty dollars a month, and besides, you just feel so much better about yourself when you work.’”
Asked how the epidemic had changed her community, Susan sighed and told me it was now just an ingrained part of the culture. Her fifteen-year-old son believes the only way to avoid its perils is to move away. “I can’t live here, Mom,” he told her. “There’s nothing here but drugs and nursing homes.”
The first time Susan saw Van Zee, he spent two hours with her, learning her medical history, including the details of her addiction and childhood abuse. She’d recently had surgery for lung cancer, and he did not make her feel like crap for continuing to smoke (though he suggested she stop).
The members of her twelve-step support group—the one led by Sister Beth—like to joke: “When you go to Van Zee’s office, you might as well take a pillow and a blanket and a book, because you’re going to wait there a long time.” They worry, though, about what they will do if something happens to the seventy-year-old doctor and the eighty-three-year-old nun. “There’s so many of us who would just be—lost,” Susan said.
Van Zee was still working sixteen-hour days, much to Sue Ella’s chagrin. He was still conferring daily with Sister Beth over their growing roster of opioid-use-disorder patients (now the preferred term)—not counting the 150 people on his waiting list—either on the phone or via email multiple times a day.
Van Zee told me his greatest fear now was of being hit by an intoxicated driver while he jogged the winding roads—not because he feared his own death but because where, then, would his patients go?
*
Nationwide, attitudes about the drug-addicted were shifting, faster in urban settings than rural. At the edge of Boston’s South End, in a neighborhood some derisively called Methadone Mile, I stood in the low light of a homeless shelter clinic where users converged on a former conference room to be medically monitored as they rode out their heroin highs, often staggering in, propped between friends. In the facility’s public restrooms, a clever maintenance worker had rigged reverse-motion detectors that sounded visual and audible alarms to summon help if a person hadn’t moved for four minutes. The initiatives were the brainchild of the shelter’s medical director, who had sometimes tripped over bodies on her way to work, some of them having been fatally struck by cars. Dr. Jessie Gaeta’s goal in opening Supportive Place for Observation and Treatment inside the shelter was to keep users alive until they were ready to be funneled into treatment, as well as to separate them from those in the homeless community already in recovery (almost a third of the shelter’s clients have opioid-use disorder).
But the brownstone-filled neighborhood was rapidly gentrifying, and the cultural obstacles, even in liberal Boston, were significant. Neighbors were worried that SPOT would just attract more heroin users, dirty needles, and crime. Many accused Gaeta and her staff of enabling continued drug use.
The project got the neighbors’ reluctant blessing, but only after Gaeta invited community leaders and officials to the shelter and showed them what would happen in the small, ten-recliner room.
Over the course of more than fifty neighborhood meetings, “I got my ass kicked, basically,” she said.
But many skeptics were won over when they realized she was treating the problems that were already happening outside indoors. In a program that didn’t even keep patients’ names on file (a strategy called low threshold, to build trust), staffers monitored those who stumbled in on heroin combined with an increasing multiplicity of other drugs.
The SPOT room was the first place where skittish rape victims would let Gaeta administer proactive treatments for sexually transmitted illness as they tentatively told her their stories in an adjoining kitchenette. Only then would they allow her to stanch the bleeding brought on by forced sodomy with a gun or by duct tape ripped from their mouths.
“Even in a mission-based organization, there’s still so much stigma around how we should treat addiction,” Gaeta said. “You have to constantly fight this notion that we shouldn’t wrap our arms around people who don’t want treatment.”
Everywhere in America, it was painstaking to walk skeptics through the social, criminal, and medical benefits of helping the least of their brethren, but worth it—even if you had to get your ass kicked.
*
In Appalachia, harm reduction was very slowly making inroads. In Lebanon, Virginia, where anti-MAT drug-court workers had once been castigated by harm-reduction proponents, Judge Michael Moore’s hair had turned from salt-and-pepper to white in the year since I’d first interviewed him.
But the top Russell County prosecutor had recently signed off on allowing the drug court’s first Vivitrol participant, a thirty-year pill addict who admitted she could not stop abusing buprenorphine. Moore praised the prosecutor’s decision and viewed it as a harbinger of greater sensitivity in the criminal justice system to the realities of addiction. Half the probationers from his regular circuit-court docket were now on Suboxone, and “we do see good things with it,” he said. If his own kids were addicted, he told me, he, too, would want the option of MAT.
“Last fall the governor declared opioids an epidemic and I was like, ‘Are you kidding me? We’ve had the epidemic since 2002!’” Moore said. One of his present drug-court participants, in fact, was born dependent on the drugs.
“It’s really discouraging and scary because what kid, sixteen or seventeen, doesn’t know that opiates are addictive? They can see it in their family, so how can they not know, and yet they take them anyway. And there are parents out here just like me, or better, who have drug-addicted kids.”
The local schools had recently adopted new prevention models, after studies showed kids were more likely to use drugs after DARE. (One advocate told me she remembered her classmates sharpening the don’t off their DARE pencils so they actually read do drugs.) A new school policy diverted first-time juvenile offenders into treatment instead of expulsion or jail.