Fighting the Epidemic

After journalist and author Beth Macy finished writing Dopesick, her sweeping examination of the origins and impact of the opioid epidemic, she found herself in what she describes as a “very dark place.” In her book, she weaves together the different strands of the larger story of how the opioid crisis came about—the loss of economic opportunity in small factory towns across America, the greed of pharmaceutical companies seeking profit with no concern about the safety of their products, the despair of people who can find no hope for their future. Immersing herself in a subject filled with such pain and despair took its toll. “After hearing story after desperate story, it begins to creep into you,” she says. “You develop your own secondary trauma.” She decided that she never wanted to write about opioids ever again.

Then, as she began speaking about her book in the media and in communities around the country, she realized that she had something more to offer than just stories of despair. She could practice what she calls “solution-oriented journalism,” passing along what she’d learned about the creative ways some communities have responded to the opioid crisis and the approaches to treatment that have been proven to work. She became an activist, taking aim at government indifference and the unscrupulous marketing methods of drug companies, while offering hope and dispelling the stigma that’s stood in the way of progress. “Doing that has helped me climb out of my dark place,” she says. “I hope there’s something in what I’ve written and said that therapists can find useful.”

Psychotherapy Networker: For many, news about the steep rise in drug overdoses and opioid-related deaths seemed to come out of nowhere. What were the roots of this epidemic?

Beth Macy: It started in the mid-’90s with the growing emphasis on pain assessment and management in the medical system. The idea was to make pain “the fifth vital sign,” right along with blood pressure, heart rate, respiratory rate, and temperature. This coincided with the seismic shift toward thinking of patients as healthcare consumers, who rated their healthcare experiences in formal surveys. That incentivized nurses and doctors to treat pain liberally. It also presented an opportunity for pharmaceutical companies to cash in.

In 1996, OxyContin was introduced. Most pain pills lasted only four hours then, but OxyContin was supposed to provide steady relief for three times as long. Its makers, Purdue Pharma, claimed that its slow-release delivery system would frustrate drug abusers chasing a euphoric rush. It soon became one of the most popular pain medications in the medical community—and the most abused prescription opioid in the United States.

Hardly any dissenting voices challenged the wisdom of prescribing narcotics at the time. Meanwhile, the drug companies spent over $1 billion on lobbying politicians between 2009 and 2015 to loosen regulations on the pharmaceutical industry. And they spent even more to ply doctors with freebies to get them to prescribe their products. In 2000 alone, pharmaceutical companies spent over $4 billion in direct marketing to doctors.

PN: Many people don’t understand the role sales reps play in marketing new drugs. Can you explain what they do?

Macy: The launch of OxyContin is a good example of how it works. The Purdue sales reps were incentivized not to report suspicious orders and to tell physicians that these painkilling drugs were not addictive when, in fact, they were. They had lots of perks to give out. They might offer free dinners at fancy restaurants to make their pitch. Sometimes they’d drop off a turkey or a beef tenderloin before holidays. Doctors were invited to stop by the nearest gas station to top off their tanks while listening to the sales rep’s pitch.

To target the most consumers for its product, Purdue gave its army of sales reps data showing which parts of the country prescribed the most opioids and where doctors were already prescribing competing immediate-release meds like Lortab, Vicodin, and Percocet. They tended to be in places that were distressed, where jobs had gone away and a lot of people were on disability because of workplace injuries, like in the coal mining, logging, and fishing industries. In those communities, it was a perfect storm. Between the job loss and the injuries, people started doctor-shopping and realizing that they could sell OxyContin and other opioids to pay their bills and buy other medicines they needed. Diversion became a huge thing. And then with little government oversight and the DEA kneecapped by Big Pharma’s political influence, it was a field day for corporate greed.

PN: How did the problem make itself known?

Macy: Starting in the ’90s, there began a steady increase in deaths related to opioids and later heroin and fentanyl, and most recently methamphetamines. In 2015, for the first time in American history, the average life expectancy started to decline. Most of that was due to drug overdoses, alcohol-related cirrhosis, and suicide, which went through the roof. Actually, many of the suicides were addiction related, though they didn’t necessarily get recorded that way; same with deaths from endocarditis and injection-related infections, like hepatitis C.

PN: As this was going on, most of America ignored the problem. How could that have happened?

Macy: Well, we “othered” places like Appalachia. We said, “That’s not going to happen to us.” But the crisis just made itself known there quicker because problems appear more urgently in marginalized communities. They have fewer resources to deal with it, fewer places to go for treatment, and less money to be able to pay for it. But then drug-related crimes started making the headlines. People were stealing things in broad daylight, burning down factories to rip out copper wiring to resell on the black market, murdering store owners who were just making a bank deposit, all to get money to buy more OxyContin.

In the suburbs and cities where people are wealthier, it was easier to hide the problem for longer. But kids started pilfering pills from their parents’ and grandparents’ medicine cabinets and passing them around at so-called “pharm parties.” They’d say, “My laptop got stolen,” and mom would buy them a new one, which they’d take to the pawnshop to get money for more drugs. The few parents who were in on the dirty little secret were too ashamed to tell their neighbors.

In one wealthy neighborhood, I interviewed a mom with two heroin-addicted sons. She told me, “When I’d see somebody I knew at the grocery store, I’d go down another aisle because I didn’t want to be asked how my kids were doing.” In that way, the stigma associated with drug abuse helped companies like Purdue keep riding this wave of profits. Until recently, it wasn’t the kind of thing that got reported in the news.

