I can’t see anything. Well, anything except the rain, that is. Gallons barrage my tiny Subaru with powerful thwacks, cascading down the windshield and overpowering the frantic, useless sweeping of the wipers. For a few terrifying seconds, I feel the car lurch and slip as I make a hairpin turn through two lush mountainsides, carefully keeping my distance from the blurry red lights of the logging truck directly ahead. Regaining traction, I exhale slowly, cursing under my breath.
“Who needs coffee, right?” I ask my passenger, friend, and photojournalist-for-hire, Craig, who stares passively into his cell phone.
“Yep, weather’s crazy around here,” he says, mostly uninterested.
I’m about 15 minutes outside Craig’s hometown of Charleston, West Virginia, headed for a small addiction treatment clinic in Parkersburg, about an hour away. It’s seven in the morning. My back is killing me, thanks to the pint-sized futon I slept on the night before. I’ve already worked up a sweat, and I’m definitely going to miss breakfast. No Starbucks in these parts.
Why am I here? To tell a story. It’s one you probably already know. Or think you do.
Plenty has been written about the opioid epidemic. About how easily addictive prescription painkillers—most prominently, oxycodone and fentanyl—were pushed by pharmaceutical companies over the last 30 years with reassurances that they were safe, despite being 50 and 100 times stronger than morphine, respectively. You might’ve heard how they were peddled by overzealous prescribers, some of whom saw fat kickbacks from the drug companies. And maybe you heard how, hundreds of thousands of opioid-related overdoses later, many doctors stopped offering painkillers altogether, hoping to avoid the wrath of state and federal governments and lawyers representing grieving families.
When the opioid supply began drying up, patients started turning to the hard stuff, like heroin, that mimicked the painkilling effects of these prescriptions. In fact, reports from the National Institute on Drug Abuse estimate that nearly 80 percent of current heroin users abused prescription opioids before turning to the illegal drug.
In 2017, which saw 47,600 opioid-related deaths alone, the Department of Health and Human Services declared opioid addiction a public health emergency and created a five-point plan for addressing it, including improving access to treatment and recovery services.
But the problem is still very much alive and well. More than 130 people nationwide die every day from opioid overdoses, according to the Centers for Disease Control and Prevention. And in West Virginia, the problem is worse than in any other state. In 2017, 833 opioid-related deaths occurred here, a rate of 49.6 deaths per 100,000 people. Despite the pullback on prescribing, providers in West Virginia wrote 81.3 opioid prescriptions for every 100 people that year, nearly 23 percent greater than the national average.
That said, there’s a side of the opioid epidemic many people don’t know about, especially in rural, hard-to-reach parts of the country. There’s a popular narrative that opioid addiction is a problem faced mostly by low-income, non-Hispanic white men. That’s false. In fact, there have been consecutive years during the epidemic when the rate increase of opioid-related deaths among women and blacks has vastly outpaced that of men and whites. Also seldom discussed are the disagreements among treatment providers about the best way to tackle opioid addiction, and the cultural and institutional barriers facing those who want to help and those who need that help.
I’m here to provide an up-close look at the realities of treating opioid addiction. But as I approach Parkersburg and the rain gradually subsides, only to be replaced by the blistering June heat, I can’t help but feel like I’m a little out of my element. I’ve driven seven hours to get here from Washington, DC, a city that often feels blissfully detached from a problem that most well-off urbanites, insulated by gourmet salad shops and yoga studios, will only read about during their morning Metro commute.
As the car whizzes past a collection of battered antique shops and gun ranges and a billboard that proclaims “Jesus Loves You! Jesus is Coming!” I feel like a beleaguered freshman politician on the campaign trail. Will I be well received by the treatment providers and patients I’m about to meet, or will they keep their lips contemptuously sealed? I’m about to find out.
The Art of Fitting In
It happens that the clinic I’m visiting understands this fish-out-of-water dilemma well. Like many small, rural American cities, Parkersburg is a place where history and tradition loom large. A Civil War–era bridge stretches out across the muddy, neighboring Ohio and Little Kanawha Rivers. After World War II, downtown Parkersburg was speckled with booming factories, which churned out chemicals, iron, and steel, becoming an industrial powerhouse in the region, only to fall on hard times a few decades later. Today, almost a quarter of city residents live below the poverty line. Outsiders, I’m told, are viewed with a healthy dose of suspicion.
