Why Is This Happening? On the frontlines of opioid addiction with Beth Macy: podcast and transcript

Chris Hayes speaks with journalist and author Beth Macy about the path of devastation wrought by opioids.
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By Why Is This Happening?

This is an intimate portrait of what addiction looks like in America. From the board rooms of pharmaceutical companies to the living rooms across America, Beth Macy traces the path of devastation wrought by opioids.

Her latest book, “Dopesick” gives life to the urgency of the epidemic, illustrating just how woefully insufficient the national response has been to the scale of the crisis. She lays out the often-insurmountable barriers that stand between someone suffering and the treatment they need, and why stigma may be the biggest obstacle of them all.

CHRIS HAYES: The story here is really... the most cartoonish version also seems not that far from being the accurate one, which is big, pharmaceutical interests essentially corruptly rigged a system to jack up their profits by essentially distributing poison across America, leading to hundreds of thousands of people's deaths.

BETH MACY: Yep, that's what happened. And when faced with evidence that they were underplaying the risks and overselling the efficacy, they just doubled down on their marketing.

CHRIS HAYES: Hello, and welcome to “Why Is This Happening?” with me, your host, Chris Hayes. Well, I'm going to start off today with some good news, which I don't think I do enough. People sometimes tell me about the podcast like, "I love it, but it's kind of dark and heavy," and I'm like, "Is it?" I don't know. Doesn't feel that way to me, but it is, of course. I'm drawn to the darkness. What can I say?

Some good news, which is that for the first time in four years, U.S. life expectancy rose, we think, it looks like, in I think 2018 is the data, so there's a bit of lag. It rose very, very marginally and it comes at the end of this period that we've discussed on the show of declining life expectancy in a developed, first world democracy that is not at war and not in the midst of an epidemic like AIDS. It makes no sense. It just shouldn't be happening. It's a real warning sign in a society where you see life expectancy go down. And one of the biggest drivers, not solely, but the big driver's what's called deaths of despair, which is people drinking themselves to death, suicide, and opioid overdoses. And opioid overdoses declined by enough to kind of increase life expectancy by a month. So that's a very small, marginal change, but it's good news and it suggests that at the local level, people have been putting policies into place that stop people from overdosing.

There's a drug called Naloxone which can save lives, it can interrupt an overdose, and more and more police departments have been carrying it around, more and more public health officials have been training first responders how to have it. So there's some very easy things you can do with at the point of contact to reduce deaths. The problem, of course, is that the epidemic itself continues to churn on with just tremendous carnage, both in the number of lives lost, the number of lives and families disrupted, places that have been destroyed and laid low.

The other bit of news, which is less good news, is the Trump administration will occasionally tout its opioid response. I even heard it from one of the president's impeachment lawyers during one of his long spiels about why people want to keep President Trump in office. But, as you'll hear in this episode, the scale of the response is just completely insufficient to the scale of the problem. And if you want to see how seriously they take the opioid crisis, the HHS had declared a health emergency about opioids and had to renew that emergency and just forgot to do it, just looked the other way. And it lapsed for about a week until reporters started asking, and they're like, "Oh, no, no we renewed it." That's how frowned upon, that's how focused this administration is on this.

I've been wanting to do something about the opioid crisis for a while. I've done a lot of reading on it, I've talked to some folks. We did do a special episode with Patrick Radden Keefe who wrote a great article for The New Yorker about the Sacklers, which is the company that owns Purdue Pharma that makes OxyContin and recently entered into a bunch of big settlements because they were sued for hundreds of millions of dollars for their role in pushing opioids. The stories, and you'll hear some of this in the discussion of how opioids got pushed into Americans, are outrageous and insane.

So I want to dig even deeper than that and one book that people kept recommending to me is a book called “Dopesick: Dealers, Doctors, and the Drug Company that Addicted America.” It's by a reporter named Beth Macy who is a newspaper reporter in Roanoke, Virginia who just started... it's a testament to how incredibly important local newspapers are as they're getting destroyed. Who just started reporting on what she was seeing in her community. She just as a newspaper reporter started doing reporting on opioids and that grew into this really incredible piece of work. Deeply profound and empathetic, and really a story incredibly and poignantly told called “Dopesick,” her book. And so I'd been wanting to get Beth Macy on the podcast to talk about the scope of this crisis and particularly where we are now and what needs to be done.

CHRIS HAYES: Maybe we can just sort of talk right now as I talk to you at the beginning of 2020 where things stand with this public health crisis.

BETH MACY: Yeah, so we've lost 400,000 Americans to this drug overdose crisis. And we're still in a situation where most people don't have access to what science says is the best treatment, which is medication assisted treatment for opioid use disorder with counseling and social supports. Got a lot of people struggling with this who are homeless, they're estranged from their families because of behavior caused by their addiction. And we need what one of my interviewees told me a couple years ago, we need urgent care for the addicted.

CHRIS HAYES: What does that look like?

BETH MACY: Well, you're starting to see it come together in various localities. Even here in Roanoke, where I live, when I was putting the finishing touches on the book in 2017, I had interviewed the head of the ER and he said, "Well, we don't believe in MAT. That's not our job." And so what I was seeing was people like young Tess Henry, who was the woman who made that quote about the urgent care for the addicted, she would come in. She would overdose, get Narcan, be sent out, never be treated for her opioid use disorder. And when she made that comment, I didn't really think much of it other than the fact that she had initially been addicted because of being over-prescribed at an urgent care. But what I came to see is what she was saying was, "Hey, I'm a person too. I was addicted initially through no fault of my own, through bad marketing practices, and why isn't the medical system treating me like a person with a disease? And I'm only being treated in a criminal justice venue like a criminal or a moral failure."

