Patients with Substance Use Histories Denied Primary Care

Shocked and Appalled

 

 

 

 

 

One of my long-time and very stable patients saw me a few weeks ago for her yearly history and physical. That’s a minimum requirement for the patients I treat with methadone or buprenorphine at the opioid treatment program. For patients in treatment for many months, I no longer need to see them frequently for positive drug screens, dose adjustments, and other things, so we make sure to set aside time each year for me to catch up on how they are doing.

This isn’t only good medical care, but it’s fun for me. I love talking to patients and hearing the ways in which their lives have improved. It’s fun for them to discuss how they are accomplishing their life goals.

This day, after asking about the adequacy of her dose, her mood, her sleeping habits and biggest sources of stress, I asked about her overall health. To start with, I asked the name of her primary care physician. She told me she couldn’t get one, because of her history of opioid use.

I asked for further details: she called a local practice about becoming established as a patient, and part of their screening was to ask if she’d ever been prescribed opioids. She said yes, but that problem was in the past, and she didn’t need opioids now. She was then told that the practice wasn’t accepting any patients with a history of opioid use.

Merely opioid use, mind you – not opioid use disorder.

This wasn’t because of her insurance status, as she is covered by the largest private insurance carrier in the state, Blue Cross/Blue Shield of NC.

She said her feelings were hurt, and she started crying as soon as she got off the phone. She said, “They made me feel like a piece of shit.” She even teared up in my office as we were talking two weeks later.

This does not sit right with me.

I gave her the website of the North Carolina Medical Board and gave her the web address and phone number of where and how to file a complaint against that practice. I told her that denying entry to primary care for a patient because of past opioid use was immoral, if not illegal. I’m not a lawyer, but I figured if she let the medical board know, they could figure this out.

She hadn’t even told them she was on methadone. I know it’s a violation of the American with Disabilities Act, the ADA, to discriminate against someone with opioid use disorder who is in recovery on medication-assisted therapy. But I didn’t think that was the case for her, since she didn’t have time to tell them she was on methadone. By her description, their decision was based only on her history of receiving opioid prescriptions in the past.

I doubt there was any misunderstanding on her part, since she’s not the first patient we’ve had who reported similar situations. Also, local practices tell our patients on methadone or buprenorphine that they don’t have the “expertise” to care for them if they are taking methadone or buprenorphine from me.

This is ridiculous, since primary care physicians care for patients with specialty medications all the time. Cardiac patients on complicated heart medications still get primary care. HIV patients on powerful anti-viral medications still get primary care. Patients with opioid use disorder are no different.

But to be denied primary care merely because opioids have been prescribed in the past…it’s a step beyond the usual discrimination I see.

Of course, if the medical board does investigate, I expect that practice will blame the patient for misunderstanding, and say they accept all patients. Maybe…but at least they will be on notice that discriminatory practices can and will get them into problems. Hopefully they will be less likely to do this again.

No wonder local death rates increased. Not only are we dealing with the continued opioid use disorder epidemic with its opioid overdose death risk, but also with a lack of medical care for those people who survive opioid use disorder. It’s a double assault on patient health.

I live in a beautiful part on this country, but the medical care in this community often baffles me.

After a free-for-all on prescribing opioids, benzos and stimulants for a decade or two, the patients in this area for whom those were prescribed now can’t even get a primary care practitioner. It’s as if local doctors think that after the pendulum swung so far in one direction, it must swing too far in the other.

Common sense should dictate care – let’s not prescribe controlled substances willy-nilly but let’s not be stingy with opioids in cases of acute pain. And let’s not deny patients care if they’ve been prescribed opioids in the past.

What about repercussions from insurance companies? Will insurance companies allow certain prescribers to opt out of treating their covered enrollees because of past prescriptions?