When Groups, a Nashville-based, for-profit opioid addiction treatment organization opened its Parkersburg location a little over a year ago, it was the new kid on the block, an outpatient, medication-assisted treatment (MAT) center going up against well-established area hospitals and a handful of abstinence-only clinics. But in the five years since Groups was founded, it’s become something of an expert at stealthily setting up shop in rural America, opening 50 clinics across seven states, 22 in the last two years alone, in response to the unrelenting opioid crisis.
It probably helps that the Parkersburg clinic is hardly noticeable, an unassuming, single-story, tan building sandwiched between a Papa John’s pizzeria and a drive-through bank. A towering sign overhead proudly trumpets Almost Heaven, West Virginia’s new slogan, taken from the famous John Denver song “Country Roads.” Otherwise, it doesn’t draw too much attention.
Inside, it’s anything but subtle. Craig and I walk through the clinic door and are immediately struck by the decor. Sea-blue walls deck the waiting room, punctuated by white and mustard yellow chairs. In the corner, a bright pink flamingo lawn ornament pokes out of a potted plant, next to a stack of Cosmopolitan magazines on a short table. A black and white Keith Haring print of stick figures precariously perched atop one another graces the wall. Two young women sit behind a thin pane of glass at the check-in counter, stacked with Rice Krispies Treats and bottled water for guests.
We’re immediately greeted by Jeremy Carpenter, the executive director, who’s been expecting us. Dressed in an untucked, blue checkered shirt and jeans and sporting a well-manicured beard befitting a Union Army general, he and Stephanie Stitt, the clinic’s cheery and very pregnant director, invite Craig and me to take a seat in Stephanie’s office.
We jump right in. I learn that every Groups clinic offers one-hour group therapy sessions four times a week for a flat $65 fee, covered by a handful of insurance companies. A nurse practitioner or doctor is present at each therapy session, who writes the attendees a prescription for suboxone, considered one of the big three medications for opioid addiction treatment. Most MAT programs charge closer to $100 for the same service, we’re told.
A treatment regimen at Groups usually lasts 18 to 24 months—“just so people know this isn’t a ‘forever medication program,’” Stephanie clarifies. Dosages are slowly tapered. Afterward, the members, as they’re called—not patients, Jeremy and Stephanie both stress—have the option of returning for their weekly therapy session at no charge. With the potential for relapse especially high, it’s something they’ve planned for in advance. “Aftercare is common in this industry,” Jeremy remarks. “Free treatment isn’t.”
Before each session, the members are drug-tested through urine samples. But unlike many places, there’s no penalty if they test positive. Nobody watches over them in the bathroom to make sure they’re being honest, unless you count the diminutive garden gnome decorating the corner opposite the toilet. If a member does test positive, the presiding social worker will, of course, have to record the infraction and notify a parole officer if one has been appointed. But otherwise, as long as the member isn’t disrupting the group, they’re free to continue treatment.
Jeremy balks at the notion of a three-strike rule, which is strictly enforced at other clinics. He says treatment providers need to be more compassionate, and addiction should be regarded no differently from diabetes or heart disease. Plus, being here is better than being on the street. “To put a number to how many times you can mess up before you’re kicked out?” he scoffs. “How long are you out? Thirty days? What kind of effect does that have? We’d be lucky to get you back at all. Plus, progress looks different from person to person. When I look at someone who went from using six times a day to three times a day—a 50 percent decrease—that’s progress. That’s how we define success here. Saying otherwise is where our industry misses.”
When it came time to set up shop in Parkersburg, those prevailing attitudes caused Groups some headaches. Six months before breaking ground, Jeremy’s team in Ohio used census data to evaluate the need in Parkersburg. They sent regional managers to meet with local police, children’s services employees, first responders, the mayor, and even coal plant managers.
Most gave them the green light. But not everyone was happy. Jeremy estimates that half the locals didn’t see the need for another clinic, didn’t want the extra stigma, or believed they’d bring even more addiction to Parkersburg. Local abstinence-only treatment centers didn’t stay quiet, either. “There’s a misconception that we’re just another pill mill,” Stephanie says, exhaling deeply. “And sadly, there’s a stigma within our industry between providers. Once we as a field start realizing that exists and do something about it, we’ll all be better for it.”
