‘Dopesick’ Author on Opioid Treatment Innovations

Beth Macy

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Marianne O’Hare : Welcome to Conversations on Health Care. This week , we welcome
Beth Macy, award - winning journalist , and author of Dopesick, and the
follow up Raising Lazarus on Ame rica's deepening opioid crisis.

Beth Macy: We know that we have a 8 7% treatment gap in this country , a nd that
means that only 13% of folks with SUD have managed to get care.

Marianne O’Hare: Fact C heck .org ’s Managing Editor looks at misstatements about health
policy in the public domain , and we end with a bright idea. Now h ere
are your hosts Mark Mas s elli and Margaret Flinter.

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Mark Masselli: The opioid crisis , and the serious missteps that caused it , have been
well documented by our guest . She painstakingly told the story from
big farmers’ office to the distress ed V irg inia mining town, and her
ac claim ed book Dope s ick has been turned into an award - winning
miniseries . 7 million Americans suffering right now from opioid
addictio n.

Margaret Flinter: And now journalist and author Beth Macy is here to tell us about the
nex t par t of the story. That's a new book . Raising Lazarus, is an
account of what she calls the everyday heroes that are fighting on the
frontlines of the overdose crisis. And as she says , patients cannot
recover if they're dead.

Mark Masselli: Well Beth, let me wel come you to Conversations on Health Care .

Beth Macy: Thanks for having me .

Mark Masselli: You know, you really have dug into the subject of those you call
‘ treatment innovators for opioid addiction ’ . And I'm wondering what
do we know about treatment and what's working be st .

Beth Macy: Well, we know that we have a 87% treatment gap in this country. And
that mean s that only 13% of folks with SUD have managed to get care
in the last year. And that's, you know, if we are getting a 13% in
school, we'd get failed out . We're fa iling. And another thing that I
have noticed , having spent the better part of eight years working on
two books about this , is that people die when t hey are facing barriers
to care, when you have most rehabs in the nation still not allo wing
the gold standard of care, Buprenorphine and Methadone . That's a
huge problem. And I have seen parents remortgage their houses and
all manner of things to send their children to exactly the kind of care
that isn't serving them the best. And it's just tragic.

What is workin g, there's this huge group, it's probably the largest
group according to SAM H SA , 40% of people with opioid use disorder
that say they don't want to stop using , they think they can't stop

Beth Macy

using , and that's largely because they've been stigmatized, either by
t he criminal justice system , or by the health care system. So, t his
approach known as harm reduction, this idea of going to them where
they are, even if they're still in chaotic use, and treating them like a
human being with a treat able medical condition is basic ally the
gateway into care. And that's what I learned from the last couple of
y ears reporting on the new book.

Margaret Flinter: Well Beth, you have some compelling stories , and certainly you talk
about resistance from law en forcement, but you also highligh t a
sheriff in Fairfax County, Virginia, who himself is organizing
medication - assisted treatment . If we know that that works, what
more can be done to provide such an approach on a broader scale?

Beth Macy: Yeah . So we need to be scaling up what people lik e Sheriff Stacey
Kincaid are doing . She was willing to take a political risk. She's an
elective sheriff . And she said, “ Hey , let's work together with the
Community Services Board , ” which is the state - funded mental health
and substance use disorder group , “ and we're going to do things
differently. So we're going to screen every person that comes in to
our jail for addiction . And if they're willing, we're going to put them
on Buprenorphine . We're going to partner with a harm re duction
group to send peers into t he jail and work with folks in their addiction
on coming out with a reentry plan. And when they get out, we're
going to physically literally meet them at the moment of discharge
and hel p them go to their next step. ”

So , a lot of new rules had to be written and rewritten. And a lot of the
deputies didn't want to do it a t first . “ We're going to have Bupe in the
jail when a lot of people here have been arrested for diverting Bupe ? ”
And so t rain, train, train, bring in experts , give the stats, oh, and we're
going to bring in peers, by the way all of whom are felons into the jail
and let them -- give them badges. You know, they were very resistant.
And then those who just simply couldn't get it were let go. That's risk.
That's c ourage. That's really I think being a treatment in novator. And
there are examples all throughout the book of people who are
managing to bridge health care and law enforcement , and some of
them are just having fantastic results .

