As the United States wrestles with the increasingly tragic level of opioid drug use, one state in particular is representative of the challenges we all face and the opportunity for innovation.
Massachusetts is being hit especially hard by the opioid crisis, and officials have even said that this "kills more people in Massachusetts than car accidents and guns combined". According to the Massachusetts Department of Public Health, more than 1,379 Massachusetts deaths in 2015 were attributable to a fatal dose of heroin or another opioid - nearly four people died each day statewide.
We must support and encourage the work that's already been done to strengthen treatment systems. Many healthcare visionaries are already working to combat the barriers that exist to treatment, and we've been fortunate enough to get to know some of these individuals.
Dr. Sarah Wakeman is the Medical Director for the Substance Use Disorder Initiative at Massachusetts General Hospital, where she uses a patient-centered approach and leverages community partners to care for patients with substance use disorder. We had the opportunity to discuss the opioid crisis with her, and how we can come together to innovate solutions that transcend the many barriers to treatment.
The Changing Face of the Opioid Crisis
"We've seen a total shift in heroin use, and a lot of that is due to prescription opioids," Dr. Wakeman says. She described the climate in the 1990s, when there was a great deal of advocacy for better management of pain. "Unfortunately," Dr. Wakeman recounts, "a constellation of factors came together with the result being that we saw this skyrocketing rate of physicians prescribing opioids."
She mentions that doctors were led to believe opioids were not addictive when used to treat pain. Today, we are suffering the effects of those beliefs. Due to a pervasive misperception that opioids are not dangerous, those with a vulnerability to addiction follow a common pathway of taking opioids by mouth, then, out of desperation, begin using heroin due to cost or accessibility.
"If you talk to these individuals, they all say they never thought they would ever inject heroin, but there's a sad, but predictable, path that happens."
The demographics of the crisis are also changing: "If you look to our last heroin crisis in the 1960s, the majority of users were male, older, 30s 40s, inner city, lower socioeconomic, equally black and white. If you look at the current epidemic, it's predominantly white, much younger, increasingly equally male and female."
Barriers to Substance Use Treatment: Stigma and Systems
Pervasive stigma also remains one of the biggest barriers in treatment; "people feel ashamed and feel they will be blamed or punished," Dr. Wakeman notes.
The stigma around substance use is perpetuated and compounded by a non-existent or inefficient treatment system.
Dr. Wakeman points to the complex process through which people must go to obtain treatment. "With addiction treatment, it's black or white, take it or leave it - these are the options," she says, adding: "The current approach is analogous to telling someone with a heart attack to go find treatment on their own."
Although our current medical infrastructure does not have an efficient or easily accessible system for treatment of substance use, Dr. Wakeman shares a message of hope: "There's a mistaken notion that this is a difficult to treat condition," she says, but contrary to this misperception, "The majority of people do recover."
Transcending Barriers and Innovation Around Substance Use
Although the barriers to better substance use treatment seem daunting, Dr. Wakeman points to some tangible strategies we can use to tackle them. The first starts on an individual level. Our words do matter when we talk about those suffering from substance use disorder, and we must avoid the negative language that's commonly misattributed to those suffering from this treatable condition.
Dr. Wakeman also emphasizes the need to incorporate quality improvement in substance use disorder treatment. We must track and improve the processes of care. Helping substance use clinicians to envision patient mapping is an important to shed light on the challenges and how to address them.
If substance use treatment could be as efficient as finding a parking spot at the local shopping malls, this would be a start. Dr. Wakeman draws this unlikely analogy because parking lots often have a digital display showing how many spots they have left. Could we not develop a similar innovation to show available clinic appointments for substance use disorder or open beds for inpatient treatment?
Data around treatment rates and overdose is also scarce, but essential. "We need a systematic way to report on outcome metrics," she says. There is a huge need for real time data, but data with substance use is difficult to obtain due to a several year lag. Because of this lack of data, it is difficult to mobilize a real public health response.
"We need to get the system caught up to where the science is," she says, pointing to the need for unified metrics and real time data reporting. Evidence-based advocacy is essential.
Dr. Wakeman is just one example of many, many clinicians trying to make a difference in the treatment of substance use disorder. And Boston is just one of the many cities struggling to protect its citizens from this devastating disease. My hope is that by sharing Dr. Wakeman's voice, we can call more attention to this issue, leverage her work beyond Boston and Massachusetts, and reduce the prevalence of substance use disorder nationwide as quickly as possible.
Please share your thoughts and comments as well as stories that will shine more light on the growing challenge of substance use disorder.