Addiction Treatment Clinics Struggle to Keep Up with COVID-19

I just watched my husband run out the door. Not straight to his job as a cook, since his restaurant is shut down during the pandemic, but to his opioid treatment provider—a facility legally allowed to dispense methadone for the treatment of opioid addiction—so he can get his daily dose before the doors close for the day.

He still has to go every single day to get his medication, without which he would go into weeks of painful opioid withdrawal. My husband is one of hundreds of thousands of people across the country who rely on medications like methadone and buprenorphine to curb addiction to opioids and stay out of withdrawal, and who are now wondering whether they are going to continue to have access during the novel coronavirus pandemic, or risk being exposed to the virus by visiting facilities daily.

The short answer is yes, facilities that prescribe and dispense these medications are continuing to run, and patients should not lose access to medications for opioid use disorder during this crisis. Methadone and buprenorphine are classified by the World Health Organization as essential medicines, which means continued access to them should be a priority. Various government agencies have issued guidelines and legal exceptions to a number of rules and regulations that usually limit access to these medications, in the hope of reducing visits to clinics.

But, of course, there’s a longer and far more complex answer as well.

Although methadone and buprenorphine treat the same disorder in relatively similar ways, they are governed by vastly different sets of rules and regulations. “On the [buprenorphine] side, the minimum you tend to see prescribed is a week. It would be easy in that case to give those patients a two-week prescription or call in an extra script with a refill. On the [methadone] side, that’s where it gets hairy,” said Zac Talbott, president of the National Alliance for Medication Assisted Recovery (NAMA-R), who also has direct experience as a patient and running facilities that provide these medicines.

Buprenorphine can be prescribed by any doctor or advanced practice registered nurse who has taken an eight-hour waiver course. That means patients can access it in a number of settings including primary care, psychiatry, gynecology, or addiction treatment facilities. Methadone, on the other hand, can only be dispensed for addiction treatment from a licensed opioid treatment provider (OTP), commonly referred to as a methadone clinic. It is governed by a complex web of rules, regulations, and policies that come from federal agencies, state authorities, and individual clinic directors. Since methadone is a better option for people with higher tolerances to opioids, and doesn’t require patients to go into withdrawal before starting it, it’s essential that both medicines are available.

“There’s going to be a broad variety in the way OTPs respond,” said Talbott. “Patients need to realize this could vary from state to state because of state authorities.”

The response is as varied as opinions on addiction.

Across the nation, State Opioid Treatment Authorities, who make state-level decisions about medications for opioid use disorder, have been looking to the federal Substance Abuse and Mental Health Services Administration (SAMHSA), for guidance on how they can respond to the novel coronavirus outbreak. This agency governs the rules around making medication available to be taken at home, instead of in a clinic (colloquially called “takehomes”), and many other methadone regulations at the federal level. Elinore F. McCance-Katz, the head of SAMHSA and the assistant secretary for mental health and substance use, told TalkPoverty by email that “SAMHSA/HHS are working in an ongoing manner with states and communities facing these issues. We have provided flexibilities to the states to help to assure that those on medications for opioid use disorders continue to get their medication. We have also been working to expand the ability to provide services by telehealth modalities wherever possible.”

Washington state, where the first confirmed cases of COVID-19 appeared in the United States, was the first state to receive the ability to dispense extended takehomes, lasting up to 14 days, to specified populations without first applying for individual permissions like providers must do normally.

“As of the 9th we have essentially put out seven different types of blanket takehome exception requests that programs can request per federal law to allow a large majority of individuals who are considered stable—and that’s determined at the discretion of each program medical director—to allow them to move beyond just daily or close to daily dosing,” said Jessica Blouse, of the Washington State Opioid Treatment Authority. “For buprenorphine there are no federal rules, so [those patients] can be moved to whatever level can be determined as safe.”

But that doesn’t mean all Washington patients will receive these benefits. Tanna, a patient who lives between the cities of Seattle and Tacoma, said she has not been offered any takehome doses. The reason, she was told, is because she has been with that provider just over three months, so she is still considered a new and therefore unstable patient—even though she transferred from another clinic where she had earned a month of takehomes.

She is also required to attend four hours of group therapy each month. Last week, her group had eight attendees and she did not notice any special precautions in place due to the virus.

