Poverty as an Obstacle to Recovery Theme Analysis

Though the opioid epidemic would go on to spare no segment of America, nowhere has it settled in and extracted as steep a toll as in the depressed former mill and mining communities of Central Appalachia, where the desperate and jobless rip copper wire out of abandoned factories to resell on the black market and jimmy large-screen TVs through a Walmart garden-center fence crack to keep from “fiending for dope.”

Three months before visiting Jones, in the spring of 2016, Kristi Fernandez and I stood next to Jesse’s grave on a rolling hillside in Strasburg, Virginia, in the shadow of Signal Knob. She’d asked me to meet her at one of her regular cemetery stops, on her way home from work, so I could see how she’d positioned his marker, just so, at the edge of the graveyard.

It was possible to stand at Jesse’s headstone—emblazoned with the foot-high number 55, in the same font as the lettering on his Strasburg Rams varsity jersey—and look down on the stadium where he had once summoned the crowd to its feet simply by running onto the field and pumping his arms

Industrywide, pharmaceutical companies spent $4.04 billion in direct marketing to doctors in 2000, up 64 percent from 1996. To get in the doctor’s door, to get past the receptionist and head nurse, the reps came bearing gifts, from Valentine’s Day flowers to coupons for mani-pedis.

The average sales rep’s most basic tool was Dine ’n’ Dash, a play on the juvenile-delinquent prank of leaving a restaurant without paying the bill. For a chance to pitch their wonder drug, reps had long offered free dinners at fancy restaurants. But soon, to-go options abounded, too, for a busy doctor’s convenience. Reps began coming by before holidays to drop off a turkey or beef tenderloin that a doctor could take home to the family—even a Christmas tree. Driving home from the office, doctors were also invited to stop by the nearest gas station to get their tanks topped off—while listening to a drug rep’s pitch at the pump, a variation the reps nicknamed Gas’n’ Go. In the spring, the takeout menu featured flowers and shrubs, in a version some dubbed—you guessed it—Shrubbery ’n’ Dash.

The doctors were witnessing the same thing that Lieutenant Stallard had seen a year earlier, in 1997, on the streets. “We had always had people using Lortabs and Percocets, but they were five- or ten-milligram pills you could take every day and still function. They didn’t have to have more,” Stallard said.

“The difference with OxyContin was it turned them into nonfunctioning people”

Though it took nearly a decade before police, the press, and drug-abuse experts fully understood what was happening, Ed Bisch watched the urbanization of the pill epidemic play out on his front lawn in 2001, as paramedics carried his son’s body away.

He retreated to his computer, where he was shocked to learn that his son’s death had been the region’s thirtieth opioid overdose in the past three months.

How was that possible when he’d only just learned the word? “The internet was still new, and back then it was mostly message boards as opposed to websites,” he said.

Conspicuously absent from the courthouse drama was the family that owned the company and its 214 affiliates worldwide- and benefited the most from the drug’s sale. Purdue had earned over $2.8 billion from the drug by 2007, including $595 million in earnings in 2006 alone. Unlike a public company that answers to shareholders, privately held Purdue answered only to the Sacklers.

In 2015, the family would earn its way onto Forbes’s “America’s Richest Families” list. With an estimated net worth of $14 billion, the OxyContin clan would edge out such storied families as the Busches, Mellons, and Rockefellers. Having gone from selling earwax remover and laxatives to the most lucrative drug in the world, the family had museum wings and college institutes named for it from Boston to Tel Aviv.

In rural counties decimated by globalization, automation, and the decline of coal, the invisible hand manifested in soaring crime, food insecurity, and disability claims. In Martinsville and surrounding Henry County, unemployment rates rose to above 20 percent, food stamp claims more than tripled, and disability rates went up 60.4 percent…

It was easy to understand the connection between joblessness and hunger, to get that hunger fueled some of the crime. It was growing clearer, too, that the federal disability program was becoming a de facto safety net for the formerly employed, a well-intentioned but ultimately disastrous way of incentivizing poor people to stay sick, with mental illness and chronic pain—conditions that are hard to prove and frequently associated with mental health and substance use disorders—prompting the majority of disability awards.