And so what it's starting to look now is the ED where I live here is now doing buprenorphine initiation in the ER. There are some communities, and I've been speaking all across the country about the book and doing a little bit of reporting as I do that and I'm starting to hear some really heartening stories about people that are diverting folks from criminal justice and into really good treatment instead.

CHRIS HAYES: When you say MAT and buprenorphine, is there a kind of gold standard model, evidence based for treatment that we know works fairly reliably?

BETH MACY: Absolutely. And that's the MAT I'm talking about.

CHRIS HAYES: Can you take me through that?

BETH MACY: Sure, absolutely. They're weaker opioids. They are opioids but they're used... Methadone is one that grew out of after the Vietnam War when soldiers came back addicted to heroin. Many did. That's been around for a long time and that's given through very regulated, federally regulated clinics that folks have to visit almost every day to get their dosage. And Suboxone, or buprenorphine, is a drug that's more recent and that's generally given in an out patient setting in a doctor's office, so it's a little bit easier. You start off coming a week and then every two weeks once you prove that you're taking it correctly.

BETH MACY: The big problem is there's still a huge stigma that says if you're taking one of these life saving medications, you're treating a drug with another drug. And I saw people over and over in my book die because of that outdated, unscientific attitude.

CHRIS HAYES: I've heard that myself and I know I can almost feel that impulse in myself. Really, is this really helping someone? Why is that not the right impulse to have?

BETH MACY: Right, and you're like, "And then the pharmaceutical companies are making it, which makes it even worse."

CHRIS HAYES: Just the history here, which some of which you talk about in the book is that there's actually a history here with opioids in which different kinds of new opioids have been introduced essentially as kind of superior to the previous generation of opioids-

BETH MACY: Exactly.

CHRIS HAYES: ... Precisely because the previous generation was too addicted. And then it was like, oh, here's opium. If I'm not mistaken, heroin starts as essentially-

BETH MACY: Right, as a cure for morphinism.

CHRIS HAYES: Yes! So people are addicted to the opium and then heroin's created as a synthetic to be... Or not a synthetic, it's derived from poppies too, I think. But it's created as an opioid to say, "Oh, people are addicted to opium, have heroin." There is a bit of a history that would lead people to think that it's a weird kind of shell game, right?

BETH MACY: Right, and I hear you on that, but the science is so absolutely clear that if you're taking buprenorphine, chances are 60 percent or better that you're going to get better. And if you're doing abstinence only, the numbers are 8 percent. So if it was my kid, I'd want him to have the buprenorphine.

CHRIS HAYES: And part of the issue, too, as I understand it... And Jason Cherkis wrote this incredible series of pieces for the Huffington Post about just how unregulated treatment is and how much abstinence only, the sort of 12 step method, how much that is what is available, my understanding, to most people in very under regulated clinics and treatment centers often launched by recovering addicts themselves with the absolute best of intentions, but not particularly evidence based.

BETH MACY: Absolutely. He had an amazing piece in '15 that led to some laws being changed in Kentucky where many drug court judges weren't allowing it. And honestly, you still have drug court judges in America, many of them not allowing it, particularly in rural areas, but you're starting to see a shift in that as well.

CHRIS HAYES: It seems to me like the big issue that we still have is that there's a mismatch between the supply of evidence based treatment available to people and the demand for it. Is that fair to say?

BETH MACY: Yeah, absolutely.

CHRIS HAYES: And what's the logjam there? Is that stigma, is that political, or is that a funding question?

BETH MACY: I'd say all of the above, but you could put all of those items right underneath the category of stigma. The funding doesn't come around because we don't see drug users as people worthy of medical care. There's so many barriers to people like Tess, the young woman that I mentioned just being Narcaned and turned away to the streets. Jails and prisons not allowing buprenorphine and so when folks come out who have substance use disorder, they'll go back to their regular dosage because they're going to be dope sick if they don't. And then they'll get heroin with fentanyl in it or carfentanil. So you see a lot of people dying because they're not getting treatment in jails and prisons. And that's starting to change in a few places, but it's still few and far between.

CHRIS HAYES: Yeah, there's something kind of maddening about this when you talk about the scope, 400,000, it seems like there's such an obvious and pressing public policy issue here which is essentially funding at scale enough treatment to deal with the scope of the problem. What I'm hearing from you is that that is just not being done right now, even years into this.

BETH MACY: Right. Exactly, it's not being done. And when I first started writing the book, I wrote the proposal in 2015. They were saying the opioid epidemic was going to plateau in 2018. I actually put it in my proposal. I was like, good timing. And then by the time the book came out, I was wrapping that up, they were saying some time after 2020 it was going to plateau. And now the best minds are saying some time after 2025.

CHRIS HAYES: What does plateau mean? Is that deaths or is that addiction? What is that? What's the metric?

BETH MACY: Yeah, overdose. Overdose deaths, yes. And you are starting to see some communities have fewer opioid overdose deaths. And a lot of public health folks are wrestling with why that is. I was in rural Kentucky and somebody said just flat out, "That's because everybody's died already." Other folks think it's because meth is making a big resurgence. You're less likely to die if you're taking methamphetamine. Of course you know it's terrible for your body and there isn't an MAT for meth. They're working on that, but you've got a lot of people who when they do overdose and they do the autopsies, almost everybody has multiple substances in their bodies, and meth is on the increase, unfortunately.

CHRIS HAYES: All right, so that's sort of where things stand. I just through we'd sort of start with that snapshot because I think that part of the story people have heard in bits and pieces, and your book is an incredible exploration of it. How did you first get interested in the topic, start reporting on it?

