ROANOKE, Va. — Last year, on the day after Christmas, I picked up my phone to hear the mother on the other end of the line sobbing.
“It’s the phone call I never wanted to make to you,” she said. “I’m so sorry to have to make this call.”
For more than two years, I had followed Patricia Mehrmann and her daughter, Tess Henry, as they endured Tess’s struggle to get off, and stay off, heroin. I wrote about Tess in these pages, using the pseudonym Erica to protect her privacy, back when her privacy mattered.
In late 2015, Tess was 26 and enrolled in medication-assisted treatment, or M.A.T. — a program in which patients are prescribed the “maintenance drugs” buprenorphine or methadone to stave off the painful symptoms of withdrawal. I drove her to the Narcotics Anonymous meetings she was required to attend as a condition of the program and walked her baby boy around the back of the room when he got fussy.
Her prescription for M.A.T. ran out a few months later, and soon she was using heroin again. I kept in touch as she lost custody of her son and couch-surfed through slumlord apartments, then as she toggled between psychiatric hospitals, jail cells, shelters, emergency rooms and the streets. “When it starts getting cold out, I’m ready to come in for help,” she told me in a psych-ward common room, where I was permitted to take notes only in pencil, as my pen was deemed a possible suicide tool.
Last year, her mother and grandfather teamed up to send her to an abstinence-only rehab center in Las Vegas. It cost them $12,000 for 30 days. (Tess had lost her Medicaid coverage when she lost custody of her son, though in this case Medicaid wouldn’t have helped anyway; like many rehab facilities, the center took only private insurance.) Tess loved books, so I sent her Tracey Helton Mitchell’s “The Big Fix: Hope After Heroin” and the latest David Sedaris. He was her favorite writer, and she’d met him once, in a coffee shop after a reading, and he was “so incredibly nice.”
But soon Tess once again succumbed to her heroin cravings. On Mother’s Day, she checked herself out of rehab. She had lost her ID and had no way to fly home, so she was fending for herself, middle-manning or dealing in order to use, stuck under the thumb of dealers and pimps. She was sleeping in the corners of casinos, I would later learn, and sometimes in an abandoned minivan.
Tess had been addicted to opioids since 2012, when a doctor at an urgent care facility prescribed her cough syrup with codeine along with hydrocodone for pain — 30 days’ worth for both prescriptions — for a case of bronchitis, according to Tess and her mother.
“What we really need is an urgent care center for the addicted,” Tess told me the first time we met. She was right. Medical overtreatment was the rule in American medicine — until the moment addiction set in, and health care scarcity became the norm.
There are two approaches to treatment, and Tess was failed by both of them: on one side, kind but abstinence-oriented recovery coaches and, on the other, M.A.T.
Suboxone (buprenorphine with the opioid-blocking drug naloxone) and methadone prevent the suffering of withdrawal and extend lives by cutting overdose deaths in half or more compared with abstinence-based programs alone. But maintenance drugs don’t work for everyone, and Suboxone can be easily diverted — a rural judge I know won’t permit his probationers to take it because he said that most sell their Suboxone to buy meth.
This ideological divide is another tragedy of the opioid crisis — keeping life-extending treatment away from a population that desperately needs it. Nationwide, only about one in five opioid users gets maintenance drugs, and even in states like Massachusetts, which has expanded access through Medicaid, only three in 10 receive a follow-up round of M.A.T.after an overdose.
We tend to think of people addicted to heroin as not wanting or seeking out treatment. But in my experience, interviewing scores of the addicted from rural outposts to city streets, that was almost never the case. The first time I interviewed Tess, she was desperate to get better so that she could be a good mother to her son. During a subsequent relapse, she wrote in her journal, “I am going to die if I keep living the way I am.”
But families, the last institution standing for many who are suffering from addiction, often get in the way of treatment. Too often relatives become worn out by a user’s behavior — the stealing and prostituting to pay for drugs, the fighting with friends and loved ones — before long-term maintenance drugs can be obtained to quell cravings and permit the addicted to work toward resuming their lives.
Tess’s mother, Patricia, wasn’t a believer in M.A.T because she thought it was widely abused. She worked as a hospital nurse and had seen patients admitted for infections after injecting themselves with buprenorphine and other opioids, as well as countless others, like Tess, who had relapsed after being on the program.
She also knew just how hard it would be for Tess to qualify for M.A.T. a second time. The hurdles Tess faced are largely still in place today: not enough physicians willing to prescribe maintenance drugs, M.A.T. doctors who refuse to accept insurance and a federal limit on how many patients doctors can treat with M.A.T.