Today, with more than 30 members enrolled in treatment, Jeremy and Stephanie say the locals view Groups more positively. Even an abstinence-only treatment center down the road had a change of heart, recently dropping off several of its own patients at Groups.
Why the shift? I ask. Was it the affordable treatment? The eclectic decor? The free snacks? The nonpunitive response to slip-ups?
All of that matters, they say. But what really sways public opinion is making treatment less one-dimensional, less transactional. Historically, many people who walk into Groups for the first time have been only a number to their doctors, Stephanie says. There’s no personal connection.
“We’re what I’d call radically demedicalized,” Jeremy explains. “Referring to other facilities, you’ll hear a lot of patients say, ‘I step into the doctor’s office, I nod my head, they check a few boxes, they provide the prescription, and then I leave.” From their very first visit to Groups, Stephanie says her staff is fighting patients’ preconceived notion that treatment is cold and impersonal. “We want to inject life into people when they come in here.” She smiles. “Sometimes, there’s no better way to do that than bright walls and pink flamingos.”
Close to Home
After hearing Jeremy and Stephanie, I want to believe it’s that simple. There’s a growing consensus among addiction experts that MAT is the gold standard of care in treating opioid dependency, far more effective than meds or therapy alone. In fact, 60 percent of patients in MAT maintain their recovery, according to figures from Blue Cross Blue Shield. Having tracked approximately 4,000 patients over the course of its five-year history, Groups puts its recovery rate closer to 80 percent. So what accounts for this extra 20 percent? Is the answer as easy as adding pink flamingoes and taking a few extra minutes to greet patients with a smile and a firm handshake?
There’s another, much more significant reason for above-average outcomes at Groups, I’m told: no matter the clinic’s location, the organization makes sure it’s managed first and foremost by locals with skin in the game. Keeping an eye out for talent, Groups often seeks out its care providers, not the other way around.
I’m introduced to Tavia Elder and Kendra Cormack, the women I saw behind the glass partition when I first walked in. They’re in their mid-20s, both graduate students at West Virginia University, with bachelor’s degrees in social work. Last November, Groups recruited them to lead its weekly therapy sessions. Today is Tavia’s turn to lead sessions, so she’s dressed accordingly, sporting jeans and a gray sweatshirt with “Groups” stitched in teal on the upper left. I’m a little surprised—and impressed—to hear that, with Jeremy back in Ohio and Stephanie working remotely most days, these two oversee day-to-day clinic operations and treat its 30-plus members almost singlehandedly.
But it’s easy to see why they were chosen for the work. For both, opioid addiction is personal. Tavia admits that her brother, recovering from a heroin addiction, is currently in treatment. And Kendra tells me she’s lost family members to opioids. After her best childhood friend died by suicide a few years ago, following a long struggle with addiction, she started working in local clinics. “I wasn’t able to save him,” she says. “So I’m trying to save someone else.”
“When it comes to working in rural communities, we keep it in-house,” Stephanie chimes in. “Tavia and Kendra went to high school together here. They’re getting married here, and they’ll raise their families here. That creates the extra boost for them to want to help their community.”
This also means the work goes beyond just facilitating group sessions. On Tuesdays and Thursdays, under a Groups policy designed to improve staff relationships with the surrounding community, Kendra and Tavia do their choice of volunteer work, whether serving lunch at a nearby homeless shelter, sitting in drug courts, or walking dogs for the local Humane Society chapter. In the summer, they sponsor one of Parkersburg’s little league teams and take the kids out for ice cream after games. And this month, they’re manning a booth at the local Pride parade.
It’s also sharpening their clinical skills, Kendra says. At treatment centers where she used to work, “you sat in a chair from the time you clocked in until you clocked out. Finally getting to work outside the facility pushed me way out of my comfort zone, and I became better at what I do because of it.”
But living where you work comes with its own set of challenges, the two admit. Last week, they bumped into three Groups members after hours in the Dollar Store down the road. And going out to eat in Parkersburg, you’re almost guaranteed to have a member as your server, Tavia says. In these cases, if the member seems receptive, they’ll say hello. “Generally, our members like it when you acknowledge them because it means we’re all real people here,” she explains.
