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The Appeal Podcast: The Regressive Pseudoscience of Our ‘War on Opioid Addiction’

With Appeal contributor Zachary Siegel, a journalism fellow at Northeastern University Law School’s Health in Justice Action Lab, and Lev Facher of STAT News.

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The Appeal Podcast: The Regressive Pseudoscience of Our ‘War on Opioid Addiction’

With Appeal contributor Zachary Siegel, a journalism fellow at Northeastern University Law School’s Health in Justice Action Lab, and Lev Facher of STAT News.


On our last episode of the year we’re doing something a little different. Joining us today is Appeal contributor Zachary Siegel, a journalism fellow at Northeastern University Law School’s Health in Justice Action Lab, to discuss false narratives around drug addiction and how prisons are increasingly choosing puritanical pseudoscience in the so-called “War on Opioid Addiction.” We will also be joined by Lev Facher of STAT News.

Transcript

Adam Johnson: Hi welcome to The Appeal. I’m your host Adam Johnson. This is a podcast on criminal justice reform, abolition and everything in between. This’ll be the final episode of the season. We will be back in the new year on January 16th with all new episodes. I just want to take time out now to say thank you for all the support and everyone for listening. We really appreciate it. 

We’re doing something a little different for this segment. Joining me today is Appeal contributor, Zach Siegel, who is also a journalist fellow at Northeastern University Law School’s Health and Justice Action Lab. There Zach helps run a project called Changing the Narrative, which aims to de-stigmatize the media and politics surrounding addiction. Zach thank you so much for joining us. 

Zachary Siegel: Yeah glad to be here. 

Adam: So given your background covering addiction, we wanted this episode to cover the topic in the context of the criminal illegal carceral system. This is a subject more than anything where misinformation, disinformation and ignorance surrounding the way addiction works, works in a feedback loop with lawmakers and the media to create a carceral system that has improved slightly, but it’s still stuck somewhere between the years 1890 and 1922 vis-a-vis the rest of the world, which has a far different, more empirical approach to this, but we’re specifically talking about the so-called opioid crisis where some call an overdose crisis or an opioid related overdose crisis. We wanted to talk about the ways in which drug courts quote unquote “treat” addiction as a sort of medical and health issue and how one pharmaceutical company in particular’s drug became the go to treatment inside jails and prisons effectively sidelining more effective treatments. And to establish the stakes here, cause I think it’s important, we’re talking about millions of people. We’re talking about a lot of people. This is a crisis. How you frame the crisis is subjective, but it is objectively, a crisis and so the main go to drug to help prisons and jails, quote unquote “treat” addiction is of tremendous import. And we’re going to focus today on one pharmaceutical company called Alkermes, which has used an aggressive sales force and marketing effort to push a medication called Vivitrol to people who are incarcerated. So let’s start out by talking about Vivitrol. What is it and how does it compare to the other popular quote unquote addiction “treatment” drugs?

Zachary Siegel: Right. So right now there are three FDA approved medications to treat what’s called Opioid Use Disorder. This is the clinical term for opioid addiction. And unlike drugs like alcohol or cocaine or other drugs people get addicted to opioid addiction actually has three medications available that do a pretty good job of treating it. And of course the issue is these drugs are not widely available, especially to people who are incarcerated. And setting the stakes here people exiting correctional settings, if they have an Opioid Use Disorder, their risk of fatally overdosing is 40 to 130 times greater than the general public. So when people leave correctional settings, they lose their tolerance to opioids, they get out, they haven’t been treated, and they go use again and this is when people are most vulnerable to overdosing and dying. And so the stakes here are literally life and death. And what we do know is when you make these medications available to people, their likelihood of overdosing and dying is greatly reduced. But really it’s two of these medications, one called methadone, the other called buprenorphine, largely known as Suboxone. These two drugs have been around for a while and all around the world they show that they slash the likelihood of a fatal overdose by 50 percent or more. When France made this drug widely available, their overdose rate plunged by 79 percent. And so in comes Vivitrol where it functions much differently than methadone and buprenorphine. So those are both opioids. Vivitrol is an opioid receptor antagonist, so it attaches to the receptor and effectively blocks other opioids from activating that receptor. So the chemistry here, the way it functions inside your brain is very different than methadone and buprenorphine. And this is where a lot of the misinformation and stigma and and politics about how we treat addiction, you know, come into play. 