BETH MACY: Yeah, I was a regional newspaper reporter here in Roanoke, Virginia. My beat was families. I wrote a lot about marginalized communities, refugees, immigrants, veterans with PTSD and things like that. But the story on everybody's mind back in 2010, it was right when heroin first landed in the very wealthy suburbs in Roanoke. And there was this nascent sell of users that got outed when one of them overdosed and died, and the other young man was about to go to federal prison for his role in having sold him the heroin. And I remember the prosecutor saying, and I couldn't sleep at night when he got the person he had arrested's phone and saw that it wasn't just these two young men, it was 50 people they were using and dealing with. And so he knew that they were just the tip of the iceberg.

So I started writing that story. I wrote a three-part series, ran on the front page of the newspaper back in '12 about these families whose lives had been upended by heroin. And readers kind of literally spit out their coffee and went, "What? Wealthy white people are doing heroin?" We had no idea.

And so the media's really late to get to this story. When OxyContin came out in '96, it starts becoming a problem especially in Appalachia in the early 2000s. But we didn't really put together the connection between the over prescribing of opioid pills and the mis-marketing of them with the heroin epidemic. And as I say in the book, they're chemical cousins, heroin and OxyContin. OxyContin's basically heroin in a pill. And once you're addicted to an opioid pill, if you can't get it because it's gotten harder to get, it's gotten more expensive, then the dealers start bringing in much cheaper heroin, people make the transition. Many of them initially start snorting it just like they did the pill and then eventually they start shooting it up. A lot of folks got initially addicted like Tess did, at an urgent care, at their doctor's because doctors were basically lied to and told that these drugs were safe to use when for a century we knew they should only be used in severe pain and end of life and cancer.

CHRIS HAYES: You have lots of stories in the book and I've heard versions of this even just in social circles of people going in for something fairly minor and coming home with just insane amounts of extremely powerful painkillers. Is that the origin of this? That is the story I think we have. Obviously there's a big lawsuit right now against Purdue Pharmaceutical that manufactured OxyContin. There's been a lot of reporting on the Sackler family behind them. Is it fair to say the work they did in promoting both the drug OxyContin and the ways they sort of work the system in hospitals and doctors is the origin of the opioid epidemic?

BETH MACY: Absolutely it's the origin. Without OxyContin and this promoting of the notion that pain is being vastly undertreated, pain is the fifth vital sign. Doctors can get in trouble if they don't treat your pain, rate your pain. Without that, there's no heroin epidemic. It's absolutely clear in my mind.

CHRIS HAYES: Where do we end up on all the pain research? Because there was this period of time in which it seemed like there was some significant pain research that pain was being undertreated. It seemed like there was significant research indicating that pain actually did have... that it wasn't just a symptom but could be a cause in a kind of loop that produced worse health outcomes overtime and that there was a tremendous amount of untreated chronic pain in America that wasn't being responded to. Was that all fabricated?

BETH MACY: I don't think it was all fabricated. The pain is a fifth vital sign grows out of the hospice movement, which was a really good thing. I remember my father had hospice in 1983 and it was brand new at the time. Of course opioids are necessary for cancer and end of life and post-surgery, but not to the extent that the American people were told they were safe and doctors were over prescribing times 100. You've seen some of those latest reports about little towns in West Virginia getting millions of bills.

Clearly heads were turning the other way of the regulators. Politicians weren't paying attention and these marketeers and pharmaceutical companies... If you're one of the parents who lost their child to this, you would say they got away with murder.

CHRIS HAYES: I want to hear about the human faces you put on these incredible stories, and we'll do that right after this break.

Talk to me about the people that you met in reporting this book and how their addictions started.

BETH MACY: I'll go back to the story about the two young men. That was a case of a young man, his name was Spencer, he was a teenager and doing a lot of experimenting and initially started by stealing some opioids from his mother that she had in a medicine cabinet that were left over from a surgery. Then started trading them around. So that's kind of a typical teenager story. There's also the typical story of I'm thinking about a football player I wrote about who was addicted by prescriptions iatrogenically by a doctor prescribing him meds for I think he had had a snowboarding injury, and football playing. Multiple injuries. Interesting thing about him, his name was Jesse, he was also taking ADD medication.

And this came up over and over just among the people I interviewed who had started out as teenagers is that many of them had started out taking ADD medicine, got really comfortable with the notion of taking pills, and then before you know, they're trading pills around at so-called "pharm parties", P-H-A-R-M parties. And once Jesse and many others were addicted to opioids, then they sort of trade their ADD meds for harder stuff. And that was his path and sure enough I interviewed a researcher who confirmed that that's more common than we know.

CHRIS HAYES: Part of what is happening here is a specific biophysical thing that opioids are doing. Why is it that this chemical compound is so addictive? Has been so addictive for, as you said, over 100 years.

Bottles of prescription painkiller OxyContin made by Purdue Pharma LP.George Frey / Reuters file

BETH MACY: Yeah, just to put it really simply, the opioids come in and they sort of overload the opioid receptors with dopamine so that if you're on them for a long time, when you stop taking them, you have this physical dependence in some cases, what almost every user called being dope sick. That was vomiting, diarrhea, nausea, sweats, and that kind of thing.

Some people, people who are prone to addiction, people who have addiction among their parents or grandparents, are as much as 50 percent more likely to become prone to opioid addiction too. Some people can get addicted in as few as five days, which is kind of shocking. Just thinking about story after story I've heard of kids being prescribed opioids for wisdom teeth surgery, 20 and 30 days. Thank goodness they're not doing that anymore. But kids who don't have meaningful activities to do, young people in Appalachia. There's somebody in my book that's asked what he wants to be when he grows up by his teacher and he says, "I want to be a drawer." She says, "You want to be an artist?" and he goes, "No, I want to draw disability." It was the only thing he could imagine for himself. So, people without hope. You see that those companies targeted the areas where the jobs were going away, so it was really a double whammy for people, and particularly, in distressed places like Appalachia.

