Jaymie Mai wouldn't say so herself, but she is a crucial character in the story of America's opioid epidemic. For 19 years, Mai has served as the primary pharmacist at the Washington State Department of Labor & Industries (LNI), a job that includes reviewing cases under the state's workers' compensation system to make sure everything is running smoothly. But at one point, Mai noticed a significant number of opioid-related deaths — and ended up blowing the whistle on the opioid epidemic.
In the early 2000s, a case manager came to Mai to ask about the deaths of fairly young workers who had experienced a minor injury on the job, like a back or shoulder sprain. The records Mai reviewed showed that the workers who died all had been prescribed opioids, and sometimes high-dose opioids that weren't necessarily appropriate for their injuries. Mai decided to look into whether what she was looking at was just a fluke, or part of a more pervasive problem.
"I was just doing my job, and I spotted something that I was very concerned about," Mai tells Bustle. "And I started to kind of pull that string to try to identify what's going on."
In 2005, there were 14,917 opioid-related overdose deaths in the United States. That year, Mai was an integral part of drafting a report that, drawing on the Washington state workers' compensations system for its research, revealed there was a serious issue with how opioids were being prescribed.
Mai is often described as one of the very first people in the nation to draw attention to the overprescribing of opioids, which plays an outsized role in the issues the United States is seeing today. What she did was so important that author Sam Quinones wrote about her role in his 2015 book, Dreamland: The True Tale of America's Opiate Epidemic. Sen. Patty Murphy (D-WA) highlighted her story in remarks to the Senate Health, Education, Labor, and Pensions (HELP) Committee. And a report Mai worked on was cited by Pacific Standard as one of five studies to read to understand America's opioid epidemic.
There is one event that various studies and books pinpoint as the beginning of the overprescribing of opioids. In 1995, the Federal Drug Administration approved the painkiller OxyContin, which has been proven effective for pain management. It was claimed to have less misuse potential than other drugs on the market, because it had an extended-release formula that would mean delayed absorption of the drug. Over the next few years, its manufacturer "aggressively" misrepresented the potential for addiction when marketing the drug, according to a 2009 study published in the American Journal of Public Health. The company behind OxyContin, Purdue Pharma, has vehemently pushed back on what it calls "misleading and inflammatory allegations" about its alleged role in the opioid epidemic.
"There were some days where you kind of want to go into a room and close the door and scream for awhile."
Mai and Gary Franklin, the medical director at LNI, tried to raise a red flag by sending letters to providers that asked them to be cautious and follow prescribing guidelines. They also went to conferences to make the medical community aware of the dangers of overprescribing. Mai says they were shouted out of rooms, and that the medical provider community and pharmaceutical advocacy groups didn't believe their data.
The general response to their warnings, according to Mai, was an insistence that opioids are life-saving for people with pain, and that those who died were just "folks that aren't following directions." Mai and Franklin addressed that criticism through their research, controlling for the potential of deaths due to combining opioids with other drugs. Their research showed that people were, in fact, dying due to opioids alone.
"There were some days where you kind of want to go into a room and close the door and scream for awhile just to get that frustration out," Mai tells Bustle. "You're like, "Argh! Why aren't people believing the data? What is the problem?"
After the Washington State Agency Medical Directors' Group published its first statewide guidelines on prescribing opioids, which Mai played a role in developing, in 2007, a provider sued the state. The provider claimed one of the guidelines prevented disabled patients from getting the medication they needed; the lawsuit was ultimately dismissed two years later.
That same year, Mai began working with the Washington state epidemiologist, whose role is partly to investigate public health risks, to expand her research beyond the workers' compensation population. It was around 2010, once she had a wider body of data the covered the entire state, that Mai says the people who had opposed her from the beginning finally started to see that "opioids may not be as safe as they were taught or were told."
It may have been too late. According to a 2014 study published in the American Medical Association's journal JAMA Psychiatry, 75% of people who were using heroin, an illicit opioid, had been introduced to opioids through prescriptions. In the 1960s, heroin had been the first introduction to opioids for 80% of people who used the drug, according to the study.
Opioid overdose deaths have not stopped increasing for at least 20 years, and with the emergence of fentanyl, a synthetic opioid that is 50 to 100 times stronger than morphine, the death rates have only increased. In 2017, the most recent year for which data is available, there were 47,600 opioid-related overdose deaths. That's an increase of more than 235% since Mai first blew the whistle that something was very wrong with how opioids were being prescribed.
Mai continues to work on ending the opioid problem in Washington, including as a co-lead on the Washington State Opioid Response Plan's Prevention team, which is tasked with assessing progress in the state's opioid misuse prevention goals and identifying any new issues. But when it comes to how the U.S. government has handled opioids since she sounded the alarm, Mai hesitates.
"It's hard to say what works and what doesn't work, because it is an epidemic, and I think everybody is just throwing everything at it," she says.
She says it's important to focus on those who currently have a substance use disorder, "because they're alive and we can try to intervene," and on preventing people from getting to that point in the first place. But she doesn't think the country is "anywhere near" done addressing its issues with opioids yet.
"We're making progress, but we have to continue to be persistent and to focus in this area," Mai says. "Because we're not close."
If you or someone you know is seeking help for substance use, call the SAMHSA National Helpline at 1-800-662-HELP(4357).