Dr. Andrey Ostrovsky's family did not discuss what killed his uncle in 2015. The man was young, not quite two weeks past his 45th birthday, when he died, and had lost touch with loved ones in his final months. At the time, Ostrovsky wondered if his uncle had perhaps killed himself.
Almost two years later, Ostrovsky was Medicaid's chief medical officer, grappling professionally with an opioid crisis that kills about 115 Americans each day, when he learned the truth: His uncle had died of a drug overdose.
Family members knew the uncle's life had been turbulent for a while before his death; they'd watched as he divorced his wife and became estranged from his 4-year-old daughter and eventually lost his job as a furniture store manager.
But Ostrovsky wanted to better understand what had happened to the man — his stepfather's younger brother. So last fall, when he found himself in southeastern Florida, where his uncle had died, Ostrovsky contacted one of the uncle's friends for what he expected would be a quick cup of coffee.
Instead the friend "let loose," revealing that he and Ostrovsky's uncle had been experimenting with a variety of drugs the night of the death. It was the tragic culmination of more than a decade of substance abuse — a pattern of behavior much of the family knew nothing about. An autopsy showed there were opiates and cocaine in his uncle's system, Ostrovsky later learned.
The revelation shook Ostrovsky — he's a pediatrician who was appointed to the Centers for Medicare & Medicaid Services in 2016. As chief medical officer of the agency, Ostrovsky had championed getting better drug treatment programs for the 74 million people on Medicaid; it's a task that became increasingly difficult after Republicans signaled they would trim the program under President Donald Trump.
Within his own agency, Ostrovsky felt he'd become something of a pariah. After he posted a tweet against a Republican plan to repeal and replace the Affordable Care Act, he was reprimanded and removed from his major projects. A conservative group known as America Rising filed a Freedom of Information Act request for his email correspondence, a move seen as an attempt to intimidate Ostrovsky.
But that revelation over coffee in Florida made the drug crisis deeply personal for Ostrovsky and his family, and led him to make a change. He realized that solutions are not just about money, but also about combating stigma — the stain he believes prevented his uncle from getting help.
So, Ostrovsky quit his government job last month and has begun speaking publicly about his family's experience, to remove the shame of drug addiction.
It may not literally be what killed him, Ostrovsky says, referring to the stigma. "But that's what killed him." NPR agreed not to disclose the uncle's name out of respect for his family's privacy.
Last fall, the Trump administration declared the opioid crisis a public health emergency, stopping short of allocating more funding for an "epidemic" that killed more than 42,000 in 2016 — more than any year on record, according to the Centers for Disease Control and Prevention. And early numbers released this month indicate 2017 may even have outpaced 2016 in drug deaths.
In one of the latest attempts to manage the crisis, Democratic Gov. Tom Wolf of Pennsylvania recently declared the opioid epidemic a statewide disaster emergency. For the first time, Pennsylvania officials will direct emergency resources toward a public health crisis in the same way they would a natural disaster.
The uncle's story offers an intimate look at a crisis that has vexed officials on the local, state and national level, strained public health resources — and infiltrated not just America's streets and drug dens, but also workplaces and successful middle-class families like Ostrovsky's.
The uncle immigrated to the United States from Azerbaijan when he was 16, seeking a brighter future than the one that stretched before him in the crumbling Soviet Union, Ostrovsky says. The family settled in Baltimore, where the Uncle married and started his own family. When he wasn't working, he grilled lamb kebabs and danced to music from his home country. He was a warm, welcoming host, insisting guests have at least a cup of tea.
"Even when he had nothing, he would take that last piece of bread and offer it to you," Ostrovsky says.
To Ostrovsky, the man was the "cool uncle," always bringing his nephew trinkets from his travels. When Ostrovsky was in seventh grade, his uncle returned from Jamaica with a shirt that read: "See no evil, hear no evil, speak no evil, s--- happens mon." Ostrovsky wore the shirt to school — and says he happily suffered the inevitable punishment. "I love him for that and was proud to get in trouble," he says.
Sometime around the early 2000s, the uncle and his wife divorced. The man began drinking more — a vice Ostrovsky attributed in part to the family's cultural heritage, but that he now suspects grew into alcoholism.
It is unclear to the family when, exactly, drugs came into the uncle's life, though his problems seem to have escalated in his 30s. His drug of choice was cocaine, Ostrovsky learned from his uncle's friend, who frequently took drugs with the uncle over the years.
The uncle's worsening ability to function at work and other financial strains eventually drove him to crack cocaine, an especially addictive, cheaper form of the drug that produces an instant, intense high when smoked.
Months before his death, the uncle lost his job and grew depressed. He began using drugs more heavily and trying new ones. He dabbled in benzodiazepines — the class of psychoactive drugs that includes Xanax and Valium — and in opioids.
Opioids, which broadly include both illegal drugs like heroin and prescription painkillers like OxyContin, can be particularly perilous when misused, because they suppress the ability to breathe. Those who use opioids also build up a tolerance over time, which leads some people to use more of the drug to achieve the same high.
These facts are especially problematic, considering that street drugs are often cut with more powerful opioids — such as fentanyl, a fast-acting painkiller — to intensify the high.
Eventually, Ostrovsky's uncle began living with his drug dealer. On the night of his death, he and his friend went through the dealer's stash when he was out, trying pills and other drugs. When the dealer returned, after the friend had left, the uncle didn't answer the door.
He was found on the couch, looking "at peace," his friend recounted to Ostrovsky. They tried to resuscitate him and called for help. Sitting on the curb outside, his friend watched the paramedics carry the uncle away.
The uncle's friend says he has since then quit using drugs and is enrolled in a methadone program — a treatment option that uses another opioid to reduce withdrawal symptoms.
Ostrovsky says his former agency, the Centers for Medicare and Medicaid Services, is "ill-equipped" right now to handle the problem of addiction; it's hampered, he says, by a White House that is putting more emphasis on overhauling Medicaid benefits. So, for now, Ostrovsky is working outside the government.
This month, he announced he's joining Concerted Care Group, an addiction treatment program based in Baltimore whose patients are mostly covered by Medicaid; the organization is looking to expand, and Ostrovsky will serve as CEO.
Ostrovsky says he first noticed Concerted Care Group when it was part of a CMS pilot program. The program stood out, he says, because it eschews what he calls the grab-and-go approach of most outpatient addiction centers.
Instead, it offers patients private spaces to take their medicine; security guards to ensure their safety; even coffee while they wait. The approach preserves at least a modicum of patient dignity, he says. In the same spirit, Ostrovsky hopes that sharing his personal story about his uncle will help combat the stigma that makes patients and their loved ones ashamed to reach out for help.
"I think this is really important," Ostrovsky says. "That people hear about his story and talk — and get over that feeling of not wanting to have that uncomfortable conversation with my family member who needs help."