“The only accommodation they’ve made [in the clinic] is at the dosing window there’s now hand sanitizer, the trash is moved a little bit, nurses wear gloves, and the [dosing] window screen is lowered,” she said.

On March 16, SAMHSA updated its guidelines specifying that all states with declared states of emergency could request blanket exceptions in order to provide stable patients with 28 days of takehome medication, and 14 days of takehome medication for patients considered less stable but still able to safely handle the extra medication. In states without a declared emergency status, each clinic is eligible to apply for similar exceptions for their patients.

The updated guidelines from SAMHSA allow states and providers greater flexibility to dispense takehome medication—but that does not mean that every clinic will utilize that flexibility to its fullest extent, nor that they will apply it to each patient.

“It may come down to the fact that patients will need to be given 14 day supplies,” said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence. “However it should be case by case …We want to let people quarantine to clearly stop the spread of the disease, [but] remember we are dealing with opioids. Opioids in the hands of unstable patients can be dangerous. We don’t want to flood the community with a lot of methadone in the hands of unstable patients who may not be able to deal with the fact that suddenly they have a two-week supply.”

“People who are least likely to get takehomes are people who are new to treatment and people who have unstable housing, unstable psychosocial situations, people who might be continuing to use other substances, people with underlying health concerns; things that mean they have instability in their life. I would argue they are the people who should get takehomes immediately,” said Keith Brown, a harm reduction advocate currently working at the county level in Schenectady, New York on the COVID-19 response. “This is going to get into the argument about which is more dangerous, giving people takehomes they might sell or whatever—but in a public health crisis, people are going to have to make determinations about what makes sense. Having a few hundred people come into a clinic every day is a transmission nightmare.”

It’s impossible to know what every single state and clinic will do with their expanded discretion. Reports coming in from patients and providers indicate the response is as varied as opinions on addiction.

Justine Waldman, the medical director of REACH, a harm reduction-based buprenorphine clinic in Ithaca, New York, has begun offering one and two month scripts to her buprenorphine patients, giving longer scripts to those who have a harder time getting in to the office or who have a history of missing appointments. Her emphasis is on access and patient health over surveillance. The caveat, she stressed, is that this is an entirely new situation that is evolving each day.

“We might decide tomorrow that the way we’re doing it now isn’t working. We are really having to come together and take it day by day,” she said.

Jana Burson, who is the medical director of an OTP in North Carolina, said that while her clinic is not giving most patients extended takehomes, they are utilizing measures to help keep the facility sanitized, and to enforce social distancing while patients are in the building. For example, the lobby chairs have been spaced to be at least six feet apart, and some counselors with smaller offices are moving individual counseling sessions to larger rooms. They are aggressively disinfecting chairs, door handles, countertops, and other shared surfaces.

In a public health crisis, people are going to have to make determinations about what makes sense.

Vanessa, a patient in North Carolina, reported that her clinic was not dispensing any extra takehomes. She normally receives takehomes for Saturday, Sunday, and Monday, but was called in this Monday for a drug test and bottle check, a practice observed by some clinics in which they count patients’ takehome bottles. She described her clinic as “really business as usual” besides seeing staff taking patient temperatures. She noted that her temperature was not taken when she stopped by for the drug test. On Thursday morning she texted me an update that she was going to be given seven takehomes, but would have to pay for them out of pocket.

Stephanie, a patient in Pennsylvania, says she has continued to receive her regular six takehomes, but that group meetings and individual counseling sessions have been canceled until further notice. When she pressed for more information, her counselor replied that for the clinic to shut down “it would have to be the end of the world and there would be zombies,” but conceded that they were giving some extra takehomes to medically fragile patients.

Emily, who has hepatitis C, has not been offered any takehome doses by her Lexington, Ky., clinic, but reported that all patients are being stopped upon entering the building and questioned about potential symptoms. People who report feeling unwell are dosed from their cars, and only five patients are being allowed to enter the building at a time. Groups have been canceled, and individual counseling sessions are being done over the phone.

Samantha, a pregnant patient in Central Florida, reported that she was given 13 takehomes and had a doctor’s appointment canceled so she would not have to go in on an extra day.