With this familiarity comes plenty of boundary issues. In the past, members have asked them deeply personal questions, like if they’ve been addicted before. And if emotions happen to get heated in a session, “there’s a chance they’ll come at you with any personal information they can use against you,” Tavia says. Sometimes, they’ll get a little too familiar. “I’ve had people come in and say ‘you look like crap today,’” she laughs.
The bottom line, Kendra says, is that most times they’re just being comfortable or curious. “That’s only natural,” Tavia interjects. “If you know my life story, I want to know at least a little bit about you.” And this closeness pays off. If members happen to relapse, they’re likelier to come forward.
Suddenly, a bell jingles as the clinic front door swings open. A tall, bulky man in a sleeveless shirt and tattoos coiled around his arms peers around the corner.
“Well, you’re early early!” Tavia exclaims.
He laughs weakly. “That’s because I’ve got no life!” he replies.
It’s almost nine o’clock, and the first session of the day is about to begin.
“What Are You Now?”
This is the moment I’ve been waiting for. Craig and I take our seats across the treatment room from each other, exchanging a nervous glance as a dozen members trickle in and sit in a semicircle of white and tangerine chairs. A few eyes meet ours, and we give a quick nod of recognition. A little less than half the group is female. Their ages vary widely. One of the younger members, a slim man in a dark hoodie and cargo shorts, looks about 20. The oldest, a heavier man wearing camouflage pants and carrying a walking stick, looks about 60.
Stephanie lets us give a quick introduction and asks aloud whether any of the members have a problem with our being here today. Nobody objects. Tavia, cradling a handful of notes, takes a seat in a small yellow rocking chair at the front of the room.
“So how was everybody’s weekend from the last time I saw y’all?”
“Don’t all talk at once,” she laughs.
“I got to see my dad,” one man responds.
“And how’d that go?”
“Good,” he chuckles. “Smoked some weed.”
Tavia nods quietly and leans forward. “Well, we’re gonna go around the room, and we’re all gonna share. How was the past week?”
A range of responses follows: Horrible. Terrible. Stressful at times.
“But when you were using, it used to be a good time, right? Then it got bad?” Tavia asks the room. “I don’t need to tell you that. You know better than anyone.”
“I didn’t care,” one man responds. “I thought I was invincible.”
“But it was a never-ending game, right?” Tavia presses. “What did you need in that moment?”
“Help,” says a well-dressed woman in a pink cardigan.
“Would you have taken it?”
“How many of you lost time with your kids?” she asks. About a third of the room raises their hand.
“I was in a downward spiral,” the youngest man says. “I had doctors throwing pills at me. I wanted to try something else. But when I started, I thought I could stop.”
Tavia nods. “Like a weekend drinker, right? Pick it up on Saturday, put it down on Sunday.”
She turns to the other members. “What are you now?”
Another range of responses: Awake. Alive. Productive. Happy.
“A lot of people think you can’t be happy and sober, right?”
“Right,” most of the members agree.
Soon, Tavia’s on a roll. Members who first slumped back in their chairs perk up and nod affirmatively when she asks whether their addictions led to lost jobs, estranged family, shame, and lying. She asks about how relatives and friends enabled their drug habits. One woman confesses that two days after she left rehab, she returned home to find her father on the living room couch “snaking ice,” shooting heroin. When he offered her the needle, she took it. “I thought I was better,” she says, “but I just didn’t have the tools yet.”
“I still don’t know what sober looks like,” the woman continues. “I don’t know how I’m gonna make it through next week.”
“You’ve gotta crawl before you can walk,” a man across the room says supportively.
“Well, your drug test says you’re doing it!” Tavia responds, smiling. “What do you guys need now that you’re living that recovery life?”
The room goes silent.
“I know you all need something or else you wouldn’t be sitting here,” Tavia presses. “I needed something or else I wouldn’t be sitting here.” She points to me and Craig. “These two need a story, otherwise they wouldn’t be here.”
A middle-aged woman with short, swept-back gray hair, bright red lipstick, and a T-shirt that reads “Y’all Need Jesus” breaks the silence.
“I needed my high school diploma,” she says. “Just got it too.”
“Congratulations!” a few members of the group exclaim.
“You couldn’t have done that if you were high,” Tavia tells her. “What do you have now?”
She smiles. “I have a great relationship with my kids,” she whispers, lips quivering.
Another woman begins to cry, then another. They pass around a tissue box. “You’re contagious!” the second woman laughs.
