Dopesick - Beth Macy Page 0,88

courts that cut off access to it.

The following spring, President Trump’s Health and Human Services Secretary Tom Price would release the first half of the $1 billion appropriated by Congress in the 21st Century Cures Act for treatment and prevention, including expanded access to MAT. But a month later, Price disappointed treatment advocates by publicly dismissing MAT as “substituting one opioid for another.” A Tennessee public health official told me Price changed his stance on MAT after NIDA director Nora Volkow showed him the scientific facts: “She worked on him in a hurry.” Price resigned a few months later amid a scandal over taxpayer-funded charter flights. In February of 2018, Price’s successor, Alex M. Azar II, signaled the administration would significantly expand access to MAT.

Drug courts remain among the country’s models for preventing recidivism and relapse, with intensive daily monitoring of participants—randomly, at all hours of the day and night—and swift consequences, such as being thrown in jail when they fail a drug test or commit another crime. Most of the country’s three thousand drug courts drop the charges when offenders complete the twelve- to eighteen-month program. Graduates are roughly a half to a third less likely to return to crime or drugs than regular probationers. Drug courts remain, then, an almost singular place where prosecutors, defense attorneys, judges, and mental health advocates gather around a table to coordinate care and punishment, and discuss the daily challenges of the addicted.

The success rate is so good in opioid-ravaged Russell County that Judge Michael Moore told me strangers approach him at the Food City, begging him to place their addicted children in his drug court, even when they haven’t been arrested for anything.

But in a place where illegal diversion of Suboxone dominates the court dockets as well as the landscape—I saw a billboard along I-81 for bristol’s best suboxone doctor: most patients are in and out in 30 minutes; call to get on the road to recovery!—only a handful of Virginia’s rural drug-court judges permitted participants to be on MAT. “We’ve had thirteen babies born to mothers on MAT, and not one of those babies had NAS,” Tazewell County judge Jack Hurley told me.

“So tell me: How do you put a price tag on that?”

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“The best research says counseling doesn’t help: ‘Just give ’em the pill. Give ’em the fucking pill,’” said a local addiction counselor, Anne Giles, who was furious about cultural biases against MAT. According to an analysis of international studies published in the Lancet, the best treatment for opioid addiction combines MAT with psychosocial support, “although some benefit is seen even with low dose and minimum support.”

Giles firmly believes that “courts should not be practicing medicine,” and yet, amid growing national consensus about MAT’s benefits, criminal justice too often trumps science, she fumed. People buying illicit Suboxone were self-medicating because federal regulators didn’t permit enough physicians to prescribe it, in her view, and privately operated clinics accepted only cash because Medicaid reimbursements were delayed and covered only a sliver of the costs.

“We should let doctors be doctors,” Giles said. “Because this crisis is a lot like Ebola, where we sent helicopters.” Given opioid-related spikes in deaths, HIV, and hepatitis C, she added, “we should be sending helicopters!”

Fury about the fundamental skepticism toward MAT is not restricted to the medical community. Don Flattery, a member of the Virginia Governor’s Task Force on Prescription Drug and Heroin Abuse, compared anti-MAT judges and police officers to climate-change deniers. He’d lost his twenty-six-year-old son, Kevin, to an opioid overdose and tortured himself for not insisting that Kevin stick with MAT. His son had been on Suboxone before but abandoned it prematurely, after feeling stigmatized for it, in favor of abstinence-only treatment, Flattery said.

Art Van Zee, too, struggled with law enforcement complaints about buprenorphine, though he conceded that too many Suboxone providers in rural America had lax practices that spawned diversion and abuse. To fix the problem, public policy makers should, in Van Zee’s opinion, incentivize more doctors to go into addiction medicine, and MAT should be predominantly expanded in the nonprofit realm of health departments, community service boards, and federally qualified health centers, where salaried doctors are less motivated to overprescribe.

“I think taking an opioid-addicted person and expecting them to do well in drug court [without Suboxone] is almost cruel and unusual punishment,” Van Zee said. “In the legal sphere, all the police and judges see is the worst, ugly part—the trafficking, the kids put into foster care because the mother’s found injecting