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.

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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.

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.

I was biking to treatment three to five days a week in the Florida heat, and had no other transportation, so I wasn’t able to come in for dosing after I came down with a fever and a deep, phlegmatic cough. But I called in, emailed, and texted each day that I missed a scheduled day of treatment. At no point was I warned of an impending discharge; my counselor simply wished me well, and suggested I go to urgent care if I felt I needed it.

When I returned to treatment the next week, though, I learned that my provider, Memorial Outpatient Behavioral Health, had assumed I was skipping to use drugs. They dumped me without even a few days’ supply of my prescribed buprenorphine, upon which my body was physically dependent; a referral elsewhere; or a solid reason.

This was in spite of my having an active prescription from my doctor and a future appointment with her. I could also no longer access the psychiatric medication I was prescribed through the same provider.

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All of a sudden, without warning, I lost all of my addiction and mental health care. As shocking as these events have been, they are not uncommon. In fact, they represent a dangerous status quo among opioid addiction treatment providers across the nation, one that defies all modern research on addiction treatment and leaves patients stranded.

“It’s an old school type of thinking which came out of how we’ve treated addiction in the past, which is that abstinence is the policy, which doesn’t make sense with a chronic relapsing disease,” said Justine Waldman, the medical director for REACH, a harm-reduction oriented health hub in Ithaca, New York. “With abstinence being the policy, once the patient isn’t able to follow the policy the patient isn’t able to be part of the practice.”

Keri Ballweber, a methadone patient and recovery specialist at Point to Point Kane County, remembers being dramatically dropped from care in 2012 by Family Guidance Center, a methadone provider in Aurora, Illinois with whom she had been a patient for roughly six and a half years. In the two years prior to her discharge, she had been gradually tapering her 160 mg dose with the goal of coming fully off methadone.

“As I got lower in my taper, it began getting harder and harder to deal with the symptoms [of withdrawal],” recalled Ballweber. “I asked them for help, but their only suggestion was to go slower. It did not seem as if there was a speed slow enough to not cause me discomfort.” Family Guidance Center declined to comment for this piece; Memorial Outpatient Behavioral Health said it does not comment on specific cases, but that “our goal is to partner with all our patients and help them heal and recover.”

Ballweber eventually turned to illegally purchased diazepam, a benzodiazepine usually prescribed for anxiety, insomnia, and seizure disorders. Mixing benzos and opioids can be dangerous, but when Ballweber disclosed the use to her counselor, she was not informed about this, nor given any harm reduction tips. She asked if she could be kicked out of the program if she continued to screen positive for the non-prescribed drug, and her counselor admitted that outcome was possible, but assured her that such a drastic action would only be taken much further down the line.

The next month, Ballweber was dismissed, and tapered from her dose within a week.

“I was very sick,” said Ballweber. “I couldn’t sleep, I was having panic attacks, muscle tremors, [and] restless leg syndrome.” Eventually, she began to experience hallucinations, which she believes were the result of sleep deprivation from the withdrawal. She was admitted to the hospital for psychosis and prescribed quetapine, an anti-psychotic medication, which helped her sleep. “I had absolutely no aftercare and cutting me off from the clinic [also] cut me off from counseling,” she said.

Ballweber also recalls seeing other patients discharged or punished with medication holds for talking back to their counselors or smoking too close to the buildings. Other MAT patients around the country have reported being dropped or threatened with dismissal for reasons such as relapsing, missing care for unavoidable reasons like being incarcerated, not attending group therapy sessions, smoking marijuana, or being unable to pay.

In my case, when the clinic refused to give me my prescribed medication, leaving me in opioid withdrawal and overcome by a sense of deep confusion and hopelessness, I did eventually use. It was a bad choice, I admit that — and I told my counselor immediately. But in many ways, the clinic itself had contributed to the outcome it had initially accused me of.

I think a part of me hoped that if I gave them what they expected — a positive toxicology screen — I would get what I needed: ongoing care. Instead, I was totally shut out and sent to navigate detoxing from both my opioid-based buprenorphine and my selective serotonin reuptake inhibitor antidepressant (also dependency-producing) at home, alone, with no medical supervision or follow-up care.

Both buprenorphine and methadone are approved by a slew of licensing bodies, including the World Health Organization, as the most effective treatments for reducing harmful symptoms of opioid addiction and opioid addiction-related deaths. Although any addiction treatment plan should be tailored to the individual patient’s needs and circumstances, these medications are designed for long-term or even lifelong use, said Mary Jeanne Kreek, senior attending physician at Rockefeller University’s addictive diseases lab and part of the team that first developed methadone as a treatment for addiction, whom I interviewed while researching a story for Filter Mag. No part of best practice includes suddenly dropping patients from care for any reason — but especially not for showing symptoms of the disorder for which they are seeking care.

“I’m afraid for any patient who has to get off MAT before they’re ready,” added Kreek.

For patients who relapse, Waldman confirmed the best practice is to “keep the patient on buprenorphine.”

At REACH, she noted, patients are not expected to adhere to an abstinence-only model of care. When patients continue to relapse, their practitioners sit down and ask the patients what they need and how they can help.