“I got to see my daughter today,” one man says proudly. “It’s the first time I got to see her since I got out of jail. She’s learning to crawl.” He smiles. “She’s just like her dad. She goes backward before she goes forward.”
“No, you’re moving forward,” Tavia says comfortingly.
It’s hard to watch the scene unfold and not feel moved. A man in his mid-20s tells her about how he relapsed three times. “I was embarrassed,” he says. “I always knew after I used that I’d feel terrible in a couple hours, but I did it anyway. I hated every minute of addiction.”
“Well, you feed it, right?” Tavia says before softening a bit. “I know it’s easy for me to sit in this chair and tell you that. But something woke you up today.” She points out the window. “I don’t care if your higher power is God, or that tree out there, but something brought you in here today. You’re here because you just want to get better.”
When the conversation starts to go off the rails—a member begins to rattle off long details about his pickup truck repairs and another begins to brag about how he can make it to 7/11 and back before his ankle bracelet alarm goes off—Tavia deftly steers it back without losing the group. “Nope! Ding! Ding! Ding!” she interrupts, crossing her hands in a time-out gesture. “That’s manipulating the conversation!”
But at times, her tone is serious, like when a young woman confesses she had a drink recently at the local bar, even though she’s on probation. “I don’t get it. I don’t even like to drink that much,” the woman says.
“Your parole office could’ve walked in,” Tavia replies. The woman shrugs. “Well, guess what?” she continues. “This is a small town, and your PO lives in this small town. She could’ve walked you out in handcuffs that day. I’m worried about you.”
When Tavia asks whether anyone else has had a problem with drinking, a man raises his hand. “And how’d you deal with it?” she asks.
“I switched over to heroin.”
The group laughs. “Okay,” she says, smiling a little. “Well, don’t do that.” There are lighthearted moments too.
What’s happening here? Is this therapy? I wonder. Between Tavia’s quick, pithy questions and the group’s lighthearted banter, it’s hard to tell sometimes. It certainly doesn’t look like the old stereotype where buttoned-up therapists reveal little about themselves and mostly stick to manualized scripts.
Then again, I’m willing to bet more than a few of the members wouldn’t touch that kind of therapy with a 10-foot pole. Tavia twists her notes in her hands. She bounces her legs, rests her head in her palms, and uses funny voices to engage the group. When senior members offer the newer ones support, she sits back and lets things unfold. She’s real. Who better to create a not-so-scary-after-all, healing environment than someone like this? I think to myself. Whatever’s going on, it seems to be working.
As the session comes to a close, Tavia makes an announcement, telling members that if anyone would like to hang back afterward to speak with Craig and me, we’d love to hear from them.
When the hour is up, the members gather their belongings and make their way out the door to continue their conversations in the hallway. As their numbers dwindle, I start to worry a little. Is anyone going to stick around to talk to us? Maybe I look too establishment, too city. I knew I shouldn’t have worn this dress shirt.
But one woman at the opposite end of the room stays. It’s the woman with the gray, swept-back hair who just got her high school diploma. “I’ll talk to you,” she says.
We move to a nearby room, mostly bare, with lemon-colored walls and a thin white table and chairs. The woman introduces herself as Cynthia. We shake hands and sit opposite one another. It’s a little formal, but I’ll take what I can get.
“I’ve been using for 20 years,” Cynthia begins. “And I’ve been clean for a year. Everybody in my family uses. My dad. My sister. My mom still uses at 60. And my brother died of an overdose.”
“Let’s go back to the beginning,” I ask. “How did this start?”
Cynthia tells me she first got addicted to pain meds when she was very young, but things escalated after a fall down the stairs permanently damaged her hip. She went to a doctor. Then another. Five doctors in, they all recommended painkillers. Percocet, more specifically. “It was so easy to say yes,” she recalls.
The pills helped. Too much. “When I took them, I felt good. I felt invincible,” Cynthia says. Before she knew it, she was taking three pills a day, spending hours in a stupor while her four young children came and went. Sometimes, her husband would ask her what she did the day before. She couldn’t remember.
“What was your turning point?” I ask her.
“Being in bed all the time,” she says. “Having no aspirations. I missed watching my kids grow up. I was absent. Not physically absent, but mentally. I don’t think I felt love, or anything really. I just felt kind of dead inside. I’d never hurt myself, but I didn’t want to live anymore.”
