Dopesick - Beth Macy Page 0,116

Adam Smith creeping around America’s suburbs, cities, and small towns, proffering stamped bags of dope. The economist had assumed the free-market economy would operate efficiently as long as everyone was able to work for his or her own self-interest, but he had not foreseen the elevation of rent-seeking behavior: the outsized greed of pharmaceutical companies and factory-closing CEOs, and the creation of a class of people who were unable to work.

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In 2017, two decades after OxyContin erupted in Lee County, Virginia’s Board of Medicine ordered that, to prevent doctor-shopping, all doctors were to check the drug-monitoring system every time they issued a prescription. This mandate arrived at the same time new CDC figures showed that residents of two rural Virginia towns had been prescribed more opioids per person than any other place in the country. (The top locality was Martinsville, and the fourth was Galax, the small cities where my book Factory Man was largely set.)

As far behind as Virginia had been in its initial response, state health-department officials were now working hard to expand MAT as well as to crack down on its abuse. The expansion was mostly modeled after a Suboxone clinic in rural Lebanon, called Highpower, where a younger version of Art Van Zee, Dr. Hughes Melton, set up practice in 2000 because he wanted to treat the underserved. Melton was helping direct the state’s response to the opioid crisis; among his initiatives was a new statewide push for syringe exchange and some tighter controls on MAT prescribing. His wife, Sarah Melton, a pharmacy professor and naloxone trainer, hadn’t just given training sessions to more than four thousand doctors about the perils of opioids; she’d turned in a fair number for overprescribing them, too.

The Meltons were so busy that often the only times I could interview them were at night or when they were in their cars. It was in their Highpower clinic that several patients had first explained the diversion and abuse of buprenorphine to me—a practice harm-reduction proponents elsewhere in the country dismissed every time I brought it up.

Finding a balance between treating and perpetuating addiction had been pursued in the United States since the 1800s, when doctors used morphine to wean patients from laudanum, then later used heroin to get patients off morphine. Soldier’s disease had sparked a period of stern prohibition in the Harrison Act and, eventually, the War on Drugs. “Our wacky culture can’t seem to do anything in a nuanced way,” explained Dr. Marc Fishman, a Johns Hopkins researcher and MAT provider.

While Fishman believed buprenorphine, methadone, and naltrexone were all imperfect solutions, they remain, scientifically speaking, the best death-prevention tools in the box. “I apologize for my white-coated, nerdy scientist colleagues who have not invented better yet, I get it!” he said. The naysayers would be more open to MAT if its proponents would more openly acknowledge the drawbacks of maintenance drugs—significant relapse rates when patients stop treatment, for instance—instead of portraying them as a kind of perfect chemical fix, Fishman argued.

The explosive costs of addiction-related illness will eventually force health systems to integrate addiction treatment into general health care, he predicted, including a smoother transition of overdose patients from hospital ERs to outpatient MAT. “Too often, we’re still giving them Narcan, then sending them along with a tired old Xerox of AA meeting phone numbers, and telling them, ‘Have a nice life.’”

In a treatment landscape long dominated by twelve-step philosophy, only a slim minority of opioid addicts achieve long-term sobriety without the help of MAT, Fishman reminded me. “AA is not a scalable solution in an epidemic like this, and most opioid addicts just can’t do it” without MAT, he said.

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In the Appalachian Bible Belt, a blend of MAT and twelve-step programs seemed to work best, which is why Art Van Zee and Sister Beth Davies still communicate daily about their patients, the nun letting the doctor know, for instance, when a shared patient suffers a personal setback, like a death in the family or a job loss. It had happened in the spring of 2017 with one of their longtime patients, Susan (not her real name), whose brother died of overdose. Then, a few months later, Sister Beth emailed me that it had happened again: Another of Susan’s brothers died of overdose, the youngest, whom she’d “practically raised. The loss is tremendous.”

Among Susan’s ten siblings, only three had managed not to become opioid-addicted, although one of the three was a pill dealer who didn’t himself use, Susan had told