Here’s another discriminatory wrinkle: life insurance companies are turning down coverage for people who have filled prescriptions for Narcan. A friend of mine sent me a link to this story:

https://www.npr.org/sections/health-shots/2018/12/13/674586548/nurse-denied-life-insurance-because-she-carries-naloxone

This is a link to the story of a nurse who was turned down for life insurance because she has filled a prescription for Narcan. This nurse works at an addiction treatment program and wanted to be able to revive people and save lives. The insurance company, Primerica, is now being criticized because it turned down her request for life insurance since she filled a Narcan prescription.

Now that they are being criticized for their stance, they issued a statement saying something to the effect that they support efforts to turn the tide on the opioid epidemic. But it appears that support doesn’t extend to offering life insurance to people who have obtained a Narcan kit.

This nurse applied at a second company and was turned down again, though she was told if she got a letter from her primary care doctor explaining why the Narcan was prescribed, they might re-consider. The trouble is, in Massachusetts, personal physicians don’t write prescriptions. To reduce barriers to receiving Narcan kits, the state allows any person who wants a kit to be able to get it under a standing order.

The physician behind this standing order is a well-known and well-respected physician, prominent in the Addiction Medicine field, Dr. Alex Walley.

Doctor Walley says he’s written other letters for similar situations where people are denied life insurance due to filling Narcan prescriptions to have on hand to save lives. He’s worried – obviously – that people will be discouraged from getting Narcan kits. These kits and their availability have been responsible for saving many lives in this nation.

These examples of poor decision making do nothing but extend the misery of people with opioid use disorder, in or out of treatment, and their families.

I’ve been working in my community for seven years, trying to inform and educate other medical providers about medication-assisted treatment. Most of the time, I feel positive, thankful to form good relationships with some providers and to coordinate care for my patients on medication-assisted treatments.

Then there are days when I feel so discouraged. it feels like there’s been no progress at all with deeply embedded bias and stigma against people with opioid use providers, their families, and the professionals who try to provide care to them.

 

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Year in Review: 2018 and the Treatment of Opioid Use Disorders

This year has been difficult for many people, due to disasters both natural and unnatural. As in any year, good things also happened. Since my blog concentrates on opioid use disorder and its treatment with medication, this entry will focus on the positive events in my field. I’ll save the more negative events for another blog, when I’m feeling grumpy, for those days will surely come.

This last year, the problem of opioid use disorder is got essential attention from governmental agencies, the press, and the public in general. For too long, no one was talking or caring about this issue. Now, this widespread medical problem is getting the kind of attention that leads to change: financial attention.

Big money for treatment

The CURES grant money, approved by legislation in late 2016, made almost a billion dollars available to help treat opioid use disorder. That money was released starting in early 2017, and has helped many patients.

In mid-2018, legislation was passed to approve another near-billion dollars to treat opioid use disorder and its prevention. Called the State Opioid Response, or SOR, this money will be released through SAMHSA to each state’s single-state agency. This money must be used for prevention and treatment, and to increase availability to medication-assisted treatment with the three FDA-approved medications: methadone, buprenorphine, and naltrexone.

From my reading of SAHMSA’s description of the SOR grants (https://www.samhsa.gov/grants/grant-announcements/ti-18-015 ), most of the money will need to be used for treatment with MAT.

This is big money, and is intended for treatment that includes evidence-based treatment with medications. In other words, the abstinence-only, “we don’t believe in medications” type programs probably won’t qualify for these grant dollars.

I’d like to pause and say a big “Thank you!” to the legislators who wisely crafted this grant.

As an example of fiscal irresponsibility of the past, with CURES dollars, some areas of our state cycled patients through five-to-seven- day detox admissions that had very little chance of helping. We’ve known the abysmal data from such short stays for decades, yet many treatment dollars were flushed down that detox drain.

Now, to get grant money to pay for detox, patients will need to start on naltrexone (probably the month-long depot injection) prior to leaving the facility. This makes sense and should improve patient outcomes. They could also be started on methadone or buprenorphine, but presumable inpatient detoxification wouldn’t be needed to start these medications.

The end of a detox is a perfect time to use naltrexone. Once a patient has started on it, it’s much easier to continue, either at an opioid treatment program or even in a primary care office. Since it’s not a controlled substance, physicians and extenders don’t need a DEA number to prescribe this evidence-based medication.

