Scripts | 1. A Hard Pill to Swallow

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This is Radio Atlantic. I came across a few stats recently in this book, Quick Fixes, by Benjamin Fong, that really confirmed a sense I had about how much we Americans love our drugs.

Fong pulls together data that shows that at 4% of the Earth's population, we use 80% of its opioids and 83% of its ADHD meds.

One in three Americans suffers from anxiety, depression, or both, and one in six is on

psychiatric medication.

Fong calls these numbers truly world historical. Why us? I mean, it can't just be biological, that these drugs somehow work differently on American bodies than they do on other bodies.
It must also be cultural, something about the way we think about them. Earlier this year, one of our reporters, Ethan Brooks, got really interested in this idea.
In particular, what happens when you combine powerful medications with powerful stories about those medications? And we're going to spend the next three weeks looking at that question in a series of episodes we're calling Scripps. For the next two weeks, we'll get into popular meds like stimulants, antidepressants, and anxiety meds, drugs we are currently taking a lot of.
But this week, we're going to start with a different type of story, a mystery, about a medication that Americans are avoiding taking, even though in another country, it saved many, many lives. Ethan will take it from here.
If you were to just imagine a medicine, or a chemical compound, that could put a stop to the opioid epidemic, that medicine would probably look a lot like buprenorphine. Hiding behind a borderline unpronounceable name is a real-life miracle drug.
It's a drug that allows people who struggle with opioid addiction

to live normal lives, and it's a proven winner.

When France was dealing with their own opioid crisis

back in the 80s and 90s, they pushed this treatment.

And overdose deaths dropped by 79% in four years.

79%.

Last year in the U.S.,

there were about 81,000 overdose deaths involving opioids.

So in 2020, the U.S. decided to do things the French way.
Patients could now be prescribed buprenorphine online. President Biden removed patient caps, cut red tape, led a federal effort to get this medication into the hands of people who need it.
And it's worth saying, like, this was a big deal. This drug had been tightly controlled for more than a decade,

for reasons I'll explain a little bit later.

Advocates had been pushing for more access for years and years and years.

And now it was happening.

Access to this incredibly effective drug was opening up.

They waited to see what would happen.

Nothing happened.

Between 2021 and 2022, the dispensing rate fell. Less buprenorphine was dispensed than the year before.
By the end of 2023, the total number of patients on this medication hardly changed. So to recap, we have an epidemic that kills over 80,000 people every year, a real-world, proven, effective medication to treat that epidemic, a coordinated federal effort to get that medication to the people who need it, and nothing.
A chasm between policy and treatment and crisis into which hundreds of people disappear every day. Why? I have asked a ton of people this question and have heard a lot of different answers.
Some of it has to do with costs, with policy, but the reality is a lot more complicated. Doctors aren't prescribing, and people aren't taking this medication for reasons that are deep and weird and personal.
Mostly, it has to do with our country's story, an often contradictory story, about the nature of addiction and what it means to recover. I want to look at that story in all these different places where it shows up, with doctors, pharmacists, but I want to start with the lives we're trying to save, people struggling with addiction and their families.
It's raining cats and dogs here. I don't know if you can hear it in the background or not.
This is Jennifer Hornack. She's a nurse in Jacksonville, Florida, and the mother of four adult kids.
First is the daughter. She's a nurse.
My oldest son is a painter, and he lives in South Carolina. And then there's Mallory and Quincy.
Got it. When for you does opioid use come into your world? Like what's the first sign of that as a mother? You know, I've always been on narcotics for my back.
I injured my back. And, well, my children, I noticed when they would come over that I'd be short on pills and things.
And then I was like, okay, what's going on? The pills started disappearing somewhere around 2015. At first, it wasn't clear who was taking them, but Jennifer figured it was her youngest, Quincy.
He'd asked her for pills a few times before. So Jennifer gave Quincy a good talking to, hid the pills, and that was that.
I guess it didn't seem as bad as shooting up heroin. It's like everybody was doing oral opioids then.
And then the phone call started. It was Jennifer's daughter, Mallory, who tells her that Quincy has made the jump from swallowing pain pills to injecting heroin.
Even sometimes he would overdose. And then when she tells me these things, and I come back and I say, what is going on with you? He tells me, well, she's doing it too.
It was both of them. And you know, it it was Mallory and Quincy.
Apparently he had shown her how to shoot up too. And then the race was on.
I had two kids in opioid addiction and I didn't know what to do. You know, I've smoked weed.
I've tried other things in life, but there's not really any type of instant gratification like there is using IV drugs. It's like, oh, I've never felt anything like this before, and it is very, very addictive.
This is Mallory Berry, Jennifer's daughter. Mallory has arthritis in both knees and tears in two discs in her spine, both painful conditions.

