Virginia Department of Health

The Virginia Department of Health is portrayed as a state institution whose role in the opioid crisis developed from early warnings and disease surveillance toward a more visible public-health response. Its record in Dopesick spans a statewide emergency declaration and naloxone access, as well as local efforts to expand treatment and prevent infection. The account also emphasizes that these actions operated within a fragmented system: state initiatives could not by themselves erase the effects of delayed recognition, political resistance, limited treatment capacity, or the difficulty of reaching rural patients.

Early warning and surveillance

Dr. Sue Cantrell, a regional health-department director, had warned state supervisors about the epidemic two decades earlier. Her concern was dismissed as a regional problem. By the summer of 2017, with the HIV outbreak in Scott County, Indiana, still in mind, she was holding town-hall meetings in coalfield counties to make the risks of injection drug use and infectious disease harder to ignore. This history gives the department’s later response a long institutional backdrop: the danger had been recognized locally well before it received sustained attention.

The department’s data also helped define the scale and changing geography of the crisis. Virginia’s neonatal abstinence syndrome cases rose from 88 in 1999 to 493 in 2013. In the Southwestern health district, 65 new HIV cases were reported in 2015 and 46 in 2016. These figures do not describe a single program or intervention; they show the public-health consequences being tracked across time, from newborn withdrawal to infections associated with injection drug use. Elsewhere, Centers for Disease Control and Prevention statistics placed Martinsville first and Norton second among U.S. localities for opioid prescriptions per person, illustrating the concentration of prescribing in rural Virginia communities.

Emergency declaration and naloxone access

In late 2016, Virginia State Health Commissioner Marissa J. Levine declared the opioid crisis a public-health emergency. She cited an average of three Virginians dying each day from drug overdose and more than two dozen overdose cases a day in emergency departments across the state. The declaration framed overdose as an urgent statewide health problem rather than a collection of isolated local incidents.

Levine also issued a standing order, effectively a blanket prescription allowing any Virginia resident to buy naloxone, an opioid antagonist that can reverse an overdose. The change addressed one immediate barrier by making the medication available without requiring each prospective user or bystander to obtain an individual prescription. The book places this step within a wider public-health response in which preventing death was treated as a prerequisite for recovery, not as a substitute for treatment.

Local prevention and harm reduction

Cantrell’s work connected state-level concern to practical efforts in the coalfields. Although Virginia had recently passed legislation paving the way for syringe-exchange programs, every legislator representing the coalfields had voted against the bill, citing concerns from local law enforcement. Cantrell hoped to arrange a visit from a West Virginia police chief to address local authorities. The comparison was pertinent: a syringe exchange in West Virginia had been associated with lower overdose deaths and five times greater access to treatment and disease-prevention services.

While broader local acceptance remained uncertain, Cantrell’s staff taught people who injected drugs to clean syringes between uses, distributing bleach packets and plastic cups. She sometimes offered free food to encourage patients to be tested and to return for their results. At a Remote Area Medical clinic, free hepatitis C testing was offered for the first time, and nearly 400 people received take-home naloxone kits and training. These clinic efforts were not all described as department programs, but they show the public-health network in which Cantrell worked and the practical methods being used to reduce immediate risks.

Access depended on more than making services available. Cantrell ran a medication-assisted treatment clinic in nearby Lee County, Virginia, where two patients either hitchhiked or walked to appointments, some from more than five miles away. The distance exposed a basic weakness in rural care: a patient could be eligible for treatment and still face a substantial journey to receive it. Testing, overdose-reversal medication, and treatment therefore depended on reaching people as well as on formal policy.

Treatment expansion and regulatory response

By 2017, state health-department officials were working to expand medication-assisted treatment while also tightening controls against its misuse. The state’s approach drew in part on Highpower, a Suboxone clinic in rural Lebanon established in 2000 by addiction specialist Hughes Melton. Melton was helping direct Virginia’s opioid response and supported a statewide push for syringe exchange alongside tighter controls on medication-assisted treatment prescribing. His wife, Sarah Melton, a pharmacy professor and naloxone trainer, had trained more than 4,000 doctors about opioid risks and reported some for overprescribing.

This effort unfolded alongside other state-level regulatory changes. In 2017, the Virginia Board of Medicine required doctors to check the state drug-monitoring system every time they issued a prescription, a measure intended to prevent doctor-shopping. The simultaneous emphasis on treatment access and prescribing oversight reflects a balancing act in the book: expanding evidence-based care while responding to diversion and overprescribing. The account does not present regulation as a complete solution; it records it as one component of a response still being built.

Structural limits and significance

The department’s initiatives took place amid restrictions and gaps beyond its direct control. Virginia’s legislature had repeatedly rejected Medicaid expansion after the Affordable Care Act. In June 2014, Republicans in the state legislature blocked the Democratic governor’s proposal, leaving federal funds and coverage for 400,000 low-income Virginians unrealized. The book contrasts Virginia with states where Medicaid expansion paid for treatment, counseling, and addiction medications, and helped cover people who were too poor for private insurance but did not qualify for Medicaid. These decisions shaped the resources available to patients and providers, even as health officials sought to widen treatment.

The lack of coverage had tangible consequences in rural communities. One uninsured teacher relied on free care at Remote Area Medical events and occasional visits to a mobile clinic; she delayed seeing her family doctor until she felt nearly at the point of dying, despite a discounted cash fee. Such accounts clarify the limits of a statewide emergency declaration: an order improving access to naloxone could reduce one immediate obstacle, but it could not by itself supply insurance, nearby clinicians, reliable transportation, or sustained treatment.

The Virginia Department of Health’s significance in Dopesick lies in this tension between mounting need and uneven capacity. Its officials gathered evidence, declared an emergency, widened access to overdose reversal, and worked on treatment and syringe-exchange responses. Yet local opposition, rural distance, coverage gaps, and longstanding failures of recognition remained part of the same public-health landscape. The department appears not as a solitary remedy, but as an increasingly engaged institution trying to intervene in a crisis whose causes and consequences exceeded the reach of any one agency.