In South Florida, my husband Ricardo still goes in for dosing every day, but told me his clinic was advising patients to be prepared to pay two weeks in advance should the need for two weeks of takehomes arise. For my husband, that means shelling out $224. For patients at other clinics, the price can vary in either direction, but not typically by much.

My husband’s experience highlights another concern facing patients on these medications. For some, extended scripts mean more money up front. Some methadone patients who pay out of pocket are only able to do so daily, relying on cash tips or weekly paychecks to pay for their medicine. Buprenorphine patients who are used to paying for one or two weeks at a time might not have additional funds for a month-long script. Patients whose medications are covered by grants or insurance sometimes have caps on the amount of doses that can be covered at one time, leaving them to pay out of pocket for extra doses. If they can’t pay, clinics are not required to dose them.

Because buprenorphine prescribing is not burdened with as many stringent regulations as methadone, it is easier for providers to adhere to social distancing recommendations while still keeping patients appropriately medicated. Many providers have reverted to telehealth. On March 17, the Secretary of Health and Human Services lifted restrictions on telemedicine practices that prevented Medicare patients from engaging by using cell phones in homes or shelters. On the same day, the Drug Enforcement Administration also waived requirements that patients starting on buprenorphine have an initial in-person visit, temporarily allowing new buprenorphine patients to engage via telemedicine from the start.

But even with these changes, economically disenfranchised patients may struggle to utilize telehealth options. “Not all of my patients have the right smartphones to do telehealth, or the minutes. When I asked them about doing telehealth, they said no way,” said Waldman.

Like Talbott stressed, the response to this crisis is going to vary between states and clinics, with wide discretion placed in the hands of prescribers and medical directors. It is a situation that is changing by the day, as states and counties continue to evaluate the impact of COVID-19 in their communities and how they wish to respond.

“I think my biggest duty right now is to reassure patients that they will not be abandoned,” said Burson.

Correction: An earlier version of this articles stated that all registered nurses were able to prescribe buprenorphine. Only advance practice registered nurses can prescribe that medication.



San Francisco Tows Cars Over Unpaid Tickets, Even When People Are Living in Them

No one likes paying for a parking ticket. But for 32-year-old MiQueesha Willis, not being able to pay for those parking tickets meant losing the only home she shared with her two-year-old son, Tobias.

It began with a $90 citation. Willis, who is a construction worker, was living in her car with her baby and parked near the worksite, but often couldn’t move her car to avoid parking tickets due to the demands of the job. She could barely scrape together enough money to put $5 in the gas tank to get to work, much less pay for a $90 ticket. Between taking care of Tobias and trying to find stable housing, the ticket became the last thing on Willis’ mind. She told herself she’d pay for it when she could save up enough money.

Then she received a second ticket, and then a third, and a fourth. Over the next few months, she had multiple tickets and late fees that added up to hundreds of dollars she couldn’t afford to pay.

One day, when she returned from work, her car — and all of her belongings — were gone. In San Francisco, accruing five or more unpaid parking tickets meant the car would be towed. If she wanted the old 1997 Lexus back, Willis would have to pay a $537 tow fee and all of her parking tickets. Willis didn’t have the money, and a few weeks later, the tow company auctioned off her four-wheeled home.

Willis’ story echoes that of the more than 1,200 homeless San Franciscans who live in their vehicles and face the threat of having their homes towed by the city. With shelter waitlists that are consistently more than 900 people long, vehicles are often homeless people’s last resort for some semblance of safety and shelter before sleeping directly on the streets.

Losing her car was the start of a downward spiral. Willis found herself constantly asking people she knew if she could stay with them, even for just a couple of nights. Some days it was with her godsister, other days a friend that she knew, but sometimes there was no one to take her in.

“When they took my car, I started trying to sleep on the bus or sleep on BART,” Willis recalls. “I didn’t go to sleep for days because I didn’t have anywhere to sleep.”

The instability led to depression, suicidal ideation, and the loss of her job from the mounting stress of street homelessness.

“It started a never-ending cycle of debt and poverty,” Willis says. “If I was able to keep the car, I would have been able to keep my job.”

The tows and parking citations are viewed as a tool to enforce parking regulations by the San Francisco Municipal Transportation Agency; it wants to deter bad behavior, especially for more serious violations, such as blocking a handicapped zone.