So for years, she treated her pain with prescription painkillers.

She worked at Bank of America, which helped cover the cost.

But when she changed jobs, moved to a smaller company, cost shot up.

I couldn't afford it.

And so what do you do but you try to find pills on the street?

Which didn't work. And unfortunately, I went right into IV use.
This part of Mallory's story will sound dismayingly familiar. DIY pain management becomes full-blown addiction.
Addiction dismantles Mallory's life. The job, her home, her friendships, everything falls away.
By 2019, Mallory is living on the street alone. And around this time, her brother, Quincy, who'd struggled with addiction for a longer time, he's doing great.
He went to rehab, and rehab put him on a buprenorphine product called Suboxone. They immediately put him on Suboxone, and he did excellent.
That's Jennifer again, Quincy and Mallory's mom.

Did he talk to you about, like, what was he saying about Suboxone at the time?

He told me, he said, Mom, this keeps me from going off the deep end. I can work.
I can live a real life on this medication. Quincy's experience here, not unusual, because Suboxone is a hell of a

drug. People who use it are far less likely to die of an overdose.
The World Health Organization

and Quincy's experience here, not unusual. Because Suboxone is a hell of a drug.
People who use it are far less likely to die of an overdose. The World Health Organization calls its active ingredient, again, buprenorphine, an essential medicine, along with drugs like amoxicillin and the measles vaccine.
One doctor I spoke to called it one of the most effective medications in medicine. Not just addiction medicine, all medicine, full stop.
And effective here doesn't just mean preventing death, which on its own, pretty awesome. Suboxone erases need.
It allows patients to swap that destructive cycle of addiction with the super boring cycles of routine living. It doesn't just prevent death, it fosters life.
Quincy was feeling that effect.

But his sister Mallory was living on the street,

so the next step was obvious.

Quincy asked Mallory to come to rehab too.

So brother and sister went to the same rehab facility and were put on the same drug, Suboxone.

My little brother was just in there prior to me,

and so it was kind of like a lot riding on it, you know.

Well, how did like being on Suboxone feel for you? Like, what was that like?

I didn't have the pain that I normally would be going through. And I didn't feel

the urge to use. So it just kind of helped you in some sense feel normal.

Normal is a normal thing to say after taking, say, antibiotics or cold medicine.

But a drug that makes you feel normal after another drug destroys your life,

that is a different kind of normal.

The pain that had kicked off her addiction in the first place,

in her knees, in her back, that had been cut way down.

And the urge to use again, that was just gone. So Mallory finishes rehab, finds a job and a place to live.
Well, how much do you attribute in terms of your experience or being able to get to where you are now? Like, how much of that do you attribute to Suboxone? I'm going to say 75% of my recovery is because of Suboxone. Up until this point, Mallory and Quincy had the same story.
Descent into addiction, first with pills, then injections, and then an ascent. Brother and sister, both on the path to recovery with the help of this drug.
And then, in 2020, the path splits. Quincy is finishing up rehab.
This one's in Orlando, a few hours from home.

So now he needs a place to live.

The next step after rehab is typically a sober house,

somewhere safe and clean to live while you look for a new job, for an apartment.

But the sober houses near Quincy's rehab wouldn't take him.

Some sober houses won't take people like Quincy,

because for them, Quincy isn't sober. They don't believe anyone on Suboxone or Buprenorphine is sober because Suboxone is an opioid, one that can be bought and sold.
Its closest cousin is methadone. The ideas behind methadone and Suboxone are roughly the same.
Swap dangerous opioids for safe ones. If you've heard the phrase harm reduction, that's the world where these two drugs live.

But it's worth saying, I think, that Suboxone is different from methadone in a few important ways. It's harder to overdose on, harder to abuse, and isn't as tightly controlled.
That combination of safety and access is the reason why there's so much excitement around Suboxone. But for some people, and some people running halfway houses, none of that matters.
Methadone, Suboxone, heroin, fentanyl, same difference. An opioid's an opioid.
Clean is clean. The opposite of clean is, well, you can't stay in the sober house.
In Mallory's world, Suboxone was a medicine, one that she should take every day for a very long time. But in the world that Quincy was trying to enter, it was a drug, a dangerous one.
Quincy's time in rehab was up, but he still needed a place to live. So he came off Suboxone.
And I said, are you sure you can do that? Yeah, I think I can.