Adam: So, before we, methadone has an interesting history, but I do think it’s important to know that history, like you said, this episode is going to be in the weeds here. So let’s talk about methadone’s relationship with the criminal legal system and how that informs the current debate within the United States. And I want to be clear, we are talking specifically about the United States. In most of the quote unquote “developed” world this isn’t really even a debate. They wouldn’t have to do this episode. So let’s talk about methadone and its history with relation to the carceral system in this country.

Zachary Siegel: Yeah, it is really interesting. So a guy by the name of Robert DuPont, he’s got some hawkish views about drugs. Like he once said that marijuana is the quote “most dangerous drug” which is false. Need to say that. 

Adam: Yeah. In the interest of clarity, not the most dangerous drug, black tar heroin is worse than that, but go ahead.

Zachary Siegel: Yet they’re in the same category. So. So anyhow, DuPont was the first director of the National Institute on Drug Abuse in the seventies and he was the second ever White House Drug Czar under Presidents Richard Nixon and Gerald Ford. And so Nixon ran on law and order and this was a time when heroin from Southeast Asia — thank you Vietnam war — was flooding American cities and DuPont convinced Nixon that prescribing methadone to people with heroin addictions would reduce crime. And since Nixon campaigned on reducing crime, he listened to DuPont. And in this era, the number of methadone clinics expanded greatly. And it’s important to talk about this because there isn’t really any other medication out there whose success is measured by a reduction in crime rates. They’re not asking are these people healthy? Are their lives better? They’re wondering, are they still robbing cars and mugging strangers and loitering and being unsightly.

Adam: This perverse kind of criteria has stayed with us. We of course always frame drugs as a crime issue, not a public health issue. It’s now become somewhat cliched, people say we need to treat it like a public health issue and a crime issue. Although the actual policy has not really changed much, the rhetoric shifted because he needed to sound woke. But the actual policies haven’t really changed much. So this is obviously the wrong approach. Methadone has been shown to get people off heroin, help stabilize their lives, build networks, sort of rebuild family connections. Now it’s not, of course sort of panacea. And obviously the drug war is steeped in racism here. And we could do ten episodes on why people like Trump suddenly care about drugs, white nationalists like Trump suddenly care about drugs but didn’t before. But we won’t. But can we talk about the kind of moral dimensions to not wanting to go use methadone versus this other which doesn’t have opioid properties and how that, why that’s popular because of this puritan streak in our country, one of its primary sales pitches for legislators. Is that, is that a fair statement?

Zachary Siegel: Yeah. So all of these false assumptions and outdated ideas about drug use and treating addiction are still with us today. And they really infect the health policy and the politics here. So as our guest will explain later the idea that prescribing an opioid to people who are addicted to opioids, and I’m talking here, opioids like methadone and buprenorphine, to do that sort of doesn’t compute with our standard narrative that if someone’s addicted to drugs, you need to get them off of drugs. And that comes from a misunderstanding of the physiology and the chemistry here. So when someone is on methadone or buprenorphine, yes they are taking an opioid but they no longer meet the criteria for addiction. They are now dependent on an opioid. The hallmarks of addiction, the literal definition of addiction is continued drug use despite negative consequences. So if you’re using an opioid like methadone and you’re going to work and you have friends and you’re just living your life, you don’t meet any criteria of addiction anymore, but you’re dependent on this drug. And to be dependent in this country on anything is an indictment of your character. It’s a weakness.

Adam: Unless it is a prescribed drug by a pharma company or five fingers of whiskey a night while you watch the game. Those are all normal.

Zachary Siegel: Right. Right. Those dependencies, you know, people feel okay with I guess, but right. So the Vivitrol comes into play here because it’s not an opioid. It blocks other opioids from activating the receptors. And so it’s a much more palatable course of treatment. And what we’ll unpack here throughout this episode is how this more palatable option has really been pitched heavily to drug courts, to drug court judges, to parole boards, to jails and prisons. Alkermes saw a huge market in prisons and jails and went after it and quite successfully dominate this area of treatment.

Adam: Right. They’ve kind of appealed to the puritan streak in this country as part of their marketing strategy. So let’s talk about the other treatment options that are not methadone, but do have opioid properties. How are those different than methadone and what is the sort of good quick primer about those so we have a sense of what the hell it is we’re talking about?

Zachary Siegel: Yeah. So methadone is heavily bureaucratized and tightly controlled and you can only get it through these special clinics and there aren’t enough of those and so it’s really hard to access. You also need to go to that clinic every single day to get your dose until you can get special privileges like take home doses. So it’s really just bureaucratized like out of utility for so many people.