CHRIS HAYES: When you talk about Appalachia and hope, it gets to me to this really bedrock question about cause and effect here. There's two stories, I think, of the opioid epidemic, and I'm oversimplifying here just for some kind of conceptual clarity, but I want you to respond to it. One is this is essentially a biochemical phenomenon in which pharmaceutical companies pushed this substance on people that was a dangerous substance that they then had a kind of physiological reaction to. The physiological addiction led to this disaster.

The other is that this was exploding in areas that had all kinds of social indicators, high poverty, high levels of disability, before opioids. If you go back and say, "Well, there's a lot of drunks in Appalachia, there's a lot of drug users in poor neighborhoods," it's like, "Right." Those things always go together because that's a kind of knock-on effect of marginalization, of social disadvantage, and of poverty.

BETH MACY: Right. Exactly. Generations of substance use disorder.

CHRIS HAYES: Right. So the question there becomes how much are we talking about a chemical that got introduced that's the problem, and how much are we talking about this idea of despair more broadly, about these economic opportunities going away and that being the kind of facilitating condition?

BETH MACY: Well, I think it's absolutely both. We know the opioids epidemic began in these distressed, marginalized communities that were already knocked down by job losses because the pharmaceutical companies targeted those areas. They sent their reps at a greater rate to go and tell their doctors that this new drug OxyContin was safe. Only addictive and less than 1 percent of all cases, and if a patient came back exhibiting signs of addiction, that was simply pseudo-addiction. Not really addiction at all, and you can fix it by yet more opioids. That was happening, but once it spreads from these hinterland areas to all over, this disease spares no one.

One of the main characters I write about is this young woman named Tess Henry, who was in her early twenties when she was initially addicted by being overprescribed. Her dad is a surgeon, her mom's a hospital nurse. They had a vacation home at the beach. If any a family should've been equipped to deal with this problem, you would think it would be hers but, just all too common, things escalated. She was in jail over and over and she ends up prostituting, and she ends up murdered on Christmas Eve in Las Vegas where she's been sent for treatment. But the treatment is exactly the wrong kind of treatment.

CHRIS HAYES: What did you learn as you talked to, I think you talked to hundreds of folks, addicts, their family members, their loved ones, about what the second-order and third-order effects of this epidemic have been?

BETH MACY: Well, gosh. Just really hurt families. A lot of children in foster care, multiple problems with neonatal abstinence syndrome. The typical story: I was just interviewing somebody today in Mount Airy, North Carolina, he was talking about this peer recovery coach he wants to hire to help him in his new program, and he's like, "Oh, she used to have a great white collar job. She got overprescribed, became addicted, and ended up losing her job, lost her relationship, lost her child, ended up in jail. Now she's putting her life back together." But that's very much the typical story.

CHRIS HAYES: One thing you talk about in the book when you talk about how you found your way to this story is that kind of racial and class lenses that sort of color all this. That drug use and drug addiction are coded in certain ways. Obviously, I lived through New York City in the crack epidemic, which was full of horrible, dehumanizing scaremongering and also a lot of pseudoscience. This idea that crack was this sort of super drug, when it is essentially the same as cocaine. How do you think those sorts of conceptual frameworks and media coverage have interacted with the ways in which we understand what's happening before us as the sort of epidemic exploded?

BETH MACY: Some experts that I interviewed talked about the fact that African Americans were initially protected from the opioid epidemic. This got around because of racism in that doctors didn't trust them to responsibly take opioids, and the data actually bears that out. More recently, we've had higher overdose numbers increasing among African Americans, particularly folks getting out of prisons and jails who will go back to their old dosage. People in some inner city areas tend to get the most heroin that's been cut the most with fentanyl, or the worst quality of it, so you're seeing a lot of overdose deaths interfacing with that, along with African Americans just being less likely to call 911 because of police issues.

CHRIS HAYES: You just mentioned fentanyl. Fentanyl, obviously, if you look at the charts of the sources of overdoses, is just absolutely skyrocketing. What is fentanyl?

BETH MACY: Fentanyl is a synthetic opioid that's 50 to 100 times stronger than heroin and-

CHRIS HAYES: 50 to 100 times stronger?

BETH MACY: Than heroin. Yeah, and carfentanyl is something you've heard about, a lot of deaths in some communities, where you have a big spate of 26 deaths in Huntington, West Virginia, a few years back in one week. That was a bad batch of carfentanyl.

CHRIS HAYES: What's carfentanyl?

BETH MACY: That's even stronger. It's another synthetic opioid that veterinarians use to tranquilize elephants.

CHRIS HAYES: Jesus.

BETH MACY: Right?

CHRIS HAYES: How did that get introduced into this sort of ecosystem?

BETH MACY: Well, it was initially a prescribed pharmaceutical, I remember some kids telling me about they were chewing on fentanyl patches, but more recently it's something drug dealers have used to cut their heroin with. It's often imported from China or it comes in through Mexican cartels. That's what you're seeing: the most increase in overdose deaths right now are pinned to fentanyl increases.

CHRIS HAYES: Is that because people are explicitly using fentanyl and they don't know how to manage the dose of it, or is it because they're using heroin that has fentanyl and they don't know it?

BETH MACY: It's both. People will say, "Oh, that person died of fentanyl. That heroin must be really good." I don't know if that's really true, but several people told me that was true. It's called hot packing. I said, "Well, why would they want to kill their customers?" "Well, if you kill one customer but I get 10 more of the other guy's customers, then that's a win–win for me." That's a pretty cynical view, but that's what I heard.