Mark Masselli: You know, I w as thinking about the tobacco settlement and what a
disaster t hat was for many of us who lived through that time and how
monies were diverted to everything but tobacco education for young
peo ple and intervention strategies. And beginning this spring , local
government agenc ies started receiving funds from the $26 billion
opioid settlement. I'm just wondering if we learned anything , and do
you think they have good plans to utilize those dollars?

Beth Macy: I think some do. The week before the book came out in early August
of this year, I met with all the county commissioner s in North

Beth Macy

Carolina . This is a state that hasn' t passed the Medicaid expansion, is
a conservative state , and my thinking was, if they can get harm
reduction here, you can do it anywhere . Rig ht ? And how did they get
over those cultural barriers. But I know from that meeting alone that
about half of the 100 counties in North Carolina didn't really have a
plan yet for what they were doing with the money. And you know,
what are the chances it's g oing to go to either something unrelated
altogether, which is not supposed to go the way of the tobacco
settlement . We know that less than 3% of the money actually went to
prevent smokin g and smoking related diseases. I was hoping that this
book c ould come out at this time when communities are making
these really important decisions. And I'm really hopeful, but also a
little cynical, that the money will be swiped by people in power for
appearing tough on crime , what some people in the book call Hug a
Thug , and that it'll go to incarceration first models , and abstinence
only models , that we know don't work as well for OUD.

Margaret Flinter: Well Beth, it seems to me that one really important system in the
United States is the Federally Qualified Health Center system that
cares for about 30 million people with about 14,000 site s. And I think
what's unique about them is not just the access piece, but removing
the stigma . Because you can be going for your regular primary care,
your dental visit, or your visit to get medication - assisted treatment. I
think the increase between 2016 a nd 2020 was over 300%. Is this an
approach that you heard much about in doing your research and
writing the book , or what more can the health centers be doing?

Beth Macy: Yeah, absolutel y. I think FQHCs are -- I mean, I think a lot of the
money should come thr ough them, because they are not dependent
on the whims of politics. I begin the book with a nurse practitioner.
He's worked all day at an FQHC doing mostly addiction and HIV care ,
a n d at night he works for harm reduction group in a rural part of
North Car olina . His name's Tim Nolan , a nd he' s meeting people where
they are. He starts out passing out needles . He quickly realizes that
he's tapped into this population . He calls them the ‘ u nseen ’ . And he
begins with Hepatitis C, treats them , starts reaching more p eople , and
then they come to the conclusion that they really need to offer low
barrier care.

And so he's going to them where they are, whether it's in a
McDonald's parking lot that they've pre - arranged to meet, and he's
getting them on Buprenorphine . And t hrough his FQHC he has
arranged discount pricing at one particular drugstore. And he wants
them to know two things . I think this is really the approach to getting
that 40% back int o systems of care. One is you can get better . Most
Americans have given up on this population . And a lot of folks with
OUD themselves , don't think they can get better. So first, we got to
have hope. Medications are actually pretty efficacious. There are a lot

Beth Macy

of studies going back to the late ‘ 80s on how well they work . And t w o ,
just don’t disappear. And that's this idea that we're not going to kick
you out if you have a relapse . We're going to increase your treatment,
your counseling, your social support . But we're not just going to shun
you and kick you out b ecause addiction is a chronic relapsing disease.
We wouldn't do t hat for somebody with diabetes.

Mark Masselli: Not at all. You know, Beth, you said that your book was hopefully a
primer for people to start thinking about plans for how they might
utilize this money. But your book is also a clarion call to examine the
laws and health policies that need to change. What policy changes do
lawmakers and regulators need to look at and what are you focused
in on?