We’ve seen the benefit of CURES grant money at our opioid treatment program, where patients are treated with either methadone or buprenorphine. (We also offer naltrexone, but don’t often get patients when they are suitable for this medication, since they are actively using opioids.)

Before CURES, self-pay patients had difficulty remaining in treatment, and often opted to taper out of treatment before they were ready. Now, we’ve seen those people stay in treatment and thrive. I don’t have data, but I’m sure it is being collected. Now with continued money from the SOR grants, we can continue to provide care to people who have no way to pay for care.

Sometimes people get angry about public funding for MAT. They feel that since they must pay for the treatment of their own chronic disease, patients with opioid use disorder should, too. I can’t comment on the fairness aspect, but I do know that each dollar tax payers spend on MAT saves between $4 – $11 in tax expenses, most of which is saved on incarceration costs, medical costs, and the like.

Personally, I’m happy my tax dollars go towards such a great investment.

Tolerance and inclusivity at some 12-step meetings

I see a trend of tolerance and inclusivity in the recovery communities…at least in my area.

In 2018, a new Narcotics Anonymous group started here with the express purpose of welcoming people on medication-assisted treatment for opioid use disorder. Since I work with patients on medication-assisted treatment, this delighted me. Some of them want to go to 12-step meetings, either Alcoholics Anonymous or Narcotics Anonymous, but don’t feel welcome at the existing groups. Now they have a meeting where they won’t be judged for being on medication, if they chose to share that fact.

This meeting was started by a handful of long-term members of Narcotics Anonymous with more than fifty years of recovery between them. They intended to honor the traditional primary purpose of all 12-step groups: to carry the message of recovery to those people still suffering. The founders of the meeting felt tearing down barriers for people on MAT was the best way to adhere to that primary purpose. At this new meeting, such NA members are full members, with the right to speak at meetings, do service work, sponsor and be sponsored.

The meeting started in February, and attendance ranged from two people to fourteen people per meeting. It’s still in a fragile state, with only a few people coming to nearly every meeting, but it’s a good start.

Some NA members have attended who didn’t share the group’s stated position on the topic. They too were welcomed warmly and asked to return frequently. Attendees don’t have to agree with the group’s position on MAT, as long as they respect the group and its members. Again, emphasis is on inclusivity. Also, the “still suffering addict” isn’t always a newcomer. Sometimes it’s the person with the most time in recovery, so everyone needs to be welcomed.

This is my opinion: if 12-step groups don’t embrace people seeking recovery who are on medications, they will become less relevant. If they fail to reach people on MAT, they will have failed their stated primary purpose, from a lack of open-mindedness and willingness, two of the essential spiritual principles of 12-step meetings.

Breaking Down Silos

I’ve seen and participated in more cross-specialty discussions about MAT in 2018.

In the past, medication-assisted treatment took place at opioid treatment programs (OTPs) and no medical providers outside the OTPs knew what happened there. Some providers and owners of the OTP companies preferred it this way; a low profile might mean no protesters outside, shouting NIMBY (not in my backyard) slogans. They tried to keep everything hush-hush, so the community wouldn’t try to expel them.

Now, providers at OTPs and owners of OTPs are asked to participate in the recovery efforts of people with opioid use disorders. Slowly, as communities desperate for answers have turned to the scientific literature for how best to treat opioid use disorder, they’ve re-discovered the literature that’s been the foundation of MAT at OTPs for decades.

Last year, I was asked to speak to a variety of groups about what we do at opioid treatment programs. In May, I spoke to a conference of U.S. probation and parole officers. In September, I was on a panel of people who spoke at a conference for pharmacists. Also in September, I was invited to talk to our state’s medical board, to explain more about medication-assisted treatment.

All these events were interesting. Some were enjoyable, and one, with the medical board, was transcendent.

I was a little worried about talking to this group, who make up the “doctor police.” When patients complain about a doctor, the medical board investigates. When physicians are suspected of medical incompetence, the medical board investigates. Each physician must have a license issued by the state medical board to work in our profession. By the nature of what they do, medical boards hold a great deal of power.