CHRIS HAYES: One thing that comes up in your book, and this is something that I think is true of substance abuse more broadly, particularly in the sphere of illegal drugs, is that the line between dealer and user is extremely faint.

BETH MACY: Oh yeah.

CHRIS HAYES: Particularly in the 1980s, I was a kid in New York City at the peak of both the highest crime rates and the apex of the war on drugs. We had D.A.R.E. police come to our classrooms, there was public service announcements, and there was this idea of this distinct cast of evildoers called drug dealers who were like this separate group of manipulative villains who preyed upon the innocent. One thing that's clear in your book, and maybe you can talk about it, is that the users and dealers are often the same group.

BETH MACY: They're the same people. They're the former football star on the high school team or the waitress or the tree trimmer. Many of people who are addicted to opioids, because of that fear of dope sickness, they've got to keep their supply going or they'll get really, really sick. A lot of them will turn to selling as a way to get their own supply. A lot of people end up getting arrested. That's why it's so important to start treating their substance use disorder while they're in jail, in prison, and stopping that cycle of in-and-out-of-jail, in-and-out-of-jail, overdose... too often leads in death.

CHRIS HAYES: Why is that? obviously, people that are in the throes of addiction, particularly in the throes of addiction to an illegal substance, likely to end up arrested. Walk me through what that cycle looks like.

BETH MACY: Well, they get arrested for a variety of things, whether they're stealing from their relatives to get more heroin so they won't get dope sick, doing sex work in order to get more heroin so they won't be dope sick. You hear about people on methamphetamine doing kind of crazy, violent behaviors. With heroin, it's more like withdrawal into a corner. Not so much violence, but it's a lot of stealing. These are the kinds of things that Appalachia started seeing almost right after OxyContin came out. Almost every family I interviewed in these small, distressed towns had a moment where everybody started locking their doors.

In Dickenson County, far Southwest Virginia, a night manager at a grocery store was making a deposit and was murdered so somebody could steal the money and buy more OxyContin, which out there they call “OxyCoffin.” Just crime on a level that folks had never before seen. I think that the media largely miss these stories happening because it was happening in these rural hinterlands, and papers like the paper I worked for, which at one time was a solid, medium-sized paper, no longer covering those rural areas. But if you go back to those places now, they're like, "Oh, the opioid epidemic. We've been dealing with that since 2000."

CHRIS HAYES: What is the reaction in those places? One thing that I've seen is that there's a real disparate reaction in the compassion with people will talk about the opiate epidemic compared to, say, the crack epidemic in New York City. I think that's true at the national level, but I'm always a little unclear if that's actually true at the local level. Was your experience in these places that were sort of ground zero for this... what was the reaction there from a policy standpoint? Was it like, "Hire more cops and throw the book at him" and all the kind of tough-on-crime playbook that we've seen play out?

BETH MACY: Mostly it was the tough-on-crime playbook and a lot of... J.D. Vance talks about this in “Hillbilly Elegy.” He's seeing people abuse the system, using their food stamp cards and figuring out ways to sell the food to get drugs and things like that. The disability rates in these communities are just through the roof in many cases. The few people that do have jobs sort of look down on those that don't and, because of just a lack of understanding about what happens to folks who have this disease, there's not a lot of efforts.

We talked about earlier, there are some good things that are start to happen. The first syringe exchange program in Virginia, which just got approved by the legislature a few years ago, was in Wise, Virginia, which is a very rural, former coal mining area, because they had a super forward-thinking health department director who said, "Y’all, we've tried everything else and it's not working." Her police department, she had a lot of resistance, they said, "Why would we give clean needles to drug users? You'd just see them on the road when you drive down the street. Why would we give them to them?" She said, "Because we have skyrocketing rates of hepatitis C and we're going to have an HIV outbreak if we don't do something. These are our neighbors and our families."

One of the good things that comes out in all the news about the lawsuit, I think, is just the fact that it's a reminder that a lot of these communities were targeted; many of these folks initially addicted through no fault of their own. I think the more empathy we can distribute in these communities, the better off. When people actually do get taken care of and they are treated... The urgent care for addicted, I kind of see that playing out as a syringe exchange. It's a place where somebody can go and they'll treat you like a human being, they're going to give you clean needles, HIV testing, Hepatitis C testing, referrals for treatment, referrals for MAT when you're ready.

I had a guy I met in Jamestown, New York, tell me he had been a heroin user for many years in New York City and he went into a syringe exchange one day and somebody said, "What do you need?" He said, "I'm hungry. I need a sandwich." Just that act of coming off the street and making connection with a person and being treated like a human being, that was the beginning of his climb out of that. He now runs a syringe exchange and recovery program in Jamestown, New York, which is remarkable. People can get better, they don't have to die, and when they do, they're amazing.

CHRIS HAYES: What I'm hearing from you, and what comes through in your book, is that the idea of stigma remains in the year 2020, 15 years into this. After all of the war on drugs' manifests failures, the idea of addiction as a character flaw and the stigma around it remains the number one obstacle to dealing with the epidemic.

BETH MACY: Absolutely. I was doing the little update for the paperback version that came out last summer and I just called around. It had been a year since I had been reporting in this space, and I called all the people I respect most and I said, "What's your magic wand that you could wave to make this go away?" They said, "I would make it so everybody's educated about this because if they were educated, then they would realize they're buying into the stigma. Stigma is at the root of all of it."

I was at a meeting in a rural town not too long ago and they were trying to figure out ways to get people into an MAT clinic. They had the spaces available, because they lived out in the county, they didn't have a ride. Many of them didn't have cars and didn't have a way to get there. So there's a meeting called together of churches that were going to volunteer to drive folks to treatment, and a local civic leader stood up and said, "I think when people overdose we should let them die and take their organs." I was just like... Another person, also a, quote, "civic leader" was mainly just worried about some drug houses because she was head of the historic society and didn't like these houses being used for drug houses.