However, for those who are unable to pay those tickets, the city’s form of debt collection for sometimes only a few hundred dollars means losing a family’s most valuable asset, their car— or home. According to a 2019 report by the Lawyers Committee of Civil Rights, 50 to 60 percent of vehicles towed for unpaid parking tickets or unpaid vehicle registration are sold by the tow company.

Tori Larson, an attorney working specifically on this issue, says, “I get calls from people every day who are living in their vehicles. When they get their cars towed, they have to start from zero. It’s a disproportionate punishment for an unpaid fine.”

In 2018, the group filed a lawsuit challenging San Francisco’s practice of towing cars for unpaid tickets. The case argues that the practice constitutes cruel and unusual punishment, a violation of the Fourth Amendment.

The City is actually losing money for enforcing its tow program.

San Francisco, which charges the highest tow fees in the country, discounts tow fees for low-income individuals to $238 dollars per tow. After the first four days in the storage yard, an additional $52 fee incurs each day. That’s not including payment for parking tickets or unpaid car registration that may have gotten the car towed in the first place. The money adds up fast and, for many, could total thousands of dollars. SFMTA tows almost 4,400 of these vehicles each year.

SFMTA has proposed lowering the tow fees to $100, but for low-income and homeless communities, “coming up with $100 is like coming up with a million dollars. People don’t have this money,” says Anne Stulhdreher, director of the Financial Justice Project, which works to reduce the disproportionate impact of fines and fees on low-income communities.

Many Americans would struggle with paying that fee. According to a 2018 report from the Federal Reserve, 40 percent of Americans would be unable to cover a $400 emergency expense, such as a car tow or parking citation.

Stuhldreher has been working with community groups to reduce the burden of towing and parking citations on low-income and homeless communities for the past several years. While she notes that this is an important first step, more needs to be done.

What’s more is that the City is actually losing money for enforcing its tow program. Overall, the City’s tow program loses $4.7 million annually with low-income tows representing about $1.4 million of the deficit. Each tow costs around $299 in city administrative labor and $275 to the tow company, Auto Return, which tows and stores the vehicles. It’s a lose-lose situation for both the city and for those most impacted by the tow fees.

Homeless advocates have long called for a moratorium on the towing of vehicles that people live in, but the significance of this demand has heightened in the midst of the coronavirus outbreak. A set of guidelines to respond to the pandemic put forth by the Coalition on Homelessness urges the city to end towing, stating that “these individual accommodations make it possible for people to self-quarantine.”

The vehicles also present a form of stability that would allow people to keep in contact with health care workers, maintain their health, and securely store their belongings, including medical documentation and medication, the organization said.

Last November, San Francisco opened its first safe parking program in hopes of alleviating the struggles that those living in their vehicles face after almost a decade of advocacy from community organizations and vehicularly housed people. However, its 30-car program — which will be terminated at the end of this year — far from meets the need of the hundreds of homeless San Franciscans living in their cars.

Those living in their vehicles not only face the threat of losing their homes to towing, but are also subject to harassment from police. In San Francisco, as with many other cities across the country, vehicle inhabitation is illegal — and could lead to a fine of up to $1,000 or up to six months in jail. Although the penalty is rarely enforced, advocates say police use the threat of the law frequently to force people who are vehicularly housed to move from neighborhood to neighborhood.

“They flash lights on the car, hit your window with a flashlight, and tell you you have to move,” Willis says of the police that would come by late in the night while she tried to get a few hours of rest. There were few places where she could park at night without being towed, ticketed, or told to move. “I didn’t know where to park — I’d park by the water, but I was scared. I tried to park where there were multiple cars so I could be safer.”

MiQueesha is still homeless. She sleeps on friends and family’s couches when they’re able to let her stay there. She’s hoping to finish school at San Francisco City College in construction management, earn her real estate license, and have more time to spend with her son.

With the help of her son’s grandmother, Willis has been able to purchase another car that she’s working hard to pay off. This time of year, though, construction work is slow.

She says, “Hopefully, this one isn’t towed.”



