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Dr. John Spangler: Addiction relapse is all too easy in N.C..

Dr. John Spangler: Addiction relapse is all too easy in N.C..

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What do you get when you cross opioid drug addiction with N.C. Medicaid?


This is the situation that faces one of my patients, Melissa (not her real name).

I saw her last Monday.

She had been doing great, but recently was beset by financial stress — from getting a full-time job.

She lost her Medicaid (because she was making too much money) and cannot qualify for Obamacare (because she was making too little); this puts her in a tight financial situation. Her addiction treatment medication — buprenorphine plus naloxone — costs about $20 a day without insurance.

So she could not afford the medication and had severe cravings and withdrawals when she was off of it. She confessed to using pain meds off the street over the weekend since she had run out.

I strongly affirmed her honesty and openness. She will talk with her addiction therapist and recovery group about her relapse as well.

Melissa is a hard worker. Abandoned by her abusive husband, she is mother of two young children and struggles to make ends meet. Part of her struggle to do the right thing is to remain abstinent of pain pills.

North Carolina is one of the states that has not expanded Medicaid under the Affordable Care Act. Moreover, lawmakers and many others in our state have disparaged Obamacare. Political candidates have campaigned to “Repeal and Replace!” in the past.

Indeed, a number of states’ attorneys general sued the federal government to have the Affordable Care Act nullified.

Two weeks ago, the Supreme Court ruled 7-2 against them, upholding the law yet again. Still, the fight is not over. Texas Attorney General Ken Paxton tweeted that day: “I will continue to fight this law — in fact, I have only just begun.”

I did some research into drug overdoses and politics in our state by analyzing publicly available statistics from the Robert Wood Johnson Foundation. Each year, this foundation publishes county-level health-related data for every state (

Using its dataset, I found that 32% of drug overdoses in North Carolina are related to two factors in each county: the percentage of the population that is white and the county’s median household income.

I obtained these results through linear regression, which lets me find predictors of drug overdoses while simultaneously controlling for other county factors (e.g., population, rurality, education, etc.).

I found that for each 1% increase in a county’s white population, there are three more drug overdoses per 100,000 population each year in that county. For each 1% increase in a county’s median household income, there is just under one more drug overdose each year.

Percentage of population that is white. Lower household incomes. Hold those thoughts.

What predicted the percentage of the vote a county had for former President Trump in 2016? Three factors: 1) The percentage of the county’s population that was white; 2) the percentage of the county’s population that was rural; and 3) the percentage of the population enrolled in Medicaid.

Higher levels of these three factors accounted for 82% of a county’s vote for Donald Trump. As you know, he campaigned on repealing Obamacare, which would have adversely affected North Carolina’s Medicaid as well. (I should note: These findings have not been peer-reviewed, which could subject them to change.)

I use these somewhat surprising results to make this point: Our state’s approach to drug addiction treatment and to Medicaid expansion through the Affordable Care Act should be neither political nor (of course not!) racial.

Indeed, if our state were to go down these paths, it turns out that lower-income whites and counties that voted for Trump probably need drug treatment and Medicaid expansion the most.

In other words, if my analysis is correct, the counties needing Medicaid the most voted for it the least.

Which brings me back to Melissa. When her job shifted from part-time to full-time, her Medicaid ended because she earned too much; and she could not get Obamacare because she earned too little.

She ran out of the medication assisting her recovery and went into severe withdrawal. She briefly relapsed.

Fortunately, our addiction clinic has since gotten this drug free for her from a charity care fund.

All people have dignity and worth. We bear the image of our Creator. But if politicians think Obamacare and Medicaid reward only the idle and indolent, they are in for a surprise.

Because the poster child for Medicaid expansion, Obamacare and addiction treatment is Melissa.

I applaud the Supreme Court for its decision and I implore our state legislators to expand Medicaid.

I implore them and our Washington congressional delegation to fully fund and support the Affordable Care Act.

Let’s not allow opioid addiction and unexpanded N.C. Medicaid to ever cause relapse again.

Dr. John Spangler is a family physician who practices in Winston-Salem.


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