But they worked through it. I'm doing some follow up reporting on this community now, and the churches are starting to come around. In fact, one of the churches just got on board to house the first syringe exchange in that county. That's just people who believe in this, who understand it, going out and word of mouth, talking to their neighbors about it.

CHRIS HAYES: I'm wondering, in these places that you've been reporting from that are fairly economically depressed, high levels of addiction, also socially and politically conservative in their leanings, how that interfaces with having the level of, say, funding for services or public support to deal with the problem at scale. Obviously, there's lots of churches and civic leaders mobilizing, but to do it at scale you need government resources, I think, and I wonder if there's a kind of inherent tension there in how people think about solving the problem.

BETH MACY: Yeah, and I think you're right: it comes back to stigma. In this particular community, this opioid response director that I'm reporting on now, he went to the judges in the county and said, "We need a drug court," and they came up with every reason why they couldn't have a drug court. It turns out, bottom line, they want to build money for a jail instead. I was talking to him today and he was like, "You should tour the jail. There are four times as many people that are supposed to be there." This is the thinking, that these people need to be jailed. They can't do MAT in the jail in this particular community because they don't have a room for intake. Are you kidding me? You can't find a little closet somewhere to do that? But that's what he's told. So, just barriers everywhere you go.

He's got some other things going. He's a former marine and he's “Improvise, Overcome and Adapt.” He's figuring out other ways to tackle the problem. That's what I see. When people do that, these are awesome stories in unlikely places. There is some positive stuff starting to happen, it's just not to match the scale of the epidemic yet.

CHRIS HAYES: I obviously 100 percent agree with you on the stigma point and empathy. The one thing I'll say in, I guess, defense of people that are filled with a lot of anger and contempt is that, and as comes through in your books, obviously you've reported this out, but it's really maddening to deal with someone in the throes of addiction and can make you feel extremely angry at them. Because there is a lot of lying, there's a lot of betrayal, there is intense narcissism, all of these character traits that if you were encountering it in a non-addict, you would be like, "That person is an asshole. I don't want to ever talk to them."

BETH MACY: Absolutely.

CHRIS HAYES: And so if you're in the throes of this and you're constantly dealing with people that are lying to you, and stealing from you, betraying to you and doing all these things that are making... There's an exasperation and rage that comes with that, that I feel like comes from an emotionally honest place, that is understandable at some level.

BETH MACY: I totally agree with that, and I saw people fall out with their families over and over. And you can't blame the families in most of those situations, that's why we need urgent care for the addictive. That's why we need places like syringe exchanges and low barrier programs where you can get MAT on demand.

CHRIS HAYES: In the places where that doesn't exist, what is the trajectory like, right? What's happening now? To the bulk of addicts that are in the throes of addiction, it's the criminal justice system in and out. Let's say you have a moment of clarity and you say, "I want to get clean." And you live in rural Virginia for instance, what's the next step for you?

BETH MACY: That's a great question, it's different everywhere. We need addiction treatment system to be woven into our healthcare system. We need every town to have a syringe exchange and a place where people can go and be connected with harm reduction services and treatment, not just put in jail, but by and large, that doesn't exist. And what ends up happening is people, they get captured but they get captured, not in the healthcare system, they get captured in the criminal justice system. And too often they get no treatment when they're in jail and they come out, they get on probation, they relapse because their substance abuse disorder has not been treated. Then they go back to jail and/or they overdose and die.

So where I'm starting to see progress come is in places... I have a piece coming out in the Atlantic in May about a rural town in Indiana where the local nonprofit hospital actually set up a treatment center in the courthouse, which is really cool. And they just kind of made it up, there was no model, but they realized they had a really bad overdose problem. And so now when people come out of jail, they get nine hours of intensive outpatient treatment, including MAT. With the Medicaid expansion, and this is something important to just remind listeners that in states that haven't expanded the Medicaid, you have much less access to treatment, but Indiana has Medicaid expansion and so they get them hooked up with jobs, they get them on MAT and they're having fantastic results. But there were a lot of barriers, it wasn't easy. It took sort of this super driven person, like that former Marine I was telling you about in North Carolina to be willing to just beat your head on the wall until you get it done.

CHRIS HAYES: I mean outside of these sort of systemic approaches, let's say that I have a opioid addiction, and I come from a family that does have some disposable income and my family members are like, "We'll pay for treatment." What does that look like? I mean that's a relatively rarefied slice, but among those folks, what happens?

BETH MACY: Often they will send... one family in the book that had two heroin addicted sons and they spent $300,000 sending their kids to out-of-state rehabs, all of which didn't allow MAT, the medicine that science say's is the best. So you see that happening over and over-

CHRIS HAYES: And this is abstinence only, like the 12 steps stuff where people just, they're sort of nursed through their dope sickness withdrawal?

BETH MACY: Right, if they're lucky they'll let you do it during the withdrawal part, but most don't even allow that. I mean Tess was sent to one of those places in Las Vegas and she was just supposed to eventually quit cold turkey and then she ends up relapsing and out on the streets. According to the American Society of Addiction Medicine, only one in five people with opioid use disorder actually needs inpatient care. But most families, in particular wealthy families, it's what they've heard of, there's been a lot of media around rehabs and most of them-

CHRIS HAYES: I'm so fascinated, I'm blown away to hear that one in five statistic right now, because my thought is like, "Oh, well that's, obviously if you can afford it that's the thing you do, and if I ever had a loved one and I can afford it, I would obviously send them away to a rehab center, that's the gold standard." And what you're saying is the science doesn't necessarily support that?