I think I can. I said, are you sure? And he's like, yeah, I think so, Mama.
I said, okay, because I don't really have any choice. And he didn't.
27 days pass. We were having a pool party at my house.
And on Facebook, my daughter sees, rest in peace, Quincy. He was in the morgue for two or three days before we even found out.
Quincy died of an overdose on July 23rd, 2020. He was 31 years old.
After Quincy's death, the whole family could have fallen apart, but they didn't. Almost everyone expects Mallory to relapse.
She's only been sober a few months. Her brother just died.
But she doesn't. She doesn't relapse when her grandfather dies the next year.
She doesn't relapse when the father of her children dies the year after that. Instead, Mallory rebuilds her life.
She gets a job and gets promoted. She manages 10 people now.
And she buys a house, a five-bedroom, three-bath, 2400-square-foot house. She stays on Suboxone, and she stays okay.
Better than okay. She got a very good job with a mortgage company, working remote.
Her life is moving forward.

Yeah, it's just striking that you have, you know,

these two kids dealing with the same issue with two different, you know, experiences with this drug.

One's a success and one is dead.

Yeah.

Four years have passed since Quincy's death. Mallory has been on Suboxone that whole time.
And then recently, she drove over to her mom's house with some news. Mallory told Jennifer that she wanted to stop taking Suboxone.
Stop taking the drug that had contributed so much to her sobriety and had seen her through this unbelievably dark period. She would start by

tapering down, but the goal was to reach zero. She's like, I think, you know, I got to wean off

of it. You know, eventually I said, no, you do not.
I blew up. That was my reaction.
I blew up.

I just really can't bear the thought of losing another child. Before we get back to Mallory and her reasons for wanting to come off Suboxone, I want to tell you another story.
One that shows how this fight over the nature of addiction medicine plays out elsewhere in the treatment world, with pharmacists and with the DEA.

It helps explain both why Mallory doesn't want to take this drug anymore

and why we're having so much trouble getting people on this medication in the first place.

So before we get back to Mallory, I want to tell you what happened to Martin.

When I got your email this morning, I said,

I was thinking, I said, should I do this, should I not?

I said, let me go ahead and do it.

This is a Njoku, pharmacist in West Virginia. Why'd you say yes? Martin's story starts in the 80s.
When he moved from Nigeria, Right now, I'm a very angry person. I'm consumed with anger and bitterness.

Martin's story starts in the 80s,

when he moved from Nigeria to the U.S.

to enroll at Southeastern Oklahoma State University.

Dennis Rodman, of all people, was there at the same time.

After school, he moved to West Virginia.

And when he got there, it was love at first sight.

It's a beautiful state.

When I came down here for a job interview, I was just like, man, you know, I love this kind of environment. Martin's first job was at a Rite Aid.
He arrives in West Virginia around the start of the opioid epidemic, a crisis in which his state would remain at the center for years. Right at the beginning, you know, I'm noticing the usage of pain medication here.
There was more opioids being pushed, pushed, pushed. No treatment.
No treatment. So when did you start to see treatment being prescribed? I would say between 2014, 2015.
That's when we started seeing doctors write production for Suboxone, Subutex. Subutex is like Suboxone.
It's that same basic ingredient, buprenorphine.

But it doesn't have the added chemical that makes it harder to abuse.

Both medicines, Suboxone, Subutex,

are approved by the FDA to treat opioid use disorder.

By 2015, Martin co-owns a pharmacy.

It's called the Oak Hill Hometown Pharmacy.

And Martin knows that pharmacies have power. Individually, they can decide to fill or not fill prescriptions.
Collectively, those decisions form a kind of landscape, an ecosystem of treatment. What medicines are available and where? So with overdose death rates in West Virginia far higher than the rest of the country, a number of pharmacies, including some of the bigger ones, made a decision that would shape that treatment ecosystem.
Martin says the pharmacies refused to fill these prescriptions. They weren't doing it.
Did you talk to any of the pharmacists in town about this? Oh yeah, oh yeah, oh yeah, we used to talk. What were those conversations like? The conversation is like, I don't want this open in my pharmacy.
You know, all these drug junkies, you know, I don't want them. That was, you know, what one of them used to say.
Martin saw the toll of the opioid crisis in his town, saw his patients struggling with addiction, and Martin loved West Virginia, loved his community, enough to put hometown right there in the name. He wanted to help.
So what happened was, you know,

the dispensing of Subutex and Suboxone

fell on independent little people like me.

Patients drove long distances

to fill prescriptions at Martin's Pharmacy.

Over the next few years,

he filled thousands of prescriptions.