The Dirty Secret of New York’s Coronavirus Response: Prison Labor

Thanks to the novel coronavirus, known as COVID-19, communities across the country are facing a shortage of hand sanitizer, wipes, and related products as people desperately try to stay ahead of an outbreak. In New York State, where the number of cases is steadily growing, the situation is especially serious: Governor Andrew Cuomo just declared a “containment area” in New Rochelle, just outside New York City. In the area, large gatherings are banned and the National Guard will be deployed.

On March 9, Cuomo announced a solution to one element of the supply problem in the wake of New York’s declared state of emergency: The state would start producing its own sanitizer, branded NYS Clean, to get around price gouging and supply issues. To start, 100,000 gallons a week will be distributed in government settings such as schools and prisons (more on that in a moment) as the state increases the speed of production. Cuomo even threatened to make the sanitizer available for commercial sale to counter price gougers, some of whom have already been fined for taking advantage of the public health emergency.

It’s the kind of bold statement designed to make a splash, but there’s little acknowledgement of who is responsible for making the product at speeds that allowed the state to ramp up production so quickly. The product is manufactured by Corcraft, which is the brand name for products produced by  the New York State prison system. “Employees” at Corcraft are incarcerated people making an average of $0.62 an hour.

Corcraft and entities like it across the nation benefit from a literally captive workforce. 50,000 people are incarcerated in New York’s state prisons, and while not all of them work for Corcraft, many do, producing things like license plates, desks, textiles, janitorial supplies, and even eyeglasses. These products are in turn sold to government agencies, educational institutions, first responders, and select nonprofits by Corcraft as a “preferred source.” These entities have to “look to Corcraft first” as a supplier, even if they’re opposed to the use of incarcerated labor.

Across the nation, incarcerated workers generate billions in revenue for the prison system, making pennies on the dollar and in some cases nothing at all for their work. While some might consider it slavery, it’s entirely legal under the 13th Amendment, which permits slavery or involuntary servitude “as punishment for a crime.” Nationwide, incarcerated people pave roads, maintain state parks, fight fires, grow crops, and manufacture scores of items.

Here’s a real bitter twist: According to Keri Blakinger and Beth Schwartzapfel at the Marshall Project, incarcerated people aren’t necessarily allowed to use hand sanitizer in jails and prisons. These workers are making a product they aren’t permitted to protect themselves with, even as conditions in jails and prisons can be extremely dirty, with even basic sanitation challenging. Sinks may be broken, sometimes no soap is provided so incarcerated people have to buy it from the commissary, and facilities are crowded.

Workers are making a product they aren’t permitted to protect themselves with

This is already a dangerous combination for the spread of infectious diseases such as hepatitis a — which is spread through unwashed hands — and influenza. Many prisoners are also trying to manage chronic illnesses like diabetes and HIV, which can make them vulnerable to infection. The response to concerns about infectious disease may be to “quarantine” sick people in isolation, an unhealthy and dangerous approach to controlling infectious disease that comes with significant mental health effects.

As New York’s Department of Corrections implements COVID-19 policies such as screening visitors, it repeats public health recommendations for “all individuals within its facilities” —  wash frequently with soap and water for at least 20 seconds, use hand sanitizer when water is not available, keep your hands away from your face, and stay home when you are sick — all of which may be, to put it mildly, a challenge for incarcerated individuals.

Incarcerated people are commonly called upon to take personal safety risks for those who are not in jail or prison, as in the case of firefighters across the West who work alongside professionals in better gear, knowing that their training may not be transferrable to jobs on the outside thanks to their criminal records. Still, asking people to whip up 75 percent alcohol hand sanitizer for the health and safety of civilians while they’re struggling for scraps of soap in the midst of a public health emergency is truly a new low.

Access to tools to prevent the spread of disease and to protect people who are particularly susceptible to COVID-19 — such as those living in institutions like jails and prisons — is vital. There’s ample guidance from experts on highly effective ways to protect ourselves, but people in carceral settings can’t access the basic things required, such as sanitation supplies and tissues so they can cover their mouths and noses when they sneeze or cough.

If there’s an outbreak in a prison setting (something that may be inevitable in a confined, unhealthy, unsanitary environment), it will be because of the refusal to make changes to the rules in order to allow people to protect themselves.


First Person

Coronavirus Is Spreading. Your Waiter Can’t Stay Home To Stop It.