I was worried about my presentation, mostly because I had about fifteen minutes to explain a few decades’ worth of science, and to dispel the common myths held by most medical professionals about “methadone clinics.”

But it could not have gone better. Board members were welcoming and friendly. I did my presentation, finished just a little over time, and asked for questions. I got great questions that showed they grasped the complexities of treating people with opioid use disorder who have other challenges as well, and how best to treat them without abandoning them.

Another presentation was scheduled right after me, but the meeting halted while nearly all of the board members, who had been seated behind a raised dais, came to me to shake my hand and thank me for coming and tell me how important this work was. I was blown away by their kindness and support, and their eagerness to understand opioid use disorder and appropriate treatment.

I left there glowing. I felt like they understood, like they got what I was saying. The drive from Raleigh to Wilkesboro went by in a happy blur.

More opioid treatment providers

We have more treatment facilities available to treat opioid use disorders Since 2014, around 254 new opioid treatment programs, formerly called methadone clinics, have opened, according to a recent article in the Washington Post. [1]

Prior to that, the number of opioid treatment programs remained unchanged.

We’ve seen a push to get more primary care providers interested in prescribing buprenorphine for their patients with opioid use disorder, rather than referring all of them to specialty programs. Project ECHO at UNC started a few years ago, doing outreach to providers, and support to them in any way needed.

UNC ECHO now has three online interactive sessions per week for buprenorphine prescribers. In those sessions, cases are presented and feedback and suggestions are obtained from other providers. There’s also usually a short teaching session provided by one of the experts, on topics ranging from treatment during pregnancy to payment issues in an office-based practice. Besides providing essential guidance, providers get free continuing medical education credits.

More providers of medication-assisted treatment should mean fewer deaths from overdose. Multiple studies show reduced death risk when patients are on MAT, with an average reduction of death by three-fold.

I’m optimistic about treatment opportunities for people with opioid use disorders. I see a gradual lessening of stigma towards people who have this disorder, as well as towards the life-saving treatments for the disorder. I hope we continue to make progress in 2019.

  1. https://www.washingtonpost.com/national/health-science/some-states-add-more-methadone-clinics-to-fight-opioid-epidemic/2018/11/09/8cace992-e133-11e8-b759-3d88a5ce9e19_story.html?noredirect=on&utm_term=.59a7b585e0aa

 

Holiday Guide for Families

 

 

 

The holidays are upon us. For many people in recovery and their families, this means family celebrations and interactions. Many of us feel stress about this. No matter how much we love our relatives, there can be misunderstandings and hurt feelings. To help families identify what could lead to problems, I composed this guide last year, and I decided to re-run it this year:

What to do:

Do invite your loved one in recovery to family functions, and treat her with the same respect you treat the rest of the family. If you have resentments from her past behavior, you can address this privately, not at the holiday dinner table. Perhaps given how holidays can magnify feelings, it’s best to keep things superficial and cheery. Chose another time if you have a grievance to air.

Allow your relative some privacy. If the person in recovery wishes to discuss her recovery with the entire family, she will. Let her be the one to bring it up, though. Asking things like, “Are you still on the wagon or have you gone back to shooting drugs?” probably will embarrass her and serve no useful function.

Accept her limitations graciously and without comment. Holidays can be trigger for drug use in some people, and your relative may want to go to a 12-step meeting during her visit. Other people in recovery may need some time by themselves, to pray, meditate, or call a recovering friend. Allow them to do this without making it a big deal.

Remember there are no black sheep. We are all gray sheep, since we all have our faults. In some families, one person, often the person with substance use disorder, gets unfairly designated as the black sheep. She gets blamed for every misfortune the family has experienced. Don’t slip into this pattern at holiday functions.

What not to do:

Don’t ask the recovering person if she’s relapsed. If you can’t tell, assume all is well with her recovery. If she looks intoxicated, you can express your concern privately, without involving everyone.

