Back in 2018, the opioid crisis in Arizona was everywhere. Headlines were dominated by it, there was a special session at the capitol to address it. Lawmakers unanimously passed the Arizona Opioid Epidemic Act, putting millions toward enforcement and treatment.
But, Dr. Melody Glenn, an addiction and emergency physician in the Valley as well as an assistant professor at the University of Arizona's Medical School, says some of the most effective treatments for opioid use disorder are too hard to get. In a recent op-ed in The Arizona Republic, she argues that fentanyl is easier for many of her patients to get than the best treatment for it.
Glenn joined The Show to discuss, and why we don’t talk about the opioid crisis so much anymore, even though it’s still very much present.
Full conversation
DR. MELODY GLENN: You're absolutely right. Even though we're not talking about it, it's not because it's magically gone away. I think we just sort of lost interest in it. We still have a huge overdose crisis in our country and in our state. In 2024, over 100,000 people died of a fatal overdose.
LAUREN GILGER: Wow, OK, so still a massive problem. You treat patients with addiction, right? And who are addicted to these particularly incredibly addictive drugs like fentanyl, right? Talk a little bit about what this looks like for people, how difficult it can be to get out of it.
GLENN: Yeah, lots of people who I see who use fentanyl and are addicted to it. They've come from a background with a lot of trauma in their lives, whether they've had family members who had addiction or were incarcerated or abused in their family. Many of them are homeless at this time or have ongoing stressors and crises, and fentanyl helps them cope, helps them manage.
Sometimes they have physical pain as well. If they don't have physical pain, there's often some emotional or spiritual pain, and the fentanyl takes that away. So there's lots of root causes there that are very difficult to unravel and to treat, and it can take a long time to do so.
Luckily there is a medication, two medications, buprenorphine and methadone, that really help people get off of illicit fentanyl, help them regain their lives, help them get stability, and then once they're doing better, they can work on some of those root causes.
GILGER: Right. So these treatments that are now available were pretty groundbreaking when they were approved. Talk a little bit about how, how they work and how effective they can be.
GLENN: If you see opioid use disorder like a chronic disease, which is how I see it and how most other physicians see it, these medications are much more effective than anything else we have.
For example, we have this thing called the number needed to treat. So for any medication that people take, the number needed to treat tells us how many people have to receive this medication for one person to receive a clinical benefit. For things like aspirin, baby aspirin, which we tell people to take all the time for their heart disease, the number needed to treat is over 50. So out of every 50 people taking aspirin, only one will have a clinical benefit.
In contrast, these medications for opioid use disorder, or mode for short, have a number need to treat only two, and that's remarkable. So for every two people taking these meds, one sees benefit.
GILGER: OK, OK. But you, you say these are really hard to get like as a physician with a patient who you know needs this kind of medication, you often can't get it. Tell us why.
GLENN: There's lots of factors involved. One is stigma. There's a lot of stigma against these medications. There is a phrase that's often used in AA called a drug is a drug, and that's been internalized by lots of people that they feel guilty getting on a medication to get off of fentanyl. They want to do it on their own. They want to do it without medications.
So there's a stigma that people maybe don't want to take these meds or their family members don't want them to take these medications. There are also regulatory challenges. Methadone is one of the most highly regulated medications in the country. For a clinic to offer methadone, they have to comply with a long list of federal requirements. It's very difficult to do. And so half of the country doesn't have access to a methadone clinic. I have lots of patients in rural Arizona who have to drive one hour a day to get methadone because they don't have one in their town.
GILGER: Wow. So lots of challenges there, but you also say there are challenges in just getting it paid for.
GLENN: Exactly. There are prior authorizations on these medications. Sometimes patients have to prove that they are going to have a failure without the meds, i.e., they have an overdose. If they survive that overdose, perhaps they can then get the prior authorization approved to get the life saving medication.
Sometimes the amount of the medication that they need is more than the average person, and so there's a prior authorization on certain amounts of medication that can be prescribed and there's also prior authorizations on certain formulations of the medications.
GILGER: So basically this means that as a physician, it goes beyond writing a prescription. You have to make an argument that this patient needs this medication, and this is why.
GLENN: Exactly. Although prior authorizations are intended to save money for the insurance companies, they don't even always do that. Sometimes patients have worse health outcomes that then lead to increased hospitalizations which end up costing the system even more money.
GILGER: So these prior authorizations are supposed to right you, like you said, control outrageous costs in healthcare, make sure that providers aren't overlooking cheaper alternatives that work just as well. Have you seen them be successful in doing that before?
GLENN: No. The AMA does an annual survey too.
GILGER: The American Medical Association.
GLENN: Yeah, yes, and it talks to physicians about their experience with prior authorizations, and it's overwhelmingly negative.
GILGER: So there have been efforts at the state legislature here and many other states and I think almost a dozen have passed legislation that would address this, that would get rid of these requirements for these particular medications. What would that do?
GLENN: I think this would make a huge difference, especially in my practice. So a bunch of my practices at the hospital level and the emergency department, and the addiction consult service where we see patients who have been admitted for other things, whether traumatic injuries, burns, infections, and we see them if they have a substance use issue start these medications, but some of these medications we can't start in the hospital because we can't do the prior authorization in time.
For my patients in the emergency department, I can't do a prior authorization form that takes seven to 14 days to get back, and I'm just seeing someone in the emergency department who I'm discharging in a couple of hours. Same with the consult service, patients might be discharged later that day or the next, not enough time to get this prior authorization. So I don't have access to a lot of medications that I would love to offer my patients, so I think we do much better on them.
GILGER: What do you do instead? So like you, you see someone in the emergency room who, you know, you can diagnose in this way, you see, you say they would really benefit from these medications. I can't get them for them fast enough. They're only here for this amount of time. What do you prescribe instead? How do you treat them?
GLENN: So I can start methadone. I can start Suboxone, and that goes underneath their tongue and it dissolves. I can start those in the emergency department. I can also send a prescription for regular Suboxone, but not all of my patients can pick up that prescription. They can't pay for it at time of discharge, even if they can, sometimes it gets stolen. Lots of my patients don't have homes. They don't have stable living environments. They would really benefit from a monthly injectable form instead. And then I usually get a call. Someone calls the consult service, lets me know my patients back. They weren't able to get their medication. They relapsed onto fentanyl. Their heart failure got worse, and now they're back in the hospital.
GILGER: It sounds like something of a vicious cycle.
GLENN: It definitely is, and it's extremely frustrating. I feel like I spend so much of my time trying to work on these systemic barriers, you know, that's why I wrote the op-ed. That's why I'm trying to get more involved in advocacy, because otherwise I just, the same things keep coming up again and again and again for my patients, and I can't fix them otherwise.