BETH MACY: No, it's better staying in your home community, get really good social supports, by and large. And then there's this thinking, if I spend $20,000 to send my kid-

CHRIS HAYES: Right, then it's got to be worth it, that'll solve the problem.

BETH MACY: Yeah, and they're not regulated, they're not standardized, and too often they don't have the medical staff to do the medication and they come from this cultural perspective that is abstinence only. Which absolutely worked for alcoholism, it doesn't work by and large for opioid use disorder.

CHRIS HAYES: And that's a nature of the sort of chemical relationship the body has to the substance?

BETH MACY: Yes, yes.

CHRIS HAYES: That chemical nature too is part of what makes the devastation wrought by the crisis so big because of the overdose, I wonder if we can talk a little bit about the sort of chemistry and physiology of that, I mean it seems like a uniquely dangerous thing that happens to people. And can you talk a little bit about why... There are addictions people can have for a long time, I'm thinking about alcohol, which is probably the most common addiction, where it's fairly rare that a person drinks themselves to death.

BETH MACY: Or they do, but they're in their 50s, like my father died at age 57 of lung cancer, but was headed that way anyways. And you have diseases of despair, depths of despair, the Deaton and Case research showing that our lifespan is going down for the first time in American history because of cirrhosis of the liver, but mostly because of opioids and also skyrocketing-

CHRIS HAYES: Suicides.

BETH MACY: ... suicides, yeah.

CHRIS HAYES: But what is it about opioids that leads to these fatal overdoses? What's happening that just from a sort of medical level that makes that happen?

BETH MACY: Well, the dopamine receptors get hijacked by the drug. And so people feel, not only... I talked about dope sickness and diarrhea, vomiting and all these physical sensations, but also this feeling that you're never going to experience pleasure again, just crushing anxiety and depression. And that can take nine months to a year for the brain to come back online and to recover from that.

And so in some ways, a sober living type facility that provides somebody an inpatient, I mean that's sort of the argument for that and really good social services and transitional housing and things like that. But so many of these rehab centers just don't allow the medicine and the sober living facilities. Transitional housing and transportation, I hear over and over, particularly in these rural areas, as being just huge barriers to people getting on solid footing with their treatment.

CHRIS HAYES: And then when people relapse is the issue, because my understanding is that overdoses often come after relapses.

BETH MACY: Right, because they're almost opioid naive at that point. And so they'll often go back to the dose that they used to take, but then they're overwhelmed. It'd be like, you and I that don't take opioids on a daily basis taking-

CHRIS HAYES: I see, so if you're an addict and you have a sense of what your own dosages are and you're using over a long period of time, your body develops a tolerance, but if you come away from it and then you go back to the dose that had been before then that kills you.

BETH MACY: Right, just you would be opioid naive again, yeah. And then-

CHRIS HAYES: Sorry what is opioid naive mean?

BETH MACY: Oh, you're not used to it. Your system isn't adjusted to it the way it would be if you're using daily. So it takes more to get you high. It takes more to just be... They always say, "It makes me feel normal again." They get overloaded, those receptors get overloaded again, in the way that if you or I took heroin we would be immediately super high.

CHRIS HAYES: What do you say about the sort of other part of this that I hear from a lot, there's a very sort of vocal group of people that whenever you do coverage of the opioid epidemic will reach out to write to you and say, "I rely on this pain medication, it's changed my life. I have a healthy relationship with it and you're going to essentially plunge me back into misery by pushing for increased restrictions on pain medication." Is there a group of people that are healthily using high dosages of pain medication over a long period of time and how do we think about the needle not moving, I guess back too far in the other direction?

BETH MACY: Right, right, somebody in “Dopesick” says, "We don't do anything with nuance very well in this country."

CHRIS HAYES: Yes, yes, that's the quote I'm thinking of.

BETH MACY: Yeah, and I think the pendulum has swung too far back for some of those folks and there's a terrific book called, "In Pain” by a bioethicist Travis N. Rieder that explores those issues. I mean, he was a bioethicist at Johns Hopkins, got in a terrible accident, motorcycle accident, and got quickly dependent on opioids and soon discovered that not one doctor that he was sent to and he was sent out five I think, had any knowledge about how to wean him off.

And so we know that people who do get weaned off it should be very, very slow and most doctors don't have very much training in that. So that's one of the big messages of his book. But he's also really concerned that some people who are being just forced tapered without their input, doctors are saying, they're scared, right? Because they're reading all these stories and they're just cutting people off. Well then those folks, they don't want to be dope sick or in a lot of pain either, many of them will go to the black market and you're seeing overdose deaths increasing among that camp as well. So we need more training obviously to learn more about pain management and opioids. So it's double-edged.

CHRIS HAYES: There's been huge changes in regulation in terms of prescription, obviously those kicked in, in the last decade that-

BETH MACY: The CDC regulations?

CHRIS HAYES: Right, so they started tracking, right? So people would go to seven different doctors and get prescriptions and then they started tracking that so that you couldn't do that anymore. That pushes a lot of people in the black market. But the data does show right, that the huge burst of pain prescriptions, oxy and other opioids, has that gone back down to the level it was before oxy was introduced?

BETH MACY: I'm not sure if it's... I think I just read that yesterday, that prescribing has gone down by about a third. But the problem is we now have 2.6 million Americans already addicted to opioids. So though the horse is out of the barn, you can stop prescribing as many, hopefully prevent future cases, right? But we've got to take care of the folks that are using it correctly and on stable dosages. But my concern is, if we say we want to prevent deaths, which I think we do, then we need to deal with these 2.6 million people who are addicted. And that means doing what the science is so clearly says it is the best thing to do and that's the medication assisted treatment.