Don’t use drugs, including alcohol, around a recovering person unless you check with them first. Ask if drug or alcohol use may be a trigger, and if it is, abstain from use yourself. If you must use alcohol or other drugs, go to a separate part of the house or to another location.

Being around drugs including alcohol can be a bigger trigger during the first few years of recovery, but any recovering person can have times when they feel vulnerable, so check with them privately before you break open a bottle of wine.

If your family’s usual way of celebrating holidays is to get “ all liquored up,” then understand why a recovering relative may not wish to come to be with family at this time, and don’t take it personally.

For some of us, remaining in recovery is a life and death issue, so please accept we will do what we must to remain in recovery, even if that means making a holiday phone call rather than making a holiday visit.

If your recovering loved one is in medication-assisted treatment with methadone or buprenorphine, don’t feel like you have the right to make dosage recommendations. Don’t ask “When are you going to off of that medication (meaning methadone or buprenorphine)?Your loved one may taper off medication completely at some point, or he may not. Either way, that’s a medical decision best made by the patient and his doctor. Asking when a taper is planned is not your business..

Refrain from giving hilarious descriptions of your loved one’s past addictive behavior, saying, “But I’m only joking!” This can hurt her feelings, and keep her feeling stuck with an identity as a drug user. She can begin to believe that with her family, being an addict is a life sentence.

Remember your loved one is more than the disease from which they are recovering. Some people have diabetes and some people have substance use disorders. These diseases are only a small part of who they are.

I hope this helps.

May all my readers have a Merry Christmas and Happy Holidays!

Pharmacists and Insurance Companies

 

 

Over the past few years, pharmacists have become important allies to my patients in medication-assisted treatment. I’m thankful for that, since it makes my patients’ lives easily, and mine. But recently, there have been some minor bumps in the road, made more pronounced because of their decreasing frequency.

Sometimes, I get cranky.

I got a message from my office staff person that a pharmacy had called because I didn’t write any dosing instructions on a prescription I had just written. “Wow,” I thought, “I must be losing my mind.”

We copy all prescriptions, so I looked at our copy. It looked complete, except under instructions, I’d written 1 ½ SL. I had neglected to write “Qd” which means once daily.

My bad. I should have written it. How else would a pharmacist be able to guess what the instructions are…except I wrote for #45, a month’s worth. And the patient has filled prescriptions for 1 ½ SL qd for about three years now, all filled every month at this pharmacy. Nope, no way for the pharmacist to decipher this riddle.

Well, I can’t really blame them; it was my mistake.

Last night I got a call from a patient who was enraged because the pharmacy was refusing to fill his prescriptions. I know this patient very well, and though he’s been doing well in recovery for about ten years, he can get angry if he misunderstands things. I told him I would call the pharmacy to try to figure out the problem.

I see this patient every two months, and my last prescription was written with a refill. He filled the first prescription a few days after I saw him. When I finally got to speak to the pharmacy manager, he said they had ordered the medication for the patient, and he would be able to pick it up the next day.

OK, I said, but that’s actually five days late, due to the pharmacy not having the medication in stock. The pharmacist didn’t seem disturbed that his patient would have been out of a life-sustaining medication for five days, so I asked why it was that the medication couldn’t be ordered so that it would be in stock when the patient was due to pick it up.

The answer shocked me with its honesty. He said the pharmacy didn’t want to risk getting ‘stuck” with the medication if the patient decided to go somewhere else to fill it, and that “these patients” flew from one pharmacy to another all the time, in order to save one dollar.

What I should have said…was something along the lines of, “You’re an asshole who shouldn’t be in the helping professions. Do you do the same thing to diabetics on insulin?”

What I did say was…nothing. I was so stunned at the lack of compassion that I didn’t say anything. I’m disappointed in myself for this, since I’m usually a little spicier. His honesty took me completely by surprise, as did his naked disregard for the well-being on my patient.

Then there was the phone call last week from a pharmacist who wanted to make sure the patient hadn’t changed the prescription. Again, this was a patient in recovery for years, whom I see every two months. I wrote her prescription for Suboxone 8mg films, one per day, #30, and I printed out “ONE” under the line for refills, as I’ve done for the past four years.

