Beth Macy, author of New York Times-bestselling book Dopesick and executive producer and writer on the Hulu series “Dopesick,” explains how FDA-approved drugs that treat opioid use disorder still aren’t getting into the hands of patients who need it most.
The United States has lost a million people to drug overdose since oxycodone HCl (OxyContin; Purdue Pharma) became available in 1996, explained Beth Macy, author of New York Times-bestselling book Dopesick: Dealers, Doctors, and the Drug Company That Addicted America (2018) and executive producer and writer on the Hulu limited television series “Dopesick,” which is based on the aforementioned book.
“And we know that's an undercount, because that number doesn't account for people who died of end stage endocarditis, hepatitis C, and HIV,” Macy said.
During the keynote session at the American Society of Consultant Pharmacists conference, Macy explained she first started writing about the opioid epidemic as a newspaper reporter in Roanoke, Virginia. She had observed in her community that the opioid crisis was festering and growing due to long-standing fissures present in American society.
“We still don’t have universal health [care], and in the rural communities where I reported from, the jobs had gone away due to globalization, and the government did nothing for the people who were left behind. At the same time, Purdue introduces its drug and changes the way we treat pain,” Macy said.
Opioid addiction grew due to the availability of oxycodone HCl, oftentimes with the original source of that addiction starting with a prescription for pain or for other health care-related issues. To manage this crisis, the country turned to the prison system as its primary solution, Macy explained.
“We were just using the tool of putting people in jail rather than treating them as folks with a treatable medical condition,” Macy said. “Today, a third of our nation’s families have been affected [by opioid use disorder (OUD)].”
Macy explained that over the past year, there has been a treatment gap of 87% for people with OUD, despite there being an evidence-based treatment available for these individuals. With only 13% of patients with OUD receiving this evidence-based treatment, Macy noted that something isn’t working in our current approach.
“If we got a 13% in school, we would be kicked out. We are failing. What we're doing now with regard to this just simply isn't working,” Macy said. “I visited the White House a couple weeks ago, and the Drug Czar [explained] only 5% of folks are on [medicines for OUD (MOUD)].”
Years of data and every governing body in the country has reported that buprenorphine, buprenorphine and naloxone (Suboxone; Indivior PLC), or methadone are the gold standard of care treatments for OUD, according to Macy; however, 95% of folks with OUD haven't had access to MOUD.
“We all know parents who have had to remortgage their houses to send their kid to an out-of-state treatment facility, spending $30,000 or $50,000 a month—and it doesn't work,” Macy said. “That's because most rehabs don't offer these medicines.”
Further, research has shown that every dollar spent on making MOUD available to patients with OUD can save $12 or more on reduced criminal justice costs and health care costs, Macy explained. This has become more important now more than ever to recognize because there is opioid settlement money coming into communities that were a part of that suit, most of which don’t know what to do with this money to address the underlying issue, according to Macy.
“My fear, and a lot of folks’ fear, is that this [money] will go the way of the tobacco settlement money, which remains the largest settlement in American history. Only 3% of that $200 billion dollar [tobacco] settlement even went to what it was supposed to go for, which was helping with prevention and treatment of cigarette use,” she said.
Macy noted that one of the victims of the opioid epidemic who she got to know the best as she was reporting on the epidemic in Roanoke, Virginia, was a woman named Tess Henry.
“She was a young woman when I first met her, and she had this little boy named Ronin—he’s about 7 now,” Macy said. “But Tess Henry is kind of the prototypical person with OUD. I met her when she had been 5 years into it. Her dad is a hospital surgeon; mom is a hospital nurse—they had a vacation home growing up. [She] should have had every way to get better—[she had] all the money that she needed [and] all the resources. Yet when I met her, she was continually running into barriers. She was sometimes living homeless on the streets doing sex work in order to buy her heroin so as not to be dopesick.”
Macy explained further that Tess’s introduction to opioids was from an urgent care center, where she was prescribed two 30-day opioids for a case of bronchitis—hydrocodone for sore throat pain and oxycodone (Percocet; Endo Pharmaceuticals) for her cough. At the end of her 30-day prescription, Tess told Macy that she quickly realized she had become addicted.
“One thing led to another, and she's doing sex work in the streets of Roanoke, Virginia,” Macy said. “She had a couple rehab attempts, and her grandfather finally sends her out to an abstinence-only rehab in Las Vegas. When she bombs out of that because she can't get medicines for her cravings, she's homeless on the streets of Las Vegas, which is a lot different.”
One evening as they were waiting to hear news of Tess from the facility, they got a call from Nevada.
“I had been reporting her story for the entire time that I worked on Dopesick. I had even originally written the ending of her mother sleeping with a phone waiting to hear that Tess is going to be able to make it home. Instead I got a call saying that Tess had been murdered on Christmas Eve. Her body found in a dumpster. Her mother Pat is now raising Tess’s son,” Macy said.
Macy explained that still today, the spirit of Tess hovers over all of her work covering the opioid epidemic.
“When she told me how she had been originally prescribed, and how that had led to her being addicted, she said, ‘Well, what we need is urgent care for the addicted,’” Macy said. “She didn't know what that meant. It's not like she thought she would just go to the CVS urgent care and get it—although that's not really a bad idea—she just knew that whenever she wanted to get on these life-saving medications, there was a waitlist, or there was only somebody that accepted cash and it costs $500 in the first visit, and $100 a week after that.”
Macy noted that Tess’s experience trying to get FDA-approved MOUDs was common, although things improved after Virginia passed the Medicaid expansion; however, by this time, it was too late for Tess.
“Two months in [to one rehab program], she was actually doing well at one point,” Macy said. “They drug tested her and when she showed up positive for marijuana, instead of increasing her treatment and increasing our counseling, they kicked her out.”
According to Macy, urgent care for the addicted has to start with getting patients with OUD access to MOUDs. However, many health care professionals working in the field of treating patients with OUD have yet to adopt this model into their practice, despite the years of data showing its efficacy.
Macy explained that in 2017, she had spoken with the head of an emergency department (ED) at a hospital in Virginia and asked him why they don't offer buprenorphine to patients with OUD in ED. The ED head Berkman told Macy, ‘Well, that's just treating a drug addiction with another drug.’
However, when she spoke to Berkman in 2019, he explained that he had gotten all his ED physicians waivers to prescribe buprenorphine.
“’And it's going great,’ and you can hear the tone in his voice change,” Macy said. “Previously, he was so hopeless about it. I said, ‘Well, what happened?’ He said, ‘Well, we read your book. And then we looked at the data.’”
Macy B. Opening General Session: Dopesick: America’s Epidemic. Presented at: American Society of Consultant Pharmacists (ASCP) 2022 Annual Meeting in San Antonio, TX; November 4, 2022.