Beth Macy: Well, you know, at the beginning of writing about this, I was kind of
naive a bout how health care work ed . I kept asking people , “ W hat
should the Federal magic wand be ? ” But finally somebody said , “ Beth ,
medicine doesn't really run at the Fed eral level. ” I mean, there can be
-- certainly powers of the purse can be employed to incentivize
peop le to treat this population differently , and I think the Biden
Administration is trying to do that. First President on record who's
used the phrase ‘ harm reduction ’ , you know, an d i s putting money
behind it.

Somebody pointed out in my research in rural No rth Carolina, he
pointed out that the county sheriff is the highest elected law
enforcement official so they hold huge sway over the way folks with
addict ion are treated in the court system . And s o I'm going to show
you innovators that I think are figuring out how to do it. So I think
immediately of Judge D uane Slo ne, who ’ s in Eastern Tennessee, an
elected judge, and he's a former tough on c rime prosecutor. And he
doesn't believe in letting his probationers beyond MAT at the
beginning. And then somethin g happens. He and his wife adopt a
baby that has NAS . They get to know the biological mother. And they
really get to know her story. And they realize she just can't do it
without this. And so he does a deep dive , a nd he looks into the data
and he says, “ How can we not be allowing this? ”

So, h e partners with this physician named Dr. Steve Lloyd . Now , Dr.
Steve is the doctor that the Michael Keaton character i s based on in
the Dope s ick show . He really got addicted himself to Oxycontin,
eventually got into recovery, and became a leader. And so Dr. Steve
meets this judge , and he volunteers to serve on his drug recovery
court, because simply he wants the voice of th e medical professional
there to start to change the thinking among the whole recovery co urt
team. And so , in a couple of years, they start wrapping services
around these folks. And they have reduced overdose deaths by 80% in
the four counties that Judge Sl o ne serves . But they had to really work

Beth Macy

against some negative thinking about it.

And if you go to the drug court, which I have, it's not like a courtroom
you've ever seen. Judge Slo ne knows these patients . Dr. Steve is
sitting there . He's weighing in on w hether he thinks they're using the
appropriate prescription dosage. And at the end of every person
reporting how they're doing this week, Judge Slo ne comes out in the
front and gives them a hug and tells t h e m he's proud of them. And,
you know, they've had a reduction in NA S cases , a huge reduction in
property crime. And you know, then he can go back to his v oters and
say, “ L ook , we're really dealing with the problems here. ”

Margaret Flinter: Well Beth, this is one problem t hat's a national problem. But at t he
heart of it, you have to have somebody who's going to be willing to
prescribe the treatment, the medica tion - assisted treatment . I was
surprised by a statistic that only 8% of physicians have done what is
necessary to get the DEA license or the waiver to prescrib e opioid use
disorder treatment. Is it a reluctance on the part of medicine , and
certainly nurse prac titioners and physician assistants can also get the
license as you refer to, or is it that kind of unrealistic maybe for a
single person to be tre ating it versus needing a team to make sure
that they really can do it safely and effective ly ? What d id you hear in
your interviews?

Beth Macy: Well, I heard a lot of stigma among health care providers, and this
idea that they're very, very busy and it's e asier not to have the
difficult patients . We don't want those kind of folks in our waiting
room is something that really happens . Now I was talking to the drug
czar, Dr. Gupta, not want ing to go , and of that 8% h e said very few of
them, even the 8% , prescr ibe . So even those that got -- not everybody
that got the waiver , takes advantage of it. We are still turning out
young docto rs who don't know how to identify addiction and treat it. I
have some good friends who just finished Harvard Med , then did the
resi dency , just took a nine hour board exam. They're married couple,
and they took a nine hour board exam. And there was exactly on e
question on addiction in that whole nine hours. So we're pouring a lot
of tax dollar money into the GMEs in the Graduate Medica l Education ,
to turn out new doctors , that can't help with the disease that took out
108,000 Americans.