Adam: Cause the idea is you don’t want people just to like take like fifty hits of, cause that’s what the, you know, opioid crisis is largely also been driven by, which is-

Zachary Siegel: Over prescribing and drugs being everywhere. Right? 

Adam: Yeah. Willy nilly. Passing out at parties, you know what the fuck? I had a rough day at the office, so why don’t I pop one? Right?

Zachary Siegel:  Right. 

Adam: Presumably there’s some logic to it other than-

Zachary Siegel: Yeah, like it mostly it goes back to the days of Nixon where the people taking these drugs are criminals. You can’t trust them. So you need to heavily watch the administration of the drug. And so that’s methadone. In comes a drug called buprenorphine. So the formulation of buprenorphine naloxone is called by its brand name, Suboxone. And in 2002 it gets approved by the FDA to treat opioid addiction. And unlike methadone, a doctor with a special DEA waiver called an X Waiver can prescribe a month supply to a patient that they can then take home. And then once a month they, you know, have a, a checkup and get their refill and go on their day. So it’s not like methadone where you need to go every morning to a clinic and get it. You can just see your doctor once a month and get your prescription. And Suboxone operates similarly to methadone. It’s also an opioid, it’s what’s called a partial agonist. So it does like activate the same receptor sites as drugs like heroin, but to a far lesser degree, it also has a ceiling effect. So say you take, a standard dose is like eight milligrams, say you take 32 milligrams, it sorta just stops working. Like it has a ceiling effect whereby you can’t take more and more and get more of the euphoria. So it’s good in that it’s more difficult to misuse and overdose on. So the preferred drug for a lot of people is buprenorphine because it has a ceiling effect and because you can take home a scrip and you don’t have to go through the clinic. So that’s the landscape. Those are the drugs that we’re talking about here.

Adam: Okay. And so there’s these kind of three primary categories of drugs, two of which have opioid properties, one of which doesn’t. Vivitrol is the one that’s becoming increasingly popular. I was shocked to learn, although I probably shouldn’t be after doing this for over two years, I was shocked to learn that the one that has no opioid properties is extremely popular with lawmakers, the sort of proverbial crusty white men who mostly drive these policy decisions. Very few prisons, if I’m not mistaken, very few states, offer an all the above approach. Can we talk about what the standard is in most states and what medical professionals and addiction activists such that they are, have said about this?

Zachary Siegel: Yeah. So first, federally, the Federal Bureau of Prisons has a blanket ban on prescribing methadone and buprenorphine and other treatments like there is literally like zero addiction treatment happening in federal prisons, which is wild. But then let’s move out to local criminal justice systems, which impact far more people. Most prisons for that matter also do not have all three of these medications available. And so Rikers Island, you know, it has a bad rap and it’s getting closed and everything, but it has one of the longest running methadone programs of any correctional facility in this country. And so Rikers Island, they’re a model opioid treatment program. They provide all of these medications.

Adam: Despite their horrific torturous conditions.

Zachary Siegel: Yeah, despite the brutal conditions at Rikers, there’s actually this like group of doctors there who have been treating opioid addiction with immense success for decades since the eighties and this model has not been expanded. The only other state that has recently got on board after a pilot program was evaluated was Rhode Island. Rhode Island started offering all three medications to every single person going inside the system who screened for opioid addiction. And when they did that, the overdose rate among people leaving the prison system dropped by 65 percent and the rate throughout the whole state dropped by 12 percent so that’s, that’s a huge success. And still, it’s not like with this evidence that it’s been rapidly expanded yet. The ACLU and other players are actually now suing prison systems, jail systems all over the country to just get people the medication that they’re prescribed to because the jails and prisons just don’t want to do it.

Adam: And all this is happening within a political context, which is a good place I think to pivot to our guest Lev Facher, who covers politics specifically as it regards to the pharmaceutical industry for Stat, which is a vertical run by the Boston Globe. So we will talk to him in just a minute. 

[Music]

Adam: Lev Facher thank you so much for joining us. 

Lev Facher: Thanks for having me.