The pharmacist wanted to know if I had written a zero and the patient falsified and wrote the “NE” after it.

I suppose that’s possible, but I except I print very clearly, and the “O” that the pharmacist thought could be a zero was way on the left side of the blank for number of refills.

This problem that will go away after electronic prescribing, mandated by the state of North Carolina, is in place. I’ve stuck with old-school paper records and hand-written prescriptions for as long as I can, but that will be a thing of the past by January 1, 2020.

I’ve saved the most insane for last.

A local pharmacy called, stating that my one-month written prescription for a patient for suboxone films was partly voided because of the insurance company’s decision.

Huh? How does this happen, I wondered.

I’m still not sure, but here’s what I was told that the pharmacist was told by the insurance company representative.

The visit prior to this one, I had written only a two-week prescription. I don’t recall what was going on, but I needed to keep a closer eye on the patient, and changed from my usually monthly prescription.

Apparently, this was the root of the problem. I wrote for #45, a 2-week prescription. Then at this last next visit, two weeks later, I decided the patient could go back to monthly visits and wrote for #90. This caused a red flag on the patient, because he had now was trying to fill #135 films within a thirty-day period. Yeah…except for the patient already took the forty-five films during a two week period that was already past.

I can’t make this stuff up.

So his insurance company said nope, you can only get #45, which will make only #90 in a thirty-day period. And the pharmacy “cancels” the rest of my ninety day prescription.

Insurance companies would make the Buddha want to bitch slap someone.

I told the staff member who took the call, “Please get the insurance company’s physician reviewer on the phone. I’ve got to hear this logic. I also need to speak to the pharmacist. I want to know exactly who thought they had the right to cancel a prescription, written by a physician, for no medical reason.”

I was riled, and kind of looking forward to what could be a very interesting conversation. But it was not to be. When my staff called the pharmacy, this situation mysteriously resolved itself. No problem now. Patient can come by to get the other #45 films, and insurance won’t give him a hard time when he comes next month with a month’s prescriptions.

Despite these experiences, most pharmacists know how important buprenorphine products are to the recovering person, and are positive and supportive of my patients on medication-assisted treatment. There are far more of these than the pharmacists who have biases against patients on MAT. It’s just that the troublesome ones stand out by their behavior.

I am a peaceful person. I intensely dislike confrontation and can get along with almost anyone. But there are times, large and small, when I have to get out of my comfort zone and make some noise.

 

Suboxone Patient Wins Lawsuit

 

 

 

 

In Maine, as in most other states in the U.S., patients on medication-assisted treatment for opioid use disorder weren’t allowed to take their life-saving medications while incarcerated.

All that changed in October of this year, when the American Civil Liberties Union settled a lawsuit with the Maine Department of Corrections. The ACLU sued on behalf of Zach Smith, who has been on Suboxone for five years as treatment for opioid use disorder. He was told he would have to stop taking Suboxone during his incarceration. I wrote of the pending case in my blog on August 12, 2018.

We know that if denied his medication, he would go through physical opioid withdrawal and would be at higher risk for overdose death, particularly immediately after release from incarceration.

The ACLU took his case and settled a lawsuit with the Maine Department of Corrections, which ultimately agreed to allow him to continue on his medication. Jailers warn that this was a “special case” and that they would not necessarily allow other prisoners to take buprenorphine as prescribed by a physician. However, this appears to be a clear precedent for other patients and other lawsuits.

I think this is a landmark case for our patients. MAT is the standard of care, and it should be illegal to refuse to provide this treatment to people who are sentenced to incarceration. The diversion of Suboxone films has been an issue for many years because patients in opioid withdrawal can’t access suboxone through any legal channel. This creates a black market for suboxone, and jailers across the country have complained loudly about this situation – that is of their own creation.

The ACLU is supporting patients in their fight to continue medication-assisted treatments during incarceration is other states, too. According to the ACLU website, a similar case is pending in Washington state.

