On Thursday nights, Judge Moore helps serve dinners to participants in a twelve-step program at a local church. He also persuades his friends in the community—from fast-food managers to local contractors—to hire his drug-court participants.
At a recent jury orientation, Moore’s bailiff was approached by two boys, ages four and five. Neil Smith thought they were the grandchildren of a potential juror, but it turned out they were only temporarily with him as foster children, and they were looking for a permanent parent—a fact that became clear when the boys took one look at his bailiff’s uniform and asked him, “Will you be our daddy?”
Smith is on the far end of middle-aged, a kindly-looking sort. Both his parents worked in the mines, and they grew a twelve-acre plot of tobacco on the side near the hamlet of Cleveland. His first memory of the judge was from when they were both kids: He remembered an adolescent Michael Moore getting on the same Russell County school bus that he rode, his face obscured by an armload of books, his bright future laid out before him.
One of the truest things I heard in my reporting came from David Avruch, a Baltimore therapist who works with a largely homeless, heroin-addicted clientele. In his experience, the base problem wasn’t a dearth of harm reduction but an economic structure that created more foster kids and fewer Michael Moores.
“The more we talk about the epidemic as an individual disease phenomenon or a moral failing, the easier it is to obfuscate and ignore the social and economic conditions that predispose certain individuals to addiction,” Avruch said. The fix isn’t more Suboxone or lectures on morality but rather a reinvigorated democracy that provides a pathway for meaningful work, with a living wage, for everybody.
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Judge Moore asked me, three times in one sitting, what I had learned from my reporting that he could feel hopeful about. He chuckled as he said, “I can’t wait to read your book, because then maybe we’ll know what to do”—but he seemed closer to tears than laughter.
I told him what Sue Ella Kobak had said, more times than I could count: “The answer is always community.” I told him about Teresa Tyson’s Health Wagon and Sue Cantrell’s commitment to stopping the spread of hepatitis C. The elusive gap between law enforcement and health care seemed as if it were finally beginning to close, I explained, even in a few remote Appalachian towns.
I described a faith-based treatment center in nearby Bristol that had just turned a donated former nursing home into a rehab with 240 beds. Geared to housing addicted people, veterans, aging-out foster kids, and ex-offenders getting out of jail, it had been brought to fruition by Bristol Recovery Center director Bob Garrett, who had spent three years forging collaborations with local courts, police, churches, and social service agencies. Participants would eventually pay to live in the center, nestled in a peaceful wooded compound, after they found jobs with the center’s help.
At first, Garrett told me, he wasn’t going to allow participants to be on MAT, but he changed his mind after serving on a community coalition spearheaded by East Tennessee State University public health professor Robert Pack. Since then, he’s preached the benefits of “evidence-based treatment” to churches across the state at dinners and presentations on addiction. “We want to show [the addicted] that they’re loved and cared about,” he told me. “And we’re trying to teach the lay folk, ‘They’re not really bad people,’ and ‘That’s a sin’ doesn’t really work.”
I told Judge Moore, finally, that Pack’s coalition—an alliance of mental health and substance abuse administrators who call themselves the working group—had just scored another coup. Of all the upstart recovery programs I had surveyed in my reporting, this collaboration represented the strongest model for thwarting governmental rigidity and bureaucratic indifference to the crisis, and it had the potential to be replicated elsewhere.
In a rural town between Johnson City and Kingsport, Tennessee, the alliance was about to open a treatment clinic called Overmountain Recovery. It was deliberately named: Overmountain, for the disparate group of local farmers and frontiersmen, called the Overmountain Men, who beat back the British in the Battle of Kings Mountain, turning the tide in the Revolutionary War; and Recovery, because the treatment is meant to go beyond MAT to include group and individual counseling, yoga, and other alternative therapies, plus job-training support. Though the outpatient clinic would eventually offer Suboxone, it would predominantly be a methadone clinic, because methadone is cheaper and harder to divert (participants drink the liquid daily in front of a nurse), and the nearest methadone facility in the region was over a mountain some sixty miles away.
“We would not have pulled this off without the working group,” said Pack, who began his addiction research after losing a dear friend to opioid-related suicide in 2006. With the backing of his university, the region’s nonprofit hospital corporation, and the state’s mental health agency, Overmountain was the latest project of Pack’s working group, which had secured $2.5 million in grants, eight funded projects, twenty-five research proposals, and the opening of a Center for Prescription Drug Abuse geared toward research. And, maybe even more important, it was co-led by Dr. Steve Loyd, a charismatic physician with local roots who had been opioid-addicted himself.
Located in Gray, Tennessee, a solidly middle-class community of farmers and suburbanites, with Daniel Boone High School just a mile and a half away, Overmountain fought a mighty resistance on its march to opening its doors, in September 2017. Headed by a respected area farmer, Citizens to Maintain Gray worried that patients taking methadone would be too high to drive safely. And, while the members of the group weren’t exactly against the idea of the center, they didn’t want it anywhere near them, even as some admittedly privately to Loyd and Pack, “My son is dealing with this.” But the working group showed up and heard them out. They brought in outside police chiefs and methadone providers, giving decision makers examples and studies from other communities that overrode their safety concerns. To win near-unanimous approval from the city zoning board and the state, they willingly endured more than a year of public ass kicking. In a community of just 1,222 residents, more than 300 people had spoken out publicly against the project, some referring to Pack and Loyd as drug lords.
In recovery for more than a decade, Loyd knew exactly how to explain himself to people in his hometown, to make them see the struggle anew: Before seeking treatment, he had doctor-shopped his own colleagues, stolen from relatives’ medicine cabinets, and even faked an ankle injury so he could have orthopedic surgery and get discharged with painkillers. His father called him out on his addiction in 2004 and forced him to get help, funneling him into ninety days of inpatient rehab, followed by five years of random drug screens, support services, and intensive monitoring.
A key component of Loyd’s success was the threat of punishment; his medical license could be yanked if he relapsed and/or made a critical medical error while treating a patient. He still checks in daily for the possibility of a random drug screen, via an app on his cellphone, even though he’s now Tennessee’s assistant commissioner for Substance Abuse Services. The daily routines of his life as a recovering addict and physician keep him committed to recovery, just as the scar on his left ankle reminds him how desperately low the drug-addicted can go.