Zachary Siegel: Hey. So one reason we wanted to talk to you Lev in particular is because you cover the government’s response to the overdose crisis and sort of the nexus of politics that determines that response, like which solutions and treatments get prioritized. And so there have been numerous investigations and long stories detailing how Alkermes, the manufacturer of Vivitrol, has pitched itself to the criminal legal system like drug courts, jails and prisons. So ProPublica covered this, NPR has been on this and so have you. To start us off, can you walk us through some of the marketing strategies? Like what would a Alkermes salesperson be saying to a sheriff or a politician or an official in the system?

Lev Facher: Sure, so obviously the pitch is going to change from person to person, but the overarching theme and one that some addiction physicians have taken issue with is the idea that there are three FDA approved medications to treat Opioid Use Disorder and only one, which is Vivitrol, the drug Alkermes manufacturers, is not an opioid, which is to say it’s not a partial agonist or a full agonist. It’s an antagonist and that means that it’s not a controlled substance. It’s not something that in their words could be diverted. It’s not really something that would be sold for illegal use. So this is something for people often who view opioid use and risky drug use as much at least a criminal justice issue as a health issue. It’s a very appealing pitch. ‘Our drug’ they would say ‘is non-addictive, it’s not an opioid. You could use it in your correctional facility. There’s no risk of it really being sold on the black market. You can’t overdose on Vivitrol.’ So that’s the kind of language and that’s the kind of appeal that Alkermes has broadly made and they’ve done it not just to physicians, as is standard in the pharmaceutical industry, but in a lot of criminal justice settings. So there’ve been pitches to parole boards for instance, that when people are released from a correctional setting, they are prescribed Vivitrol because it makes one essentially immune as they’d say to the effects of a drug like heroin or in a drug court setting there would be requirements ‘Sure we’re not going to put you in jail as a result of your drug possession conviction, but if we’re going to give you community service or some non incarceration alternative, one thing that would go along with that is being prescribed Vivitrol.’ So there’s been this very aggressive and very broad push at the federal level, at the state, at the local level to make sure that Vivitrol is seen as this non-addictive, non-opioid drug regardless of the efficacy measurements compared to the other two drugs that have also become part of the standard of care for opioid addiction, methadone and buprenorphine.

Adam: So let’s talk about this efficacy issue. Cause that obviously seemed central here, this all seems rather puritan to me as a layman, that there’s obviously these things are very measurable. You can sort of quantify and qualify the extent to which, which one’s better than the other. It seems like the marketing appeal is a fundamentally conservative appeal. It sort of seems more wholesome, which does not necessarily make good health policy. So can we talk about the efficacy concerns, what some of the downsides are to this kind of cold turkey method and what are health experts finding frustrating with the ways in which the Trump administration and the media is sort of playing into this kind of puritanical dichotomy?

Lev Facher: Sure. So you’re right that efficacy is going to be the central question here. We can go back to November 2017, that’s when the National Institute on Drug Abuse put out a study comparing two drugs head to head, they were Vivitrol and Suboxone, which is a very common formulation of buprenorphine combined with naloxone and found essentially that the two drugs had roughly equivalent efficacy when it came to reducing overdose and reducing mortality related to drug use. There’s a huge caveat though, which is that people notoriously have difficulty continuing courses of treatment on Vivitrol. So essentially what this NIDA study said was that for people who continue to take Vivitrol, treatment is as effective as with people who continue to take buprenorphine. So essentially two people both in recovery and they both continue to take these different options, these different pharmacological treatment options, each of them, their mortality likelihood is reduced. Their risk of drug use is going to be reduced by about an equivalent level. So it is an apples to apples comparison that shapes up very well for Vivitrol with the caveat that people just have much more trouble continuing Vivitrol treatment, which is to say overall there is an emerging body of data that suggests people on buprenorphine are just more likely to not experience an overdose and to not experience an overdose death . But as I said, there’s not a ton of data here. And of course, as I said, the marketing is really central just in terms of Alkermes and not just Alkermes, but a lot of people who have, you know, kind of more old fashioned attitudes about addiction and behavioral health disorders and treating addiction. There’s really a very fundamental appeal in prescribing and taking a drug that’s not an opioid, that’s not a controlled substance. And that’s really central to the whole debate. 

Adam: Right.

Zachary Siegel: And there’s another big caveat with that study. So there’s this like induction problem. So with Vivitrol people need to be off of all opioids for about a week before they can start it. So that means they need to go through a quite grueling withdrawal process before they can be administered their first Vivitrol shot. Whereas with methadone or buprenorphine, you can start methadone the same day. So people really don’t need to experience that nasty withdrawal phase. And with buprenorphine you have to wait, you know, depending on which opioid you were addicted to, like 24 to 36 hours, which is really before the withdrawal becomes very intense. And so in the literature it’s just like called “the induction problem” whereby it’s harder to get people started on Vivitrol in the first place and then like you’re saying, it’s also more difficult to keep them on it month to month.