In the picturesque Shenandoah Valley town of Woodstock, more than two hours north of Roanoke, bulk heroin cut in a Harlem lab had just made its way down I-81. It was the last thing Shenandoah County sergeant Brent Lutz, a Woodstock native, would have expected to find himself doing: stalking a major heroin dealer. But here he was, at all hours of the day and night, clutching a pair of binoculars while crouched in the upstairs bedroom of his cousin’s house a few miles outside of town. He’d spent so much time there in recent days that the mile-wide stench of chicken entrails coming from George’s Chicken across the road no longer bothered him.

NIDA, the Institute of Medicine, the World Health Organization, and the White House drug czar’s office would all agree that indefinite (and maybe even lifelong) maintenance treatment is superior to abstinence-based rehab for opioid-use disorder. And even Hazelden, the Betty Ford-affiliated center that originated the concept of the twenty-eight-day rehab, changed its stance on medication-assisted treatment, or MAT, offering Suboxone to some patients in 2012.

But the rehab Jesse went to was aimed at abstinence, as most were, then and now.

By 2014, the suburban heroin-dealing scene had become entrenched in Roanoke’s McMansion subdivisions and poor neighborhoods alike. But the largest dealers weren’t twice-convicted felons like Ronnie Jones with elaborate dope-cutting schemes, multiple cars, and hired mules. They were local users, many of them female, dispatched to buy the heroin from a bulk dealer out of state, in exchange for a cut. And they were as elusive as hell to catch.

Tess was nearly seven months pregnant when she left jail in June 2015. For a month, she lived with her mom and tried to make a go of it with her boyfriend, the baby’s father—“disastrous,” Patricia and Tess agreed—before they found a private treatment center two hours away that would take Tess during her final month of pregnancy. Private insurance covered most of the $20,000 bill while her dad paid the $6,500 deductible, using the remainder of Tess’s college-savings fund. The Life Center of Galax was one of the few Virginia facilities that accepted patients on medication-assisted treatment (methadone or buprenorphine). Tess was now taking Subutex, a form of buprenorphine then recommended for some pregnant mothers. (Suboxone is typically the preferred MAT for opioid users because it also contains naloxone, an opiate blocker; Subutex, which is buprenorphine with no added blocker, was then considered safer for the baby but more likely to be abused by the mom.)

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 just left goodwill, can you please transfer $4 so I can get a pack of cigarettes please?

The birthplace of the modern opioid epidemic—central Appalachia—deserves the final word in this story. It is, after all, the place where I witnessed the holiest jumble of unmet needs, where I shadowed yet more angels, in the form of worn-out EMTs and preachers, probation officers and nurse-practitioners. Whether they were attending fiery public hearings to advocate for more public spending, serving suppers to the addicted in church basements, or driving creaky RVs-turned-mobile-clinics around hairpin curves, they were acting in accordance with the scripture that nurse-practitioner Teresa Gardner Tyson had embroidered on the back of her white coat:

Verily I say unto you, inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me. (Matthew 25:40)

If the federal government wouldn’t step in to save Appalachia, if it steadfastly refused to elevate methods of treatment, research, and harm reduction over punishment and jail, Appalachia would have to save itself.

Tess was still homeless, and another week passed before she called Patricia with an address via a borrowed phone, possibly belonging to a current or former pimp. “Are you in danger?” her mom asked, and Tess claimed she was not, repeating a line she often said: “I’m a soldier, Mom. I’ll be fine.

“Yes, love.” Patricia responded. “But sometimes even soldiers fall.”

It was January 2, Tess’s birthday. She would’ve been twenty-nine.

Patricia tucked the treasures of her daughter’s life inside the vest—a picture of her boy and one of his cotton onesies that was Tess’s favorite, some strands of Koda’s hair, and a sand dollar.