The Borderlands Are Not Flooded with Fentanyl: A Q&A with Dr. Melody Glenn, author of Mother of Methadone

Dr. Melody Glenn is an associate professor of emergency medicine at the University of Arizona. She’s also the author of Mother of Methadone, available now from Beacon Press. In the book, Dr. Glenn tells the story of Dr. Marie Nyswander, who developed methadone maintenance as a therapy for heroin use in the 1960s, weaving it together with her own story of incorporating addiction treatment into emergency medicine. (Whereas Dr. Nyswander primarily treated heroin users, Dr. Glenn’s patients today mainly use fentanyl.)

The book blends memoir, history, medical sociology, and what Dr. Glenn calls “speculative nonfiction”—using elements of fiction to reconstruct events that would otherwise be lost to history. The Border Chronicle spoke with Dr. Glenn about her work, her book, and its relevance to the border.

Why did you choose to work in emergency medicine?

One reason I liked emergency medicine is how we were able to treat everybody. We don’t have to worry about copays. Whoever needs help can come, and we’re there for them. We treat men, women, children, and all kinds of medical problems. I also see the emergency department as our country’s safety net for health care. Everyone can go in, without needing to have health insurance, without needing to be documented.

In the book, you discuss three different medications used to treat addiction: buprenorphine, also known as Suboxone; methadone; and naloxone. How do they all differ?

Methadone and buprenorphine are both medications for opioid use disorder. Methadone is a “full opioid agonist.” So if you imagine a ball and a cup, the cup is your brain’s opioid receptor, and the ball is an opioid. When those molecules are bound, the brain feels more calm, more relaxed. Pain dulls. People slow down their breathing. If you take a full opioid agonist, there’s more of an effect. And so there is the risk of overdose.

Buprenorphine, meanwhile, is what we call a “partial opioid agonist.” So there’s a ceiling effect. It’s like taking a dimmer switch and putting it just on the medium setting. People can take more and more and more, but the light won’t get brighter, whereas with methadone it will. So bupe is very hard to overdose on.

Naloxone is an opioid “antagonist.” It reverses the effects. It detaches that ball from the cup. So if someone has had an opioid overdose—they’ve taken too much fentanyl, for example—you can give them naloxone. Any layperson can do this—a little spritz up their nose, and then they’ll wake up, as long as it hasn’t been too long.

Is fentanyl use particularly prevalent in the borderlands?

No, I think this is a huge source of misinformation and the politicization that is not really based in fact. Here in Arizona, we have just average rates of opioid overdose. I hear this argument all the time: that because fentanyl is coming from Mexico and it’s coming through the border, Arizona is going to be flooded with fentanyl. But that’s just not what we’re seeing. It’s just very average levels.

You are the medical director for several border fire departments. What does that entail?

The biggest one is Nogales Fire. There’s also Rio Rico, Sonora, Elgin, Patagonia, and Tubac. I work with them on the protocols that their paramedics and EMTs follow in the field when they’re providing medical care.

Are those fire departments facing challenges that are unique to the border region?

A little bit, but not so much. I think the biggest factor is that they’re just very rural. They have to transport longer distances, and they have fewer resources. Sometimes they do respond to calls on the border. Usually, it’s for U.S. citizens who have been in Mexico, were hospitalized, and they’ll transport them to a U.S. hospital. It’s a pretty calm, tranquil area in general.

 

Can you talk about the Naloxone Leave Behind program that you helped start?

The fire departments in Santa Cruz County were the first in the state to offer “leave behind” naloxone. Other fire departments have always carried naloxone on board, so that if they respond to someone who’s overdosed, they can give them the medication and wake them up. But it was very rare to actually give out these kits to community members, to families, friends, or people who use drugs, so that if they were to witness an overdose, they themselves could give them medication—because it might take some time for the fire department to arrive, especially in these rural areas.

EMTs and paramedics are the front-line responders for the opioid epidemic. They see so many people who have overdosed. They see the same people over and over again, sometimes on the same shift, and they often felt very frustrated by this.