Lev Facher: Right. And I’ve actually written, with the huge caveat that I am not a physician, but there’s a growing movement around the country to induce people on buprenorphine treatment almost immediately after a nonfatal overdose. So in an emergency room setting, it’s becoming more common for an emergency room physician to offer someone buprenorphine. I wrote a few months ago that the state of New Jersey actually, the health commissioner there authorized paramedics to induce people who’ve just been revived or treated for a non fatal overdose in the state of New Jersey, I wrote recently the health commissioner there has authorized paramedics to offer people who’ve undergone a non fatal overdose buprenorphine essentially on the spot. So paramedics in ambulances can carry buprenorphine and can begin the treatment process very soon after someone is stabilized post nonfatal overdose. As you say, yeah, it’s very difficult to immediately begin Vivitrol treatment. It does require what people would call a detox period. One thing that has helped with that is that in 2018 the FDA approved a drug called Lofexidine, which is specifically targeted to treat opioid withdrawal symptoms. So people see that if you want to use Vivitrol, if that’s the desired treatment drug, people do see that drug Lofexidine as a bit of a bridge through that week or ten day period to treatment. But absolutely the thing about methadone and buprenorphine that a lot of physicians view as a huge advantage is the rapid nature in which you can begin treatment because when people seek treatment, addiction physicians like to be able to provide it.

Adam: I want to establish the kind of stakes here in terms of suffering. I imagine that if I am someone with an addiction problem and you offer me the thing that’s similar to the thing that I had an addiction to and this other thing that just told me cold turkey, I’m probably going to prefer the former and I imagined that week or ten day period is pretty goddamn miserable. Is there any sense of how that’s quantified into this equation? Is there any data about like the sort of suffering involved in that, cause I know that efficacy looks at like curing or sort of getting over addiction, but obviously there’s a sort of mental health component and is there any sense of suicide rates or anything that would indicate that a cold turkey method is basically kind of a hellish experience and how does that sort of quantify? How do we put that into the calculus here?

Lev Facher: You know, I don’t have data to cite for you, nor have I experienced this myself, but I can tell you that people view unsupervised detox, untreated detox as dangerous and agonizing. There’s no question, and I think there are instances in which people have died during this detox period. I’m not saying that has anything to do with use of Vivitrol or intention to use that drug, but it’s absolutely a very, very vulnerable period for people, especially sometimes people who are incarcerated, don’t have access to the drugs that they had previously been using and also don’t have access to the treatment drugs like methadone and buprenorphine that would mitigate those withdrawal symptoms.

Zachary Siegel: Right. And I think, changing topics slightly, there’s the sort of stigma and misinformation about drugs like methadone and buprenorphine that are part of the marketing pitch and the political landscape. And you wrote about Trump’s Opioid Commission back in 2018, so he convened a group of experts to sort of come out with a plank to mobilize a federal response to the overdose crisis. And you wrote a piece about how that commission wrote in favoritism for Vivitrol specifically. Can you sort of talk about why, again, the notions of addiction and how to treat it are sort of all pointing in Vivitrol’s favor?