CHRIS HAYES: At some level, it's like this story here is really kind of... The most cartoonish version also seems not that far from being the accurate one, which is big pharmaceutical interests essentially corruptly rigged a system to jack up their profits by essentially distributing poison across America leading to hundreds of thousands of people's deaths.

BETH MACY: Yep, yep, that's what happened. And when faced with evidence that they were underplaying the risks and overselling the efficacy, they just doubled down on their marketing. Even after the '07 guilty plea, the settlement agreement that was here in Western Virginia where Purdue paid $634 million in fines for criminally misbranding the drug, sales of Oxycontin went up the next year. And one of the big playbook rules was blame the abusers, "We must hammer on abusers in every way possible," said the CEO of Purdue, blame the people we helped addict.

CHRIS HAYES: Wow, that is perverse. So it actually reinforcing the stigma and the kind of moral stain on the addicts themselves and those who have sort of fallen prey to their product actually becomes a means of essentially trying to distance themselves from the responsibility.

BETH MACY: Yeah, and one hell of a business model.

CHRIS HAYES: It's really astounding.

BETH MACY: It is, absolutely, it's heartbreaking. When you see the families... And I mean this one guy I've been following, he was one of the first parents to lose a child of OxyContin overdose in 2001, his name's Ed Bisch. He's an IT worker from Philly and he started this website called oxykills.com and he organized parents from all over the country to get the word out. And he helped federal investigators that were investigating Purdue for the misbranding. I mean this is somebody that's been fighting this for almost 20 years now. And I get emails from him every day. He's still in the trenches. He's better than Google, he's sending me all the latest stories and the latest research, and I'm sure he's tired. He would like to see the companies and the corporate executives punished. He'd like them to see them admit their guilt in this. He'd like to see them stripped of their wealth, but most of all he'd like to see them make addiction treatment as available as they once made those opioids.

CHRIS HAYES: It seems to me that that is one solution here is that the people that brought this about need to pay for the solution.

BETH MACY: Absolutely, some experts think it's going to take $100 billion to get addiction treatment embedded into the healthcare system. Other experts say, the cost of this, the country's already spent a trillion dollars in lost production and costs of the opioid epidemic. So numbers aren't getting that high yet with these settlements that you're reading about now. But hopefully eventually there'll be more urgency about getting treatment on the ground to these folks that really need it because their families are so worn out and their loved ones don't have to die.

CHRIS HAYES: Last question for you, which is about national politics and policy. The president convened an opioid task force, there was some debate about whether there's going to be a declaration of a public health emergency, Chris Christie served on it. It never seemed to go anywhere. I know there's been several rounds of legislation that have been passed and signed to law targeted towards expanding opioid treatment, but what has been done in the last three years at a federal level and what needs to be done?

BETH MACY: Right, so I think he said he was going to, when he was campaigning he said he was going to declare a national emergency, but instead he declared a public health emergency, which released no new funds. Now Congress has added, I think it's a total of $6 billion towards the opioid crisis, but it's nothing to match the scale. We talked about $100 billion being needed and all the little improvements have been good, but they're just tinkering around the edges of the problem and nothing's being done to match the scale of the actual crisis.

CHRIS HAYES: Is there any legislation, is anyone proposing legislation at the scale needed?

BETH MACY: Elizabeth Warren I believe has proposed legislation. She's one of the co-sponsors of a bill that would get at that kind of level. Kind of to make treatment available on demand the way treatment was made for people with HIV and AIDS back in that era. I'm not completely up to date on what all the candidates are proposing, but I have read some in depth reports about her plan and it looks really good to me.

CHRIS HAYES: Yeah, it looks like $100 billion is so far from $6 billion, it's just insane to me that we still have this mismatch in the acuteness and scope of the crisis and the solution.

BETH MACY: And no real leadership, I'd like to see the governors and the president talk about this more and there's just so much more in the news to attract our attention right now, it's unfortunate.

CHRIS HAYES: Beth Macy is the author of the very widely praised, “Dopesick: Dealers, Doctors, and the Drug Company that Addicted America,” it was a 100 Notable Books of the New York Times Book Review. She is author of two other books as well, “Truevine” and “Factory Man.” Thank you so much Beth, really appreciate it.

BETH MACY: Thanks Chris, it was great.

CHRIS HAYES: Once again, my great thanks to Beth Macy, author of “Dopesick: Dealers, Doctors, and the Drug Company that Addicted America.” If you like that conversation, you should check out our conversation with Patrick Radden Keefe about the Sacklers and also our conversation with Jonathan Metzl about his book, “Dying of Whiteness,” which looks at some of the political dimensions that have led to the opioid crisis. We'd love to hear your feedback. You can tweet us with #WITHpod, email withpod@gmail.com.

There's also a great piece about the opioid crisis that to me kind of crystallized a lot of the issues that Beth talks about called, “My Friend and I Both Took Heroin, He Overdosed. Why was I Charged with His Death?” That is about the fact that there's not some neat dividing line between users and addicts and dealers on the other side, that this is all the same folks, and criminalizing them really doesn't help.

“Why Is This Happening?” is presented by MSNBC and NBC News produced by the “All In” team and features music by Eddie Cooper. You can see more of our work including links to things we mentioned here by going to nbcnews.com/whyisthishappening.

RELATED:

"Dopesick," by Beth Macy

"Dying to Be Free," by Jason Cherkis

Dying of Whiteness with Jonathan Metzl (March 26, 2019)

"In Pain: A Bioethicist's Personal Struggle with Opioids," by Travis Rieder

"My friend and I both took heroin. He overdosed. Why was I charged with his death?" by Morgan Godvin