You can go home again

My introductory email to state Sen. Dan Foster began, “Greetings from a fellow Stanford Mountaineer.” Like many people who grew up in West Virginia, I retain loyalty to my home state as well as a desire to connect with other members of the hillbilly diaspora. I had learned from a previous issue of this magazine that, after earning his MD at Stanford, Dan went on to become a surgeon and state legislator in West Virginia.

I didn’t have to guess which public policy issue consumed most of Dan’s time: addiction. My home state leads the country in tobacco smoking and in fatal drug overdose. Meth labs dot the landscape, heroin traffickers do a thriving business in some cities and, in some impoverished towns, bars and liquor stores are among the few going concerns. The prevalence of addiction makes a mockery of our state motto, “Mountaineers are always free.”

At the time of my email to Dan in 2010, I had just finished a year in the Obama White House as a senior drug policy adviser and had returned to being a psychiatry professor at Stanford and an addiction researcher in the Veterans Affairs Palo Alto Health Care System. I told Dan that what I had learned might be relevant to West Virginia’s addiction crisis. He invited me to the state capitol to speak with lawmakers about some solutions.

West Virginia is distant in many respects from Stanford University. As an academically achieving teenager, I somehow got it into my head that I could apply here, only to receive the painful news from my mother that our family could not afford for me to attend (financial aid was not so generous in those days). Much more recently, I was paging through West Virginia’s latest annual budget and noted that it was less than that of the university. Whereas opportunity was limited most of where I looked in my youth, at Stanford it never seems to end. Such contrasts tend to make us “Stanford Mountaineers” profoundly grateful that we get to partake of all the university has to offer while instilling a desire not to forget where we came from and what we owe to those who are not so fortunate.

Before I left for my first trip back to West Virginia, my wife overheard me practicing my speeches to the state legislature and asked why I sounded different — I realized that even imagining speaking to my own people was bringing back my accent. Returning to Charleston, the state capital, was richly nostalgic for me. I hadn’t been there since a state math contest in the ninth grade, and I still think of Charleston as “the big city” because it was the only place with more than 100,000 people I’d been to when I was growing up. I was comforted throughout my visit by the mountains all around: When I left West Virginia to pursue a Midwest education, I had been unnerved by the unlimited, empty horizon of the flat states, the absence of mountain mama cradling me in her arms.

Dan escorted me around the capital to hearings at which I testified, meetings with reporters in which I talked about the state’s addiction problems, and a briefing for the governor. Everyone in the legislature treated me well, which I suspect was mainly an effect of Dan’s halo, but nonetheless meant a good deal to me because it relieved my worry that I might have been gone so long that people no longer saw me as one of their own.

Starting on that first visit, I worked with the legislature on a range of policy options that I had seen be effective in other states. One was to equip first responders such as firefighters and police officers with the overdose rescue drug naloxone, which nonphysicians can safely administer to prevent brain damage or death from lack of oxygen. Another was to return cold medicines containing pseudoephedrine to prescription-only status. Pseudoephedrine is used to make methamphetamine, and states that make it a prescription drug have curtailed the explosions, fires, burns and environmental damage of meth labs.

Because careless (or intentionally inappropriate) opioid prescribing contributes to addiction and overdose, I worked with the legislature on programs that could monitor prescribers without limiting access to pain medication for those who need it. I have also spent time with state as well as city and county officials trying to scratch up some funds for addiction treatment services, which are in short supply in much of the state.

Last but not least, it struck me that West Virginia is an anomaly among states in having very low tobacco taxes despite having virtually no tobacco industry (the usual explanation for low taxes). I consider raising low tobacco taxes valuable even if the resulting revenue were burnt on the Capitol lawn, because higher prices discourage use, particularly among teenagers. But given that higher taxes would bring in revenue, why not use it to provide treatment to addicted people?

Working these issues required me to negotiate a legislative process different from my experience with the U.S. Congress. Like many states, West Virginia has a part-time legislature, a political arrangement with costs and benefits. On one hand, every session is a mad dash in which many good bills die simply for lack of time (West Virginia’s deadline is 60 days). For example, the bill to expand access to naloxone was killed by the legislative clock four times before it was passed in 2015, despite no significant opposition to it. On the positive end, part-time legislators by necessity have real jobs outside of politics, which keeps them in touch with their communities. I often find that when I work with states on mental health or addiction issues, the legislators who have the best sense of what is going on are those whose day job as a nurse or police officer or teacher brings them in touch with afflicted people.

Those of us working for better policies regarding addiction have certainly experienced struggles and disappointments. The cold medicine industry’s ferocious lobbying — which one journalist commented inspired envy even from the all-powerful coal industry — narrowly defeated the effort to return pseudoephedrine to prescription-only status. Raising tobacco taxes has been a nonstarter in the past few years. The state legislature also sometimes floats bills with which I don’t agree and which I don’t think work, such as proposals to drug-test welfare recipients.

But I take comfort in the fact that first responders reversed 3,000 overdoses with naloxone last year, no doubt in many cases saving lives. Addiction treatment has established a beachhead in some parts of the state and has garnered some funding. The state’s prescription monitoring program is better resourced and more proactive than ever before. And Gov. Earl Ray Tomblin surprised us (in a good way) by announcing in this year’s state of the state address that higher tobacco taxes are now on the table.

At a personal level, reconnecting with my home state has been one of the deepest satisfactions of recent years. With my parents now retired to North Carolina and my siblings and friends having left to pursue educational and career opportunities, I probably would never have visited West Virginia again if not for my newfound legislative collaborations. Each time I see the moon rise over the Appalachians, hear the wind rustling through rhododendron-filled hollows or, most of all, hear a friendly voice say a word like “y’all” or “crick” or “leastaways,” I realize what a profound mistake that would have been. Dan, in his generous way, tells me that my state is grateful to me and continues to need me. But I think the truth is closer to the other way around.