When floods devastated parts of the state in 2016,

he took care of more patients. Many paid out of pocket.
So about 9.20 this morning, we issued an immediate suspension order and issued an administrative inspection warrant to Oak Hill Hometown Pharmacy, which is Oak Hill, West Virginia. On August 8, 2019, the DEA suspended Martin's ability to dispense controlled substances.
This is the U.S. Attorney for the Southern District of West Virginia, Mike Stewart, in an interview he gave on the day of the raid.
Why did the feds raid the Oak Hill Hometown Pharmacy? Well, we had what we refer to as unresolvable red flags with respect to this pharmacy, and everybody knows the crushing burden of these pills, these drugs on this region. We take our responsibility seriously.
Martin filed an injunction, ended up with a hearing in front of a federal judge, and then argued again before a sort of DEA administrative judge. And the cases, well, they're pretty weird.
The cases are weird because both sides, Martin and the DEA, claim to be doing the same thing. The DEA on one side, as you just heard, suspended Martin's license to ease the burden of drugs in the region, and Martin on the other, who dispensed addiction medication to ease the burden of drugs in the region.
The DEA's allegations, among others, were around the number of prescriptions Martin was filling. That his patients would drive to Pennsylvania to receive prescriptions, the fact that some paid out of pocket, all red flags.
They also worried that he dispensed too much Subutex, that version of Suboxone that's easier to abuse. In short, that what Martin was dispensing could be used by his patients as a drug, not as a medicine.
And it's worth saying, I think, that this view, this fear from the DEA, it's not without justification. It's part of the basic history of opioids.
Heroin was first marketed not as a painkiller, as a party drug.

It was a treatment for morphine addiction, opioid addiction, just like buprenorphine is.

Eventually, both judges decided in Martin's favor.

And in their decisions, both judges reframed the DEA story.

They find that Martin's patients sometimes got their prescriptions out of state because West Virginia's addiction services were lacking.

That patients paid out of pocket because they didn't have insurance, or their insurance wouldn't cover treatment. The red flags that got the DEA involved in the first place, there weren't as much red flags for Martin as there were for the state, for the country, the way we're treating addiction.

It would be hard to overstate how decisive this victory was for Martin.

It would also be hard to overstate just how little that victory mattered.

I had to shut down the blood pharmacy.

I lost everything that I worked for.

That's nothing.

I mean, literally, you know, everything that I worked for just vanished. Despite having his registration reinstated, Martin's pharmacy went under.
Insurers cut ties with him, customers left. The accusations against him had far more staying power than the reality.
Martin is in his 60s, and instead of being retired, he's now still working. No longer for himself, but for another pharmacy.

Effectively, he's back to where he started. And then, just a few months ago, he got a letter from the DEA.
DEA and Health and Human Services, they issued a letter on medication for opioid use disorder. That's Suboxone.
The medicines like it. DJ is asking its registrants to ensure an adequate and uninterrupted supply of medication for opioid use disorder products.

This year, the DEA sent a letter urging pharmacists to prioritize Suboxone and similar drugs.

Basically, to do the thing that had destroyed Martin's livelihood.

Which might explain some of the anger, the bitterness. I mean, you know, it made me sad.
Because this letter should have been issued back in 2015, 2016. Yeah.
To me, it's too late to a letter. To me, this letter is too little too late.
Martin says that the pharmacy where he works now, like so many other pharmacies, is very cautious about dispensing suboxone and drugs like it. He says it can be a challenge to even get enough inventory for the patients who need it.
But Martin, he wants to change that. I'm a staunch advocate, you know, for people to get help.
Yeah. Despite everything that's happened.
I feel like there's a world where somebody else has been through everything that you've been through and says, you know what? I've had enough. I'll leave this to somebody else.
I would be an advocate for people with addiction to like that. I would do it I die because they are God's creation.

We shouldn't

throw them away.

We shouldn't

lock all of them away.

We shouldn't just,

you know,

just say,

okay,

let them die.

No,

that is,

to me,

that is morally wrong.

In my heart,

you know,

God

did not create

any junkie.

When we come back,

Mallory's reasons for coming off Suboxone. It's been four years since Mallory got off drugs with the help of Suboxone.

It's also been about four years since the judges decided in Martin's favor.

Today, the world of opioids looks much different than it did a decade ago.

Fentanyl has taken over, and fentanyl complicates Suboxone.