Earlier this month, I contracted the flu — not COVID-19 but the regular, everyday, miserable but run of the mill flu that has been floating around my community.

I developed a severe case which turned into bacterial pneumonia; although otherwise fit and healthy, I have asthma, which makes me especially susceptible to respiratory illnesses. I spent Valentine’s Day flat on my back, wheezing and struggling to breathe while the antibiotics worked their magic.

Say what you will about azithromycin; it sure does kill bacteria good.

I work as a server, and I almost certainly contracted the flu from my workplace; prior to becoming sick, I served multiple customers who told me they were ill, which means exposure to their breath, used plates, napkins and cutlery, and surfaces they have touched. Moreover, several of my coworkers were ill with the same symptoms on the last shift I worked before becoming sick.

If you are worried about infection from COVID-19, you should be less concerned about hoarding masks and hand sanitizer (which you really shouldn’t be doing) and more concerned about the ways that poverty, a lack of access to health care, and general class inequality in North America could contribute to spreading it.

In Canada, where I live, servers are usually paid at or slightly below provincial minimum wage, and in the USA it’s often less than the already abysmal minimum wage. Most food service workers — servers, like myself, as well as cooks, bussers, and a vast variety of other folks working for an hourly wage — do not get paid sick days, which means taking time off even when you are pretty much dying costs you money.

Money you probably don’t have, which means you come into work sick.

For me, this was the first time in my 15-year career in the service industry that I have ever called in sick for multiple, back to back shifts. Tips are variable, but I estimate my three days off cost me about $350, plus $100 worth of medication. That doesn’t include the cost of my emergency room visit, which an uninsured American would also have to pay for.

I recovered faster because I got the medical care and rest I needed.

I’m really lucky that I work with good people and have a kind boss, who helped me cover my shifts; in many restaurants, the culture is not so forgiving, and calling in sick with anything less than a brain aneurysm is a sign of weakness. You’ve “screwed everyone over” by not coming in and making someone else work a double or else work shorthanded. In many other restaurants  I’ve worked in, you may find yourself missing shifts you would usually work on the next schedule — a “punishment” for the selfish act of allowing a virus to infiltrate your body and replicate within your cells, you lazy prick.

The main reason I was able to take a couple sick days this time around — regardless of the fact that I had to, since I couldn’t actually get out of bed — was that I have another job where I’m self-employed. In short, I had some extra money and could afford to not go to work and sweat and sneeze and cough all over people, food, and objects.

Not only does this mean I didn’t infect other people — COVID-19, incidentally, is primarily spread through respiratory droplets in the air, and by person to person contact — but I recovered faster because I got the medical care and rest I needed, which means I returned to work more quickly. Better for me, better for my boss, better for the health of everyone.

By contrast, as I recently tweeted about, this isn’t the first time I’ve had pneumonia; in 2013, I had walking pneumonia for two weeks, during which I worked the majority of the time handling food in close proximity to customers. I didn’t do that because I’m a selfish jerk unaware or unconcerned about the health of others, I did so because I wouldn’t make my rent if I took time off and because I was working in a place where I was afraid of what would happen if I called in.

Not only was I sick much longer in that case — and therefore capable of infecting others for a longer period of time — it took me months to fully recover, which had further economic impacts for me. I would have been a better worker, infected fewer people, and been less of a strain on the health system had someone just given me a goddamn paid sick day; it would have been cheaper and better for literally everyone in my community.

In 2017, 130 people were sickened by an outbreak of norovirus — a highly contagious gastrointestinal illness — which was directly linked to Chipotle’s management policies around sick workers. It’s not just about the policy, though; even if workers had been “allowed” to call in sick and supported by management to do so, they’re going to come into work if missing that shift means no gas in their car, or their kid doesn’t get lunch tomorrow, or it’s ramen for dinner every single day for the next week.

When you economically punish people for getting sick, more people are going to get sick.

All signs point to COVID-19 being a genuine pandemic that we should all be concerned about and thinking about — which means we need to care not only for ourselves, but for others. If you care about your health, care about how the people around you live and are treated in their everyday lives.

Viruses don’t care how much money their host makes, but how much money their host makes, and how we treat working-class people when they get sick, may impact how many opportunities COVID-19 has to spread.