So , the whole s ystem really needs to be revamped. I'm hopeful that if
this MAT Act , which is currently in the Senate , gets passed, that will
axe the X - waiver, the so - called X - waiver, that will get rid of this which
is another huge barrier. You don't have to have a special waiver to
prescribe Oxycontin for instance, or Percocet, but you do to prescribe
the addiction that you got from Oxycontin or Percocet . So , I think that
wi ll open it up. There are still these patient caps , p eople who've been
prescribing , can prescribe , after t hey've done it for a year or two , up

Beth Macy

to I think 275. And, you know, these are barriers . And I think we've
got to make the treatmen ts easier to access than the dope , because
the dope is out there and it's very easy to access , and Fentanyl is in
almost all of it now. I was in Baltimore last month , and a public health
worker told me that Fentanyl was selling for a dollar a pill , and tha t's
frightening .

Mark Masselli: You know , not to toot our own horn, but all of our providers are MAT
providers in the national program tha t Margaret set up for training
nurse practitioners. It's a prerequisite for anyone going through the
program. So Marga ret was saying earlier about, you know, it's a
national problem . But there are some communities that are severely
affected by this opioid crisis. And NIH reports that as many as 10% of
newborns are affected by neonatal opioid withdrawal syndrome.
What do w e know ab out treatment for these babies?

Beth Macy: We know that, you know, people will say addicted babies . They're not
addicted , t hey're d ependent on the medicines. And I'm sorry, but I am
not -- that is not top of mind for me right now. But we know it's a
huge concern. And it has led to a 17 times increase in foster care. I
write about Batesville, Indiana in the new book. And, you know, even
the foster care parents are getting their foster kids taken away from
them. So we're going to be looking at just a tsunami if we don't go
upstream from this.

Margaret Flinter: Well, that is heartbreaking , and certainly warrants all of our attention.
And medication - as sisted treatment is our best hope right now. But
you've noted, I think , that there may be some room for more
breakthroughs on the horizon. We've heard about FDA - cleared drug -
free non - surgical device that uses neuromodulation to help in the
reduction of symptoms as sociated with opioid withdrawal. Anything
else coming down t he research pathways that you think is promising ?

Beth Macy: You know, my real goal with this book was really to show people out
in the communities that are scaling these barriers of get ting
treatment access. I am not as up - to - date on the new scientific drugs
and research as I probably shou ld be for this conversation. But you
know, we have these lo w - hanging fruits of axing the X - Waiver , and
then reaching this really hard to reach populati on of folks that simply
aren't captured. And so I think harm reduction, this idea of going out
and going to people where they are, and really enveloping them in
systems of ca re is where we've got to start. I'm also a fan of safe
consumption, which is very controversial. But again, it's anything that
gets people into systems of care , whether it's a needle exch ange,
passing out Fentanyl test strips, or even safe consumption , which you
know New York City right now is the only location , has two sites, and I
think plans for a few more, because that's a big political lift these
days , so .

Beth Macy

Mark Masselli: You know, we think about health care providers legally prescribing
opioids to treat pain . And you hear all kinds of anecdotal stories about
doctors holding back on prescribing opioids, even when they might be
helpful , and certainly the DEA always looming large over pra ctices .
Are we headed in the opposite direction , too much of an
overreaction?

Beth Macy: Yeah, a lot of folks think so , and there has been some re cent research
showing that people are being fo rced taper, people who are not
misusing their medicines , and the re's a lot of anger among chronic
pain patients at the CDC guideline that came out in 2016. I think they
walked a little bit of that back. I mean, opioids shouldn't be the first
line of defense for somebody with a moderate injury . B ut there is this
large g roup of folks that are already out there on stable dosages, and I
hear from them a lot. They're really angry, they're really hurting. And I
tried to address that in the new book, just because I knew they felt so
unheard.

And there's example in the book of a doctor getting arrested for
over prescribing , a nd we know the DEA has really cracked down on
that. Some doctors have gone to jail. But what abo ut the other
patients that are the chronic , legitimate chronic pain patients ? And so
I try to parse out like wh at's the best way to treat them . It's not to
force taper them because then they're just as vulnerable to going to
the black market where the wh ole illicit drug supply has been
poisoned with Fentanyl . So I think it has come back maybe a little too
far and w e just need more education about all of it.