Lev Facher: Sure, so I’ll put it in the political context first. As you said, when President Trump was inaugurated, he very quickly commissioned a panel to address the opioid crisis. It was chaired by Chris Christie who then was the governor of New Jersey. It had a lot of really credible voices in addiction policy. Patrick Kennedy was on that commission, a few other governors, and they put out this sweeping set of recommendations later in 2017 that the addiction policy experts I spoke with largely thought were very holistic and really a good direction in which to move federal addiction policy. And President Trump knew that the opioid crisis wasn’t just a huge issue in terms of the health and wellbeing of Americans, but it was a huge political issue. It was something that candidates heard about all over the 2016 campaign trail and here we are in 2017 all of a sudden, Republicans control the Senate, they control the House, they control the White House. So there is a desire for action on the opioid crisis, but the action is really being orchestrated on the part of people who are largely conservative and largely and historically have taken the view that drug use is a criminal justice issue. So to their credit, there are a lot of Republicans who in a very short span of time really evolved on the concept of medication assisted treatment and use of drugs like buprenorphine and methadone to treat opioid addiction. But there were some early mishaps, so Tom Price, he was the Health Secretary until late 2017 when he resigned in scandal, but he at one point infamously said essentially that he viewed use of a drug like buprenorphine as essentially substituting one opioid for another. Obviously, when you compare outcomes with, for example, heroin use and buprenorphine use, it’s really not a good comparison. It’s not medically sound and he was pretty widely condemned by addiction physicians. But I say all this only to illustrate there really was a desire to distinguish between continuing strong enforcement efforts and not doing what people in conservative advocacy circles would characterize as facilitating opioid use. And in that frame, the White House put out a white paper in 2018 that essentially guided treatment. It recommended a course of treatment for the roughly 185,000 people incarcerated in the federal prison system and it essentially said for those people with substance use disorders, specifically with Opioid Use Disorder, upon their release, we are going to administer injectable naltrexone. And as I wrote back at the beginning of 2018 there is only one manufacturer of injectable naltrexone and it is Alkermes and their drug Vivitrol. So essentially the White House was recommending for the thousands and thousands of federal inmates who had an opioid addiction, we are going to give them this one drug of three potential options, which by the way is far and away the most expensive. This is a monthly shot that can exceed $1,000 per dose. And that was essentially the, the crux of that story.

Adam: Let’s talk turkey here, let’s talk what are the kind of forces at work behind the lobbying effort. Now, you had mentioned earlier that they sort of throw a lot of weight around. You live in DC. That’s kind of your beat. To a large extent, which is the influence aspect of this. Aside from the sort of anodyne sales pitch about not replacing one drug with another, which again sounds really warm and fuzzy for a certain crowd of people, how much money are we talking in terms of lobbying, in terms of pushing their weight around and what are the, what are the other solutions doing? I’m not sure exactly who the players are here. What are they doing this sort of counterbalance that and is it, is it just a thing where everyone’s throwing money around and the reason why Vivitrol is popular is because it fits into a kind of Jeff Sessions worldview more easily?

Lev Facher: So Alkermes is absolutely a major lobbying presence here in Washington as is Pharma, the trade group for pharmaceutical companies that includes Alkermes as one of its members. Alkermes has a lot of lobbying firms registered to advocate on its behalf here in Washington. In 2018 they, in terms of my napkin math, spent just shy of $4 million on lobbying here. They’ve also funded a group called the Addiction Policy Forum, which has done some really valuable work in terms of creating a tool for people all over the country to find local addiction treatment resources and it doesn’t point people in a particular direction on what treatment drug they should use, but at the same time, that group was run initially by a woman who had been registered to lobby for Alkermes at the time she founded the nonprofit, which was in turn funded by Pharma and Alkermes. So accounts really vary in terms of how hard Alkermes has pushed and lately it’s not so much simply because Washington isn’t really working on addiction treatment legislation lately. They did that in 2018 they signed a big bipartisan bill. There was a bill signing in the East Room of the White House, President Trump really basked in the applause there. But at the time of that bill in 2018 and in 2016 when Congress passed the Comprehensive Addiction and Recovery Act, there was certainly a lot of pushing and shoving between various manufacturers of addiction medications, but Alkermes really was insistent that when federal money was being distributed to treatment providers, those providers would be required to offer drugs in the three different categories, the opioid antagonist, the partial agonist and the full agonist and it’s just that when you write that into law, the effect it has is that providers have to carry Vivitrol because it’s the only drug that fits into that opioid antagonist category. And to be clear, there are physicians who think Vivitrol is a fantastic drug. It’s a huge medical advance. I don’t really know anyone who thinks it shouldn’t be an option for patients with Opioid Use Disorder. I think it’s just people want to make sure it is one of many options and not the only one because as we’ve talked about, there are obstacles with withdrawal. There are obstacles with costs, there are obstacles just in terms of patients having the flexibility to choose what drug works for them. But as with really anything to do with the pharmaceutical industry here in DC, Alkermes and Pharma have a major lobbying presence and those addiction bills were not immune to the advocacy pushes that really occur with every major piece of legislation that moves through the city.

