The Value of Science Theme Analysis

In the United States of Amnesia, as Gore Vidal once called it, there were people in history who might have expressed skepticism over Haddox’s claim, had anyone bothered reading up on them. Ever since the Neolithic humans figured out that the juice nestled inside the head of a poppy could be dried, dehydrated, and smoked for the purposes of getting high or getting well, depending on your point of view, opium had inspired all manner of commerce and conflict.

By the 1870s, injecting morphine was so popular among the upper classes in Europe and the United States that doctors used it for a variety of ailments, from menstrual pain to inflammation of the eyes. The almost total lack of regulatory oversight created a kind of Wild West for patent medicines, with morphine and opium pills available at the nearest drugstore counter, no prescription necessary. As long as a doctor initially OK’d the practice, even injected morphine was utterly accepted. Daily users were not socially stigmatized, because reliance on the drug was iatrogenic.

But what exactly was adequate pain relief? That point was unaddressed. Nor could anyone define it. No one questioned whether the notion of pain, invisible to the human eye, could actually be measured simply by asking the patient for his or her subjective opinion. Quantifying pain made it easy to standardize procedures, but experts would later concede that it was objective only in appearance—transition labor and a stubbed toe could both measure as a ten, depending on a person’s tolerance. And not only did reliance on pain scales not correlate with improved patient outcomes, it also had the effect of increasing opioid prescribing and opioid abuse.

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.

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.

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.