Back in 2016, Tess’s doctor accepted only cash, and the doctor’s drug-testing and counseling protocols seemed lax to Patricia. Tess, too, had clearly figured out how to abuse the drug — Patricia found spoons and buprenorphine powder among her things, and Tess told me she doubled her dosage when stressed.
As a reporter, I’m not supposed to try to change the outcome of a story. But in Tess’s case, it seemed wrong to remain silent. When Tess was stuck in Las Vegas and couldn’t board a plane because she’d lost her ID, I urged Patricia to help her get on maintenance drugs so that she could make the three-day bus journey home without getting dope sick. Once, when Patricia texted me about taking care of a 25-year-old patient on Suboxone who had contracted endocarditis, an infection of one of his heart valves, from injecting it and other drugs, I gently replied that while Suboxone was sometimes abused, at least there wasn’t any fentanyl in it, “so it’s somewhat safer than street heroin.”
Patricia saw only the problem Suboxone users, in other words. She didn’t see the people I knew who were now stabilized on M.A.T. and getting their kids and jobs back. She didn’t see them because, understandably, these former addicts feel the stigma of being on M.A.T. and remain a quiet bunch.
Tess herself believed that abstinence-based rehabs were her best shot at success. She believed this despite the fact that of all her friends who used, she knew only two who had achieved a lasting recovery by following the 12 steps — and only because they were brothers whose parents shelled out more than $300,000 for multiple long-term rehab and aftercare stints.
Last fall, Tess wasn’t ready, yet, to stop using. She told her mother and me repeatedly not to worry. She wanted desperately to get better for the sake of her young son, whom she hadn’t seen in months but loved more than anything. She wanted to get healthy to honor the memory of her best friend, Jordan Gilbert, who’d overdosed in Roanoke, Va., that year. She was a soldier, Tess assured her mother and me, in mid-December. She would be O.K.
Opioid deaths in Nevada were high, as they were everywhere in America, with fentanyl-related deaths having gone up 56 percent from 2015 to 2016. A week before Christmas, Tess assured her mother and me that she was preparing to return home and into treatment. Her grandfather agreed to fund another 28-day round of rehab in Roanoke, Tess’s fourth, at a cost of $20,000 — in another abstinence-only facility. Patricia moved mountains to get her daughter an ID so that she could board an airplane.
“I just got on Subs,” Tess texted her mom on Dec. 23, referring to the Suboxone she needed to prevent her from throwing up and having diarrhea on the plane.
“I’m so glad you reached out — so many people pulling for you,” I told Tess, in our last Facebook Messenger exchange.
“Can’t wait to be home really,” Tess wrote back.
Tess’s body was found at the bottom of a Las Vegas apartment complex dumpster on Christmas Eve, the cause of death given was blunt trauma to the head. Tess’s last words to me echoed as her mother relayed her final moments over the phone, each detail worse than the last. Not knowing how to respond, I did the only thing I could think of at the time, which felt ridiculous and impotent but wholly necessary: I made her mother soup.
Tess’s quest for treatment had lasted six years, during which time she was repeatedly left to fend for herself by the police, the medical community, the state legislators who refused to expand lifesaving access to Medicaid, weary family members and treatment advocates urging abstinence and tough love and, once, when she begged me to pick her up from a drug house — and I declined — by me.
It takes the typical opioid-addicted user eight years — and four to five treatment attempts — to achieve remission for a single year, according to John Kelly, a researcher and professor of psychiatry at Harvard Medical School.
Tess didn’t have eight years. Her murder remains unsolved.
The day of her funeral in January, Dan Polster, a federal judge in Cleveland, was presiding over a hearing in the continuing mass litigation case against opioid makers, distributors and retailers. “About 150 Americans are going to die today, just today, while we’re meeting,” Judge Polster said.
Last month, a lawyer representing some of the plaintiffs in that case called me to discuss a potential settlement. She wanted my ideas about how to treat the more than two million opioid-addicted Americans.
I told her about Tess. It occurred to me that only in death are those who are addicted seen as victims, as patients who might have been worthy of medical care. What this country needs is an easy-access system of urgent care centers that triage the addicted and, when they’re ready, funnel them into M.A.T. programs. Call it syringe exchange. Call it needle recovery. But make it a place where professionals can mule the burdens when a family’s good will is spent.