Zachary Siegel: And we don’t have to really even be hypothetical about what it would look like to offer all three options inside a correctional facility. We have the Rhode Island study which offered methadone, buprenorphine and naltrexone, all three to all incoming prisoners or inmates who got screened and if they screened positive for Opioid Use Disorder, they were offered all three. And I’ve talked to the researchers of that study like Tracy Green and she said, you know, overwhelmingly people choose buprenorphine. Some people choose methadone, some choose Vivitrol, and it just, it’s like when you practice medicine, everyone’s body is different. Everybody responds to medications differently. And if there’s three drugs on the table for one condition, that’s just how medicine works. You offer all three. So all of the issues to, you know, barring that from happening, again, just go right in the direction of Vivitrol as the only drug, which is, like we’re saying, you know, bad medicine. Bad policy.

Adam: Yeah. Which I mean, so my question would be, right now we’re talking at or about a party, I’m curious what the party, the effect of the party we’re talking to both incarcerated and people with drug issues, the groups that are fighting on their behalf or the organizations on their behalf what is their general feeling about this in terms of the actual stakeholders and people who are being harmed here? Do you have a sense of what the consensus is on that? Is it a kind of all the above approach?

Lev Facher: I have not talked to any treatment and recovery advocate here in Washington or elsewhere who wants anything other than all three of those drugs to be made available for people seeking treatment.

Adam: Right. So it’s not even really a debate at this point. It’s sort of just a, I mean cause this, to be clear to our listeners, and we, we talked about this at the top of the show, like that is not at all what the standard is now. That’s the standard only in a handful of places.

Lev Facher: Absolutely. And at this point I should say even Alkermes would tell you that they want their drug to be offered in the context of a broader array of treatment options. It’s just that specifically when we’re talking about criminal justice settings, when we’re talking about drug courts, when we’re talking about federal prisons, when we’re talking about the incarcerated population, there are concerns there. If you can imagine a prison warden who is not a physician, is not an expert in addiction treatment and doesn’t want any degree of people effectively trying to smuggle buprenorphine into the prison or methadone. And those are different conversations and we can talk about it for a while, but essentially the thinking is ‘I don’t want people using unprescribed opioids under my supervision regardless of whether they’re using them in what they would say is a recreational sense or whether they’re using them as a defacto mechanism for addiction treatment’ even though they haven’t been prescribed the drug, which is something we often see with buprenorphine. There’s a lot of unprescribed use, but that’s not really what people would characterize as drug misuse. It’s just unprescribed addiction treatment and we’ve seen varying approaches and municipalities to policing what they would refer to as buprenorphine diversion, but I digress. Yeah, there are criminal justice settings in which Alkermes has pushed Vivitrol as, practically speaking, the only option just because a prison, a drug court isn’t going to be in a position isn’t going to want to facilitate buprenorphine or methadone use and Vivitrol is pitched as such a low risk drug, again, not a controlled substance, not an opioid that there are settings in which it’s been pitched as not one of several options but the only one and that’s where experts in policy and in medicine really have a problem.

Adam: This has been really informative. You want to talk about the work you do at Stat and maybe push them wares here in terms of what you’re working on and where people can check out your work and what they have to look forward to.

Lev Facher: I appreciate that. So people should check out statnews.com we’re a health and science website run by the Boston Globe Company. We’ve really taken the lead in covering Purdue Pharma’s role in the opioid crisis. We actually spent about three years battling Purdue in court in Kentucky. Recently the Kentucky Supreme Court ruled that Purdue has to release all records of some depositions conducted with members of leadership in that company and the Sackler family that owns it. And those documents are still being released and Stat is still reporting on them. So if that’s something that interests you, by all means follow us on Twitter and check our website. A lot of really good comprehensive coverage of addiction, both from a policy and political standpoint and from a medicine standpoint and just what it’s done to communities across the country.

Adam: Alright, Lev Facher, Stat News. Thank you so much for joining us. We really appreciate it. 

Zachary Siegel: Thank you. 

Lev Facher: Thanks so much for having me.

Adam: Thanks to our guest Lev Facher from StatNews and I also want to thank our special guest who joined us in the studio today, Zach Siegel, thank you so much for coming on. 

Zachary Siegel: Hey, thanks for having me. I’m just really glad that this topic is getting out there. 

Adam: Thank you so much. I really appreciate it. I am too. This episode was a collaboration between The Appeal and Northeastern University Law School’s Health and Action Lab Changing the Narrative. The episode was co-produced and co-written by Zachary Siegel. The show is produced by Florence Barrau-Adams. The production assistant is Trendel Lightburn. Executive producer is Craig Hunter. I’m your host Adam Johnson. Thank you so much. We’ll see you in January.