If you are a patient – or know a patient – who is being denied medication-assisted treatment during incarceration, I hope you have a lawyer who is willing for fight for your rights. If you do not, consider reaching out to the ACLU in your state:

For North Carolina: https://www.acluofnorthcarolina.org/

 

Book Review: “Dopesick: Dealers, Doctors, and the Drug Company that Addicted America,” by Beth Macy

Dopesick, by Beth Macy

This well-written book has it all: compact information about how the opioid epidemic started, how our nation failed to act early to mitigate the damage of the epidemic, and how the epidemic shifted into our present predicament. The author did a great deal of research and talked to experts with vital information, but she humanized this data with personal stories about people affected by the opioid epidemic. She told this story not only from the view of the person with opioid use disorder, but also illustrated the grief of families who lost loved ones. The prolonged grief of families who have lost loved ones to opioid overdose deaths is rarely examined as well as it is in this book.

This is a book that will be staying on my shelf for a re-read.

The author is a journalist who works for the Roanoke Times newspaper, so this book focuses mostly on events in the western part of Virginia.

Avid readers on this topic will recall the book “Painkiller,” by Barry Meier, who also covered rural Western Virginia. Ms. Macy’s book picks up where Mr. Meier’s left off. They talk about many of the same communities and the same treatment providers, fifteen years later.

Mr. Meier’s book, published in 2003, could have been an early warning to the U.S. healthcare system. Unfortunately, the book wasn’t widely read, so few people took any note of what was going on, other than those of us already working in the field. I understand Mr. Meier wrote a second edition of “Painkiller” this year, and I plan to read and review it.

The most remarkable theme of Ms. Macy’s book is how the opioid use disorder epidemic grew worse over the past fifteen years. After physicians finally stopped prescribing so many opioid pain pills, these pills were less available on the black market. Many people with opioid use disorder switched to cheap and potent heroin.

In Ms. Macy’s book, she tells the experience of a rural physician, Dr. Art Van Zee, who was also interviewed for Barry Meier’s book. He was one of the brave people who stood up at conferences and raised the question about the ethics of Purdue Pharma, manufacturer of OxyContin, when it wasn’t easy to question anything about that drug company. He’s the first physician I can recall who actively sought answers about his perceived over-prescribing and mis-marketing of OxyContin.

This isn’t in the book: I remember Dr. Van Zee at an Addiction Medicine conference called “Pain and Addiction: Common Threads,” that I attended in 2003 o4 2004. I bought the recordings of the conference, because I was so excited to learn more about Addiction Medicine. I remember a recorded session where Dr. Van Zee asked a question after a lecture, asking – as I remember it many years later – why Purdue Pharma was still peddling their OxyContin as a relatively harmless opioid for chronic pain, while he was seeing patients with lives destroyed by this drug.

It was one of those moments where all you hear are crickets. His question wasn’t answered, but rather he was reprimanded by the speaker. He was cautioned to remember our conferences were sponsored in part by Purdue money, and that appropriate prescribing of OxyContin was a huge benefit to patients. He was told it wasn’t the drug, it was the prescribing that needed to be fixed.

Fast forward to 2007. As described in “Dopesick,” Purdue Pharma pled guilty to fraudulent marketing of OxyContin, which was a felony misbranding charge. Purdue paid $600 million in fines. Its top three executives pled guilty to misdemeanor versions of the same crime, and ordered to pay a total of $34.5 million.

So yes, inappropriate prescribing was a big part of the problem, but Purdue deliberately misinformed physicians about potential dangers of the drug, which contributed to inappropriate prescribing. From a 2018 perspective, that speaker’s answer to Dr. Van Zee seems disingenuous at best.

Dr. Van Zee’s perceptions, based on his clinical experiences, were correct. Around that same time, I was seeing the same thing in rural Western North Carolina. I remember having twenty to thirty new patients show up on admission day, all of them were using OxyContin, almost exclusively. This drug was easy to crush to snort and inject, and Purdue knew it.