PN: In your book Dopesick, you describe how addiction to opioids is not so much about the pursuit of pleasure as it is a desperate need to avoid the pain of withdrawal. How are opioids different from other kinds of drugs?

Macy: Addiction to opioids happens very quickly, and the withdrawal is intensely severe. Many opioid-addicted people describe it as the worst flu you’ve ever had times 100. There are relentless cycles of diarrhea, vomiting, restless leg, and crushing depression and anxiety. All kinds of traumatic feelings and memories can come rushing back. Opioid users will do anything, even stealing from the people closest to them, to not feel all that pain.

PN: Although opioid addiction is a massive public health problem, there doesn’t seem to have been much progress in combating it. What’s gotten in the way?

Macy: Well, partly it’s because people addicted to drugs aren’t the easiest patients, and addiction treatment is the stepchild of our healthcare system. Many doctors and healthcare professionals just don’t want to work with drug users. You hear them say things like, “I don’t want those people in my waiting room.”

But beyond that, there’s the fundamental belief that abstinence is the way to go with opioid treatment—despite the fact that only eight percent of people get better in those programs. It takes the average heroin-addicted person eight years and four to five treatment attempts just to get sober for one year. Given that it takes the brain of a person addicted to opioids at least 90 days just to get back “online,” it’s no wonder the 28-day abstinence rehabs, which are the most common treatment programs, haven’t been shown to be very effective.

PN: What have we learned about what treatment is effective?

Macy: The science is clear that medication-assisted treatment (MAT) must be part of how we treat opioid addiction. Every study shows that prescribing buprenorphine prevents relapse and overdose deaths by 50 to 60 percent. Obviously, adding counseling and social supports can also make a big difference, but if users just take buprenorphine, it’s still protective. It’s not a panacea drug, and there are problems of diversion and abuse with it. But if you talk to somebody who’s using it correctly, and getting counseling and in an intensive outpatient program, they say, “The medicine makes me not feel dopesick, so I can start to work on the other things in my life.”

But only one in five people with opioid abuse disorder get MAT. Most rehabs in America don’t allow it. Too much energy is going into abstinence-only programs. Of course, even MAT doesn’t always take the first time, but the more times a person with opioid use disorder goes through the treatment, the likelier it is to click in. The most important barrier to dealing with the opioid crisis is that in America we treat too many drug users as criminals, rather than people in need of medical care.

PN: What about critics who say that using a drug like buprenorphine means trading one drug dependency for another?

Macy: The science is clear that buprenorphine saves lives. But experts still wrestle to quantify just how long an addicted person should be on it. We know that when users come off the MAT, they’re more likely to relapse, even if they’ve been on it for a long time and are just taking a small dose. Some people may need to be on MAT for the rest of their lives, just as a diabetic is likely to be permanently on insulin.

PN: If there’s one thing that would make a difference in our response to the opioid epidemic, what would it be?

Macy: It all comes down to stigma. In most places, if you have an overdose and go to the ER, they’ll Narcan you and turn you back out on the streets. But a few places around the country are beginning to take a different approach. Some hospitals have begun doing buprenorphine initiation in the ERs and funneling people into outpatient treatment. They hook them up with a peer-recovery coach before they leave and give them enough buprenorphine to get them to that first appointment.

That’s the kind of thing happening in the few states that are starting to see a downturn in their overdose deaths. They’re providing plenty of harm-reduction services, programs where people who aren’t quite ready to stop using drugs can get clean syringes until they are. Bear in mind that 50 percent of people who go to syringe exchanges go on to get treatment.

These programs also help tamp down the spread of diseases like hepatitis C and HIV. They save money, and they save lives. But because of the stigma, there’s still resistance to them. In fact, I got into a public battle with our local police chief about a syringe-exchange law that had passed a couple of years ago. He refused to sign off on it because he said giving out clean needles was like handing out marijuana cigarettes in the playground. So there’s a lot of public education still to be done.

PN: Do some programs seem especially promising?

Macy: A lot of the innovations have to do with making connections among different kinds of systems. For example, a nonprofit hospital set up an intensive program with MAT inside a courthouse. So when people on probation tested positive on a drug test, they weren’t automatically put back in jail with no treatment. Instead, the therapists who run the program are empowered to say, “I think Kenny is really trying; let’s give him another chance.” And they’re having amazing results. More often than not, when people come out and relapse, they go right back to jail. That’s why all our jails are overcrowded. But we’re learning that we can’t arrest our way out of this problem.

Here’s another example. If you’re homeless in Cambridge, Massa­chusetts, where I was not too long ago, there’s a place you can go to use the computers to try to get a job, get free needles, and get connected with treatment when you’re ready. That simply leads to better results. But because of the stigma, and this idea that we’re enabling users with these programs, we’re still not making much progress.

PN: What are the fundamental misconceptions about treating addictions that we should be rethinking?

Macy: A lot of what’s getting in our way has to do with the AA model and the idea that you’re “clean” only if you’re totally abstinent. I’ve seen people die because of that belief. But the therapists who are most knowledgeable about addictions understand what it means to treat a chronic relapsing disease. There are no easy victories. It’s difficult, frustrating, often heartbreaking work, filled with many, many disappointments.

But if you’re going to have the patience and the fortitude to stay with doing that kind of work, it helps to bear in mind the passage from the Bible in which Peter asks Jesus, “How often should I forgive someone who sins against me? Seven times?” And Jesus says, “No, not seven times, but 70 times seven!”

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PHOTO © JOSH MELTZER