People addicted to fentanyl sometimes get sick. they take a full dose of Suboxone, so much so that some doctors are having their patients microdose Suboxone when they start, a method that seems to help with the sickness.
These drugs are still extremely effective, but need to be administered with a lot more care. So for patients starting on Suboxone, things aren't as straightforward as they once were.
For patients who have been on, patients like Mallory, fentanyl raises the stakes. It can be 50 times as potent as heroin.
And if Mallory were to relapse after coming off Suboxone, she would do so without the same built-up tolerance. Some doctors, when they start patients like Mallory on Suboxone, will explain that this drug is not a.
It's a band-aid. And it's a band-aid that you have to wear for a long time because it's so dangerous to come off.
In other words, if you're in, you need to stay in for the long haul. And Mallory wants out.
I really, really, really needed Suboxone for the first two years. but the desire to get high has left my mindset and my body.
Yeah. But how do you know that that like, how do you feel, I guess, that that lack of desire isn't tied to the fact of taking Suboxone, of taking medication? To be honest, I don't know.
I don't. On a recent weekend this spring, Mallory drove over to her mom's house in Jacksonville and told her that she started tapering down on her Suboxone dose.
You know, you're not doing opiates. You're just doing a different form of narcotic.
As a matter of fact, I found out in sobriety that I have ADHD. I've refused to get on medication because I don't want to be on any narcotics.
Yeah. So it's like, it's like whether it's a, it's in that category of like a treatment or medicine, or if it's not for you, there's not really much of a difference.
Yeah. I just don't want to be on narcotics for the rest of my life.
And is it just the idea of depending or is it more of like wanting to be fully clean and sober, like off all this stuff? It's just the idea of depending upon a drug. And why is that? Why is that bad? I did that in addiction and I just don't want to be on a drug that I don't have to be on if I don't have to be on it.
It is a very hard sell to ask someone for whom opioid dependence destroyed their life to depend on a different opioid. To treat dependence, depend on something else.
Even if that person has seen firsthand the transformational power of that drug, if they lost their brother when he went off that drug. For Mallory, the distinction between drug and medicine just doesn't matter anymore.
But dependence, it's not the only thing driving Mallory. She told me that Suboxone is like a medical scarlet letter.
Any doctor she goes to, any time they ask what medication she's taking, the second she says Suboxone, a change happens. The word addict is suddenly in the room with them, an unwelcome guest.
When she interacts with the medical world, a trip to the ER, a general checkup, the world of medicine will treat Mallory like an addict. But even though these things, the dependence, the scarlet letter, even though these things bother Mallory, what seems to bother her most are her teeth.
I literally have six teeth of my own in my mouth. I have a full-on denture, and the teeth that I have in the bottom of my mouth are still falling.
They're falling apart, and I'm likely going to have to either get implants or a denture on the bottom. There's an FDA warning that applies to drugs like Suboxone.
The tooth decay and other dental issues have been reported by patients. Issues that were not unfamiliar to Mallory when she was in active addiction.
But she expected them to stop when she stopped using drugs. I would have expected that if that was something I was still using, but I'm not.
I'm taking care of myself, I'm healthy, and my teeth are just still falling apart. It's very discouraging.
Yeah. It's like having to deal with that is sort of like a reminder being an active addiction or something.
Like you can have all this stuff that's changed, like the house and like the job, but if you still have this everyday sign of the old days, then that being a difficult thing to deal with. Right.
I mean, not just the reminders of trying to forgive yourself

and the damage that you caused to your family and your children.

But, you know, it's like I did all this work to get sober and to get my life right,

and yet my teeth are still falling out like I'm a meth head or something. What's happening to Mallory's teeth is more than just a reminder of addiction.
It's a stand-in for it. Maybe not addiction itself, but for the way that we Americans think about it.
We talk about being clean, like sobriety is having some big set of pearly whites. By that way of thinking, meds like Suboxone give the appearance of that same pearly white sobriety, but they're veneers.
A facade for something broken, still broken, and rotting underneath. That story of medication as a false front is everywhere.

It's there in the DEA's policy towards these drugs over the last few decades,

in pharmacies' refusal to carry them,

in doctors' hesitance to prescribe these medications in the first place.

It's a story that's an epidemic in its own right,

widespread and stubborn,

living right alongside the opioid epidemic itself,

contributing to all that loss of life.

Since we spoke, Mallory did what she said she was going to do.

She tapered down on her Suboxone dose, and now she's completely off.

It's been about two months.

She says she's feeling fine. Thank you.
Claudine Abade is the executive producer of Atlantic Audio. Andrea Valdez is our managing editor.

Next week, a story about stimulant medication and the cure for unrealized potential.

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I'm David Frum, a staff writer at The Atlantic. I'm starting a new show where each week I'll dig deep into the big questions people have about our politics and our society.
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