Eventually, Cynthia reached her breaking point. She checked herself into rehab, where she stayed for a month. But the treatment didn’t stick. “Everybody around me was saying, ‘I’m an addict, I’m an addict,’” she says. “And I remember thinking, I’m not an addict; I’m just in pain.”
A few months after relapsing, she stumbled into Groups. It wasn’t an easy transition. “When I first came in, I was very mean to Tavia because I got scared that I was getting too comfortable once the medication started working. But then I sat in group and told my story. They started asking me what I wanted in life, where I wanted to go. Nobody asks you that in rehab or 12-step programs,” she says. “Here, they’re not concerned with today: they’re concerned with where you’ll be down the road. Here, I can plan. And I know if I keep doing what I’m doing, I’m going to be okay.”
She credits Groups with the bulk of her recovery. “I don’t think I’d be here without them,” she says, tears streaming down her cheeks. “Because I couldn’t take it anymore. The fight inside me was just too much.”
She stops for a moment, reaching for a box of tissues. “I know why I used,” she continues. “My dad used to beat me every day until the day he died. I used to blame him, but I don’t now. When he died, my mom told me how he was mentally sick, how he’d been abused by his own parents. If I’d known then what I know now, I think it would’ve made a difference in how I perceived things, how I handled things.”
“It sounds like you’re breaking the cycle,” I tell her.
She nods. “After watching him, I’ll never do that to my kids,” she says, dabbing her eyes. Her oldest is 24, the youngest, 18. Two have children of their own. “I can share what I’ve learned with them,” she says. “They turned out really good despite me. They don’t act nothing like me.”
Looking back, Cynthia doesn’t blame prescribers entirely for her addiction, or for the opioid epidemic. But she says they can’t pretend they didn’t know the damage they were doing. “You know that phrase Do No Harm?” she asks, invoking the Hippocratic Oath. “They don’t realize the harm they’re doing.”
Mostly, though, she’s just grateful to be on the recovery path. “I can look back a year ago and say I like the person I am now,” she says. “I feel like I know this person. Now, on a normal day, I get up and look at everything with different eyes.”
I ask if she’d like me to share a message with all the therapists who can’t be here. It’s a simple one. “Do what the doctors didn’t do,” she says. “Just take a couple extra minutes with us. When we talk, just listen.”
Chasing the Ghost
“They say you only have to change one thing in recovery,” Kendra tells me shortly before I leave. “And that’s everything.”
It’s a quote that sticks in my mind as I make the drive back to Charleston. Tomorrow morning, I’ll be returning to Washington, DC. As the sun sets, I pass a string of coal plants, and watch in the rear-view mirror as the rusted yellow bulldozers rumble down tiny mountains of black soot.
I’m emotionally and physically spent. It’s hard to imagine what it’s like to do addiction treatment day in and day out in a place like this, where you’re constantly fighting an uphill battle against a problem so pervasive, with resources and allies often in short supply. Doing this work is like trying to chase a ghost, Jeremy tells me. Much of the time, it’s hard to know where to begin.
Part of me feels as if I’ve been through a war today, with the nagging feeling that I’ll return home and tell this story, but my family and friends won’t really understand it unless they’ve seen these things themselves. But I’ve only been here one day: it’s people like Kendra and Tavia who are on the front lines. If we can call therapists heroes, their work is as heroic as it gets.
As always, there’s hope. More therapists are recognizing there’s still a problem. They’re getting off the sidelines and into a job that isn’t always pretty, but comes with big emotional rewards. When a long-addicted person gives birth to a healthy baby after a year of sobriety, they share that victory. When someone gets a high school diploma, or makes peace with an estranged parent, they share those victories too.
“Our members are good people, and we’re all one slip away from winding up in their shoes,” Tavia likes to say. “Sometimes, you’ve just got to be the light in their eyes.”
PHOTO © CRAIG HUDSON
Chris Lyford is the Senior Editor at Psychotherapy Networker. Previously, he was Assistant Director and Editor of the The Atlantic Post, where he wrote and edited news pieces on the Middle East and Africa. He also formerly worked at The Washington Post, where he wrote local feature pieces for the Metro, Sports, and Style sections. Contact: firstname.lastname@example.org.