Margaret Flinter: Yeah . Well it is a complicated issue. And you may have seen some
polling that show s Democrats , and interestingly to me low income
Republicans are generally more open to paying more taxes to fund
opioid treatment programs. I think awareness is actually pretty high in
the country that people are dying. I don't know anyone who doesn't
know someone who lost a kid , or a parent , or a friend. But the polling
also shows that Republicans and Democrats do not support placing a
clinic close to them in their community, kind of like feels NIMBY
problem. So it's a public perception issue, but it's also a real barrier.
What have you seen ? And is that part of the drive towards integrating
treatment into maybe mor e generic health care systems or primary
care systems? What are your thoughts on that?

Beth Macy: So , in Roanoke where I live, which is the largest c ity in the western
half of Virginia , needle e xchange finally became legal in 2017, I think.
And it was a co uple years before we actually got one open , because
the law was initially written that city council and the chief of police
had to sign off on it. So , finally, two years later, we get one in
Roanoke. It's only the second one in the whole state . And then it gets
close d by one little three minute story on a local CBS affiliate about

Beth Macy

needle litter. So it's that nimbyis m, it's that cave, citizens against
vi rtually everything , and instead of sending a group of volunteers to
fix the problem, let's just have a con versation . So what can we be
doing better ?

You saw the same thing happen in Charleston, West Virginia, when
they located their needle exchange at the Public Health Department
downtown across from their fancy mall that they were proud of, and
then needle l itter . And then that really blew up and became a huge
political third rail. And you now have politicians the re running on an
anti - harm reduction platforms, which is just shocking because the city
has the nation's most concerning HIV outbreak. So the thing that
Roanoke did and what Charleston did , was going to people w h ere
they were , having mobile vans, so they can't say it's , you know, not
my backyar d, because it's all over the place. I mean, I think that's
something that all communities need to look at, be cause it is
politically more palatable. And in the words of Judge Slone, who I was
talking about a little bit earlier, like when people are reluctant t o start
a new program like this, call it a pilot, just start doing it, and then
show the results six mont hs later, you kno w, and try to draw attention
to t his works , w e did something new, the world didn't end , and
people got better treatment .

Margaret Fli nter: Good organizing strategy.

Mark Masselli: It is. Beth, one last question. You called on President Bid en to end the
ban on Federal funding of syringes. If he's listening right now, we
hope he is at least on tape delay , h ow would you make the argument
t o him?

Beth Macy: I would say come visit some of th e needle exchanges I've been to.
People think they ar e these big scary places . They look like preschool
classrooms. There are inspirational sayings up on the wall . People can
come and get food . They can get non - ju dgmental connections to care.
And we know their number one expense is buying the syringes. We
know that people who visit syringe exchanges are five times more
likely eventually to enter treatment. And that's what we all want. And
I know he's read the resea rch. I know he knows this. It's a political
thing. And like Sheriff Kincaid did that began our con versation in
Fairfax County, we've got to have courage.

Mark Masselli: Great.

Margaret Flinter: Well, thank you Beth for your incredible journalism. That's brought so
much insight and attention to the opioid addiction issue. And thank
you to our audience f or being here. You can learn more about
Conversations on Health C are and sign up for our email updates at
www.chcradi o.com . Beth, thank you again so much for joining us t oday.

Beth Macy

Mark Masselli: Yeah .

Beth Macy: Thank yo u for having me.

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Mark Masselli: At Conversations on Health Care, we want our audience to be truly in
the know when it comes to the facts about health care reform and
pol icy. Lori Robertson is an award - winning journalist , and Managing
Editor of Fact Check.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in U . S . politics.
Lori, what have you got for us this week?