“There have only been two patients that I can think of who weren’t able to get care at REACH,” she said, “and they were displaying more violent behavior that just didn’t feel safe within our workplace.” She makes a point to add that REACH ensured those patients were placed with a more appropriate provider.

Losing access to medication also affected my ongoing child services case, switching it from a reunification track to one in which my children will be given up for adoption due to an assumption by my caseworkers and my judge that I am at fault for “failing” treatment. This doesn’t guarantee that I will permanently lose my two young daughters, but it makes it a much tougher battle to win. Now, I am no longer entitled to the little assistance I was receiving from my local child welfare agency in obtaining the services I need to reunify with my daughters. They are oriented toward settling my daughters into permanency with their grandparents.

When I told my counselor that this would happen if they dropped me from care, she responded that she thought I should get my daughters back, and was probably a great mother, but was not a dedicated enough patient.

During a recent visit to her pain clinic, Stern’s pain management doctor informed her that her treatment plan was going to need to change again: Now, she would have to choose between taking Xanax and taking hydrocodone (also known as Vicodin). The doctor was not concerned that she was misusing her medications, but that law enforcement would come after him if “something happened to [her].” So, Stern had two options: medicate her pain, or get enough sleep. She chose the latter.

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While Stern’s story may seem extreme, her experience is representative of many chronic pain patients who have come up against various barriers that have been set by state governments, the medical field, and corporate pharmacies. According to recent CDC findings, 50 million Americans have chronic pain; although chronic pain affects people from all economic backgrounds, it tends to hit those in poverty the hardest. People in chronic pain tend to experience greater poverty, and struggle with the cost of medications and frequent pharmacy or doctor’s visits. The treatment of chronic pain also has major disparities when it comes to race, and black women in particular have suffered the consequences of those disparities.

Many of these access issues stem from a response to the opioid addiction and overdose crisis, declared a public health emergency by the Department of Health and Human Services in 2017. However, early response efforts have increased chronic pain and its consequences, leading to worse outcomes for chronic pain patients that should be addressed as a new public health crisis.

This crisis accelerated when the Centers for Disease Control (CDC) released their set of guidelines on opioid prescribing, intended for use by primary care providers, in 2016. The CDC has since clarified that the guidelines were recommendations, not strict policy, but the harm to many chronic pain patients like Stern has been done.

“The only treatment available [for my condition] at this point is treating the pain and the chief of urology at OHSU instructed my primary care doctor to allow me to have a monthly supply of opioid pain medication,” Stern said, but the results of opioid scaremongering have left her in agonizing pain instead. Part of the CDC’s 2016 guidelines, under the heading “Assessing Risk and Addressing Harms of Opioid Use,” stated that “[c]linicians should avoid prescribing opioid pain medication and benzodiazepines concurrently.” For someone with complex medical issues like Stern, this guideline is not useful.

Some government agencies are starting to recognize the consequences of cracking down on pain patients’ opioid prescriptions; the Food and Drug Administration (FDA) recently released a safety alert on the negative effects of sudden discontinuation or abrupt tapering of opioids, which can include “serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.”  The authors of the 2016 CDC guidelines for opioid prescribing also recently clarified how its guidelines are meant to be used as a response to widespread misapplication of those guidelines.

The misconception that opioid prescriptions lead to opiate addiction has been widespread, and overarching state and federal measures to combat the opioid overdose crisis are reaching a fever pitch. There’s the Oregon Health Authority’s (OHA) now-tabled proposal to force-taper all Medicaid patients on opioids for certain chronic pain conditions; Senators Kirsten Gillibrand and Cory Gardner’s controversial proposal to limit all acute pain medication prescriptions to a seven day fill, which sparked massive pushback from the chronic pain and disability communities; and Ohio Senator Rob Portman, who favors a three-day fill limit. In contrast, the American Medical Association (AMA) has come out against arbitrary pill limits, as has a group called Health Professionals for Patients in Pain (HP3).

Very few opioid addictions begin with a patient who has a doctor’s prescription: Up to 80 percent of people with an opioid addiction illegally obtained pills from another source like a friend or relative first. While the opioid overdose epidemic from illegal heroin and fentanyl is a serious problem, federal and state actions to decrease the number of opioid prescriptions and/or pills in circulation overall will have — and are already having — a hugely negative impact on chronic pain patients who take opioid medications. While the number of pain prescriptions has declined since 2010, the number of deaths due to overdoses involving heroin and synthetic fentanyl has increased.

According to Thomas Kline, MD, a physician in North Carolina who maintains a list of chronic pain patients who committed suicide after being forced off of their medications, the anti-opioid hysteria that has taken root in the medical field and the federal government has resulted in “people [being] killed.”

Senators and state representatives are not medical doctors, and overarching government intervention of the kind that we are witnessing in private medical treatment can and does have consequences that are bad for chronic pain patients.

A one-size-fits-all policy, whether at the state or federal level, when it comes to chronic pain and opioids may have unintended consequences for chronic pain patients. Dr. Kline puts it more starkly: “Limiting the number of pills [that patients can get] is not going to work. All it’s going to do is screw people.”