First an Opioid Addiction. Then a Life-Altering Criminal Record.

America’s criminal justice system wasn’t designed for a drug epidemic on the scale of the opioid crisis. For four years I was at the epicenter in North Carolina, where as a small-town lawyer, the best I could often do was beg for probation in exchange for pleading my client to a low-level felony.

My job was to keep people out of jail, but I couldn’t control what kept bringing my clients back into the courtroom.

A common example was a young mother, caught with pills and charged with a felony for possession with intent to sell; loses her job because she couldn’t afford the bail set at $1,500; pleads guilty to the felony in return for probation so she can get out of jail; fails the drug tests on probation and ends up with the felony on her record; loses her driver’s license because of unpaid court costs and fines; and then her children because she cannot afford to provide them with food, clothing, and shelter.

I saw that every week: Someone who entered the courtroom an addict and exited a criminal. According to the North Carolina Second Chance Alliance, more than 2 million people in the state have criminal records, 90 percent of large employers ask about that history, and more than 1,000 different laws in the state deny rights and privileges due to convictions.

And like in many states, it’s difficult to expunge those convictions because of long waiting periods and narrow rules of eligibility, which makes it hard for a person to find a decent job or stable housing, or obtain the education they want. According to the Center for Economic and Policy Research, in 2014 the United States went without an estimated $78 to $87 billion in gross domestic product because of people who were unable to reenter society and participate in the workforce due to their criminal background. And that’s devastating for communities that were hardest hit by the opioid epidemic.

My hometown in the foothills of North Carolina was once the home of some of the largest manufacturing businesses, including the American Furniture Company. But slowly those jobs left town and went to China, or were lost to automation. From the year 2000, when that company finally closed, to 2014, my county experienced the second worst decline of median income in the United States: from $47,992 to $33,398.

And that’s when the pills came in. Doctors overprescribed Oxycontin, Vicodin, and Percocet to people who were in pain and out of work. Many got hooked and some sold the painkillers on a black market out of their medicine cabinet. In 2007, the county experienced the third highest overdose rate in the country.

Because of a lack of funding at the state level, there’s no public defender’s office. So when I came home to work as a lawyer, I took appointed cases to supplement what I brought into our firm as a young criminal defense attorney. That meant representing as many as 15 clients a day and sometimes as many as 50 in a week. We’d be lucky to meet for more than a few minutes at a time to go over the facts before trial or to run through a plea offer while standing next to a bailiff in one of the holding cells behind the courtroom.

For every case disposed, I’d get appointed to another. Drugs were an underlying factor in almost every fact pattern.

Since 2013, the incarceration rate in rural America has risen by 26 percent.

My county wasn’t unique. The same forces of globalization and automation were devastating towns all across the country. But we didn’t discuss what was happening in those terms, and we didn’t learn about these deaths of despair by reading about them in The Atlantic. The stories were personal. It wasn’t uncommon to walk into the courtroom and see the faces of childhood friends, a young man from church, or even a next-door neighbor.

There’s a stereotype that the opioid crisis affects only middle-aged white men, but addiction doesn’t discriminate by age, race, or education level. Where there is discrimination, though, is in access to treatment. If you were from a rich household, or had a strong support system, your family could afford to send you to rehabilitation for as long as it took, up to a couple of years if need be. For everyone else, recovery options were limited and usually led back to the courtroom. (In North Carolina, programs like the Substance Abuse Prevention and Treatment Block Grant spend more than $44 million per year on recovery services, but without Medicaid expansion, many in recovery are still on their own and unable to afford inpatient treatment.)

What happened in my town happened before, in the 1970s and the 1980s, when cities hollowed out and the response to a crack epidemic was mass incarceration. Now, because of organizers and advocates in those communities, the urban incarceration rate has declined in recent years. But because of the opioid crisis, since 2013, the incarceration rate in rural America has risen by 26 percent.

Today there is legislation in North Carolina called the Second Chance Act that would expand eligibility for record expungement. Hopefully, lawmakers will get that bill passed soon. What I saw in an Appalachian courtroom wasn’t because my hometown was full of bad people. It was because the factories closed and we treated poverty and addiction by locking up the victims.