Purdue Pharma testified before congress in 2003 that they were nearly ready to release a new formulation of their OxyContin pill that was more abuse resistant. As it turns out, that new formulation wasn’t released until 2010. With that change, people with opioid use disorder changed to other opioids, easier to misuse, such as Roxicodone and Opana. Eventually Opana underwent reformulation to a less abused form.

But I digress; back to the book. The author’s first few chapters summarize the history of opioid use disorder and the factors that lead up to the release and promotion of OxyContin. It related how this drug crept into the social fabric of Southwestern Virginia, and how early attempts to sound an alarm about its abuse were met with contempt from drug company representatives.

Chapter Three tells of the “unwinnable” case brought against Purdue Pharma by Virginia attorney general John Brownlee. He went up against the famous Rudy Giuliani, who was one of the lawyers who represented the drug company, and successfully negotiated the eleventh-largest fine against a pharmaceutical company. This chapter contrasts this legal victory with the devastating grief of parents who lost their children to overdose death with OxyContin. The book describes the creation of the “OxyKills.com” message board, which became a sort of a database for overdose deaths. The chapter after that contains depressing descriptions of how Purdue Pharma’s corporation executives and the owners, the Sackler family, distanced themselves from the profound harm caused by their medication and criminal mis- marketing.

The next several chapters contain the tragic stories of people who became addicted to opioids, and their journeys through the criminal justice system, the addiction treatment system, and the pain their families felt, every step of the way. The author illustrates the ridiculousness of our patchwork system of care for people with opioid use disorder, and how ineffective treatments are often pushed as first-line options.

Then the book details efforts to pursue the heroin ring that sprang up in Virginia, and how the ringleader, a man named Ronnie Jones, was eventually arrested, charged and convicted of trafficking heroin from Baltimore to the Roanoke suburbs. Many of Jones’ drug runners were addicted young adults, many female, from Roanoke’s suburbs. Families were shocked when they found out their children were involved with the drug trade. Heroin used to be an inner-city drug, but times have changed. Heroin is now plentiful in suburban and rural areas, as this book illustrates repeatedly.

I was most interested in the author’s description of available treatments. Usually I dread reading writers’ summaries of treatment for opioid use disorder. If they describe medication-assisted treatment at all, it’s often couched in negative terms. However, this author did her homework.

She describes the accurate reasons why medication-assisted treatment with buprenorphine and methadone is the gold standard of treatment, and even writes about some of the success stories. However, she also writes about the more common public perception of buprenorphine: “shoddy” prescribers located in strip malls who don’t mandate counseling or do drug testing patients. She writes about the poor opinion of Virginia law enforcement officials, who criticize doctors for not weaning people off the drug, and for allowing patients to inject the drug & sell it on the street.

However, it’s clear the author was able to grasp harm reduction principles, and latest research findings, since she said (on page 219) the unyielding opposition to MAT was the single biggest barrier to reducing overdose deaths.

I felt gratified to read this in print. I underlined it.

She also pointed out how some states’ refusal to expand Medicaid when given the opportunity kept many people with opioid use disorder from being able to access treatment. That’s more perceptive than I expect from a writer who isn’t trained in public health or substance use disorder treatment.

But my favorite part of the book was on page 221, where an addiction counselor named Anne Giles said of the opioid overdose death epidemic: “We should be sending helicopters!”

I underlined this too.

She pointed out that if the same number of people dying from opioid overdoses were dying of Ebola, the government would be sending helicopters of medical help to rescue people and contain the epidemic, and she’s right. We ought to be sending helicopters….helicopters loaded with emergency medical personnel and treatment medication. (By the way, per most recent data from NIDA, over 49,000 people in the U.S. died from opioid overdose in 2017. That’s one-hundred and thirty-four people per day. If they were dying from Ebola…helicopters for sure.)

So I heartily recommend this book to anyone interested in this topic. Even if you aren’t interested, it’s so well-written that it will entertain you. I particularly appreciate the author’s talent at describing so many facets of this opioid epidemic and the obvious scope of her research.