Once they realized they could start giving out naloxone, once they realized that there are very effective treatments that they could talk to patients about, it really changed their approach to people who use drugs to one that was much more open and accepting. They were so supportive of this program. I just couldn’t get over it. They really took off running with it. And as a medical director, I can tell you that doesn’t happen for lots of things that I try to implement. But they went on the radio and gave public service announcements, they had tabling events in town, like, they hung up giant banners on the stations telling people to come and get naloxone. It was so cool to see.

In the book, you describe a “narco farm” in Kentucky along with a methadone clinic where you have worked. How would you compare or contrast those two different models?

Really, not a whole lot has changed over those two time periods. Treatment environments feel like jails and prisons. That’s what the narcotics farm, also known as “narco,” was. It was jointly run by the U.S. Public Health Service and the Bureau of Prisons. Because they really couldn’t figure out whether addiction was a crime or a medical condition, they just treated it like both. This was in Lexington, Kentucky. There was another one in Texas. Patients could either check in voluntarily or, if they were arrested for drug-related charges, they could be sent there instead of another jail or prison. There were a lot of people there, men and women. The therapeutic model they followed was abstinence based, so there was no maintenance treatment. They did start using methadone pretty early on, but just to detox people off of heroin—so for like two weeks, you would get a tapering course of methadone, on to nothing. One of the first Addicts Anonymous groups was founded at the narco farm. They were also supposed to do outdoor activities, eat healthy, plant kale, work on a farm. Kind of similar to what RFK has been talking about in terms of his wellness farms. But they tried that, and it didn’t really work. The relapse rate was around 90 percent when people left.

And the methadone clinic. I started working at a methadone clinic a few years ago. When I first showed up for my interview, I was just sort of shocked at what it felt like, how different it felt from other clinics. There was a police officer patrolling. The parking lot was surrounded by barbed wire and a fence that locked after hours. There were people milling about that the police officer was trying to tell to leave. Once I went inside, there were all these bulletproof Plexiglas windows between the patients and the staff. You have to be badged into different areas. There were all these rules on pieces of paper taped to the walls about mandatory urine drug screens and other things. If you go to a dermatology clinic, for example, it’s the exact opposite.

 

 

How can we be good neighbors to people who use drugs in our communities?

A basic thing is to realize that if you see someone, it might be in a moment of crisis. If you see someone sort of walking down the street, maybe muttering to themselves, looking a little disheveled, that is probably not how they look all the time. I have seen patients like that in the emergency department, and then I see them a few weeks later at the methadone clinic, and it’s a completely different state of mind, and you wouldn’t even recognize them. So I think that’s important to recognize.

What kinds of systemic change are still necessary?

I think we need to make treatment much more accessible. Lots of Arizona doesn’t even have access to a methadone clinic. I think federal regulation around methadone needs to change so it can be dispensed at any pharmacy, because now patients have to go to the methadone clinic basically every day to get their dose. It would be really nice, especially in these rural areas, if they could just go to their Walgreens or CVS or whatever and pick up their methadone for the week or the month.

I think we need to spend more resources on harm reduction, treatment, and housing, and less on persecution, criminalization, and incarceration. A large amount of our prison population expansion has happened because of the war on drugs. It’s estimated that two-thirds of people who are incarcerated have a substance use disorder, but very few of them are getting any kind of treatment. We’re still using incarceration as the primary way to handle addiction.

In terms of the border, the fact that this is being used as justification to militarize the border has been shocking for me to watch. The United States has always used drug-control policies as a way to scapegoat a racialized population. We did that with our very first anti-drug legislation with Chinese Americans in San Francisco when we passed opium laws, when we had mandatory minimums for crack cocaine that were 100 times greater than for powder cocaine targeting Black Americans. We’re doing it again with fentanyl, with Mexican Americans and Mexicans.

I hear people say, if we just stop the supply, if we just build the border wall and seize more drugs, we will solve the problem, so we don’t need access to treatment. But studies show that’s not true. After drug seizures happen, there are usually more overdoses in the community. And we’ve just never been successful at eliminating the supply ever before. People use drugs. People like to get high across the centuries. That’s been a fact. And that’s not changing.

Mother of Methadone can be purchased from Beacon Press.

This interview has been edited for length and clarity.

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