Lori Rober tson: The number of people without health insurance in the United States
has go ne down under President Joe Biden by 1.1 million people from
2020 to 2021. That's according to the Census Bureau's latest annual
report. We looked into this , and many other stati stical measures of
Biden's presidency in our latest quarterly report that we c all Biden's
numbers. We published similar quarterly reports when Donald Trump
was President and when Barac k Obama was in the White House.

In 2020, 28. 3 million people , or 8.6% of the U . S . population , lacked
health insurance for the entire year. Those figu res dropped to 27 .2
million or 8.3% in 2021. The census report was published in
September . Most of the population had employer - based insurance
coverage in 2021. Al together , 66% of Americans had private
insurance, which includes work - based plans, TRICARE, w hich is
insurance for military members an d their families, and Affordable
Care Act Marketplace plans. Public or government sponsored plans
enrolled 35.7% of the population , split n early evenly between
Medicare and Medicaid.

The National Health Interview S urvey which measures the number of
uninsured at the time people were interviewed , found a decrease in
the number of uninsured people of 1.6 million from 20 20 to 2021.
Early release figures from that survey show those lacking health
insurance declined furth er in the first quarter of 2022. The estimates
are that 8% of the population was uninsured in the first quarter, down
from 8.8% in the fourth quarter of 2021.

And that's my fact ch eck for this week. I'm Lori Robertson, Managing
Editor of F act Check.org.

Ma rgaret Flinter: FactCheck.org is committed to factual accuracy from the country’s
major political players , and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you’d
like check ed , email us at www.chcradio.com . We’ll have
FactCheck.org’s Lori Robertson check it out for you here on
Conversations on Health Care.

Beth Macy

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Margaret Flinter: Each week , Conversations highlights a bright idea about how to make
wellne ss a part of our communities and everyday lives. Health care
providers are forever on the lookout for that magic elixir that can cure
a host of chronic ills in one step. And in the ca se of obesity,
depression, anxiety and stress, that elixir could be a num ber of steps
as in taking a hike. A large study conducted by several institutions,
including the University of Michigan and Edge Hill University in the
UK, looked at the medicinal ben efits derived from regular group hikes
conducted in nature .

Dr. Sara Warb er: We could see that these two different types of help for our mental
well being , they're operating independently. That means that if we go
out in nature for a walk , we are getting an additional boost to our
mental well being.

Margaret Flinter: Researchers evaluated some 2000 participants in a program called
Walking for Health in England which sponsor ed some 3000 wal ks per
week across the country.

Dr. Sara Warber: There was investment i n these walking groups , in training leaders to
take people on walks, find ing trails that were good for people they do,
ev en if they had health problems.

Margaret Flinter: Dr. Sara Warber, Professor of Family Medicine at the University of
Michigan School of Medicine, said this study showed a dramatic
improvement in the mental we ll being of participants .

Dr. Sara Warber: Depression was reduced, perceived stress was reduced , and there's
been really lovely research that's shown that when we have positive
emotion s we actually have better health in the long run .

Margaret Flinter: And t he effect was cumulative over time. Dr. Warber says this is the
first study that revealed the added benefits of group hikes in nature
and significant mitigation of depression .

Dr. Sar a Warber: Because we ’ re really interested in if you are more stressed wou ld you
get some better benefit from being in nature , and in fact, that did pan
out.

Margaret Flinter: Walk for Health , a simple guided group nature hike program, which
incentivizes folks suffering from depression and anxiety to step into
the fresh air with others, improving their mood, reducing their
depression, increasing their overall health at the same time , n ow
that's a bright idea.

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Mark Masselli: I'm Mark Masselli.

Beth Macy
Marga ret Flinter: And I'm Margaret Flinter.
Mark Masselli: Peace and H ealth .
[Mu sic]
Marianne O’Hare: Conversations on Health Care is recorded in the Knowledge and
Technology Center Studios in Middletown, Connecticut, and is
brought to you by the Community Heal th Center , now celebrating 50
years of providing quality care to the unders erved where health care
is a right , not a privilege , www.chc1.com and www.chcradio.com .
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