Take a look back at our first season as we recap what we’ve learned about the opioid crisis. It’s the first season finale of The Problem!
It starts with a plant.
The opium poppy, which goes by the name of the breadseed poppy more often these days, is a greyish greenish plant, about a yard tall.
This plant has been with us for as long as we’ve been going as a species, and over the millennia, we’ve made the fruit of the poppy stronger and stronger, bringing opiates and opioids into the world.
From heroin to fentanyl, our medicines grew into more powerful weapons in the battle on pain.
Around thirty years ago, that battle became an outright war, as doctors declared pain a fifth vital sign – something to be eliminated and conquered outright in the course of clinical practice.
We’ll never know if that declaration to destroy pain, in a vacuum, would have led to the opioid crisis.
How could we? In a society, nothing – big or small – occurs in a vacuum.
The fifth vital sign movement was joined by a letter to the editors of the New England Journal of Medicine by a physician named Hershel Jick, whose study on the effects of opioids in inpatient settings was misinterpreted and used to justify the proliferation of opioids.
It was joined by the collapse of manufacturing jobs. It was joined by direct marketing, and it was joined by the great recession.
It wasn’t one cause that led to the thousands of deaths we’ve seen in the opioid crisis.
A catastrophic failure of multiple industries and policies piled up within the span of a few decades, and an awful convergence of commerce, culture and prescriptions led to something that would take the efforts of professionals from a wide variety of fields to even begin to untangle.
Welcome to our first season finale.
I’m your host, Phil Lofton.
Over the season, we’ve looked at so many different disciplines and institutions’ perspectives on the opioid crisis – how they talk about it, how they fight it, and how they think about it.
We could focus on discussing the diversity of approaches presented by our experts, but I think the previous episodes did a bang-up job of that already.
Instead, I want to focus on the commonalities – those little threads that leap out from individual episodes and show how these disciplines come together to fight the crisis.
This episode, we’ll talk about the history of the crisis, how we’ve learned to improve care, reduce harm, and why fighting the stigma associated with substance use disorder may be one of the most important steps we can take.
One of the biggest things that we’ve learned this season is how the crisis began.
Here’s a clip from our talk with Kurt Kroenke, the legendary symptoms researcher, from back in episode 2.
I’d say there’s been a couple waves. So when I first started out, pain was always felt to be an indicator of something else. Something specific. As I mentioned earlier, there’s this disease model. We think everything crosses back to a disease, but there’s a lot of pain that’s mainly a symptom somewhere in the body and we are testing doesn’t help us, you know, MRIs, blood tests and so forth. So then a little over 25 years ago, the early two thousands, there was a movement to represent, to recognize pain as an entity onto itself and a more humane approach to pain. So there was a big push to recognize pain, better treat pain, look at pain as any other disease because it causes a lot of suffering. So there was a big push to screen for pain, treat pain. And along with that came the issue of using more opiates.
Andy Chambers, the Addiction Psychiatrist that you heard from in our fifth episode, also had some thoughts about the origins of the crisis – especially how it related to mental and behavioral health.
It kind of began with deinstitutionalization in the sixties and seventies closing a state hospitals and um, at the same time you have the war on drugs, which was really of a political and cultural movement in the United States to decide we’re going to address the drug problem through criminalization. So think of those two things happening at the same time, right? The, the, the slow motion, sort of degradation of behavioral health care while criminalizing drug addiction. And no one knew that mental illness and drug addiction are biologically interconnected diseases of the brain.
So what you end up doing now is beginning to criminalize mental illness itself.
A lot of our guests have had some ideas about how we can use the lessons from this crisis to provide better care to folks experiencing addiction. Chris Harle, one of our informatics experts from episode 6, talked about changing patients’ electronic medical records to provide the most relevant information to doctors all in one place.
What are all the things we’ve tried to treat them with, but having to work. What are the things we’ve tried that did work, what are they currently on and what are the risk factors and what are the doses of their medications? Are these moderate risk or high risk doses of opioids that we need to cut back on? We need all of that current and historical information in a single place and organized in a way that’s a cognitively pleasing. The way that they sort of fits with the way their brain works and it’s not how information is typically presented in the EHR. It’s all over the place and it makes it hard
During our conversation with Jim McClelland, Indiana’s Drug Czar, he applauded local efforts by Indianapolis’ safety net health system, Eskenazi Health, to integrate mental health with addiction care, to better care for the whole person.
The surgeon general issued a report earlier this year that indicated that about 45% of people with a mental illness diagnosis also have a substance use disorder. Although only about 51% are getting treatment for either, and only a small minority are getting treatment for both and they’re connected with each other. Eskenazi has done some really interesting work that was published not too long ago where they, at their federally qualified health centers, they have integrated primary care and behavioral health, including a treatment for addiction and mental illnesses and augmented those services with nonmedical services, that help deal with some of the social and behavioral problems that individuals are facing. And they found that that combination significantly reduced future hospitalizations and visits to emergency departments. So it’s a way to save money and also improve outcomes.
Earlier in our season, we interviewed two people at the forefront of this new care model, Author of the 2 by 4 model, Andy Chambers and Eskenazi Midtown CEO Ashley Overley.
There’s no reason we can’t move to this integration within behavioral health where patients with basically any major addiction in any major mental illness can get, can walk into a building and get all that treated in whatever combination that got it without going somewhere else, without needing to do that. And if you do that, the care is going to be better and have more effective, better outcomes.
The addiction psychiatry group is fairly important. Keystone to this. But you know, you want all the professionals on the team in this kind of clinic to be comfortable and competent and in fact expert at both mental illness and addiction. So you have this professional group. It’s a team. What happens is any combination, the patient presents with PTSD and nicotine addiction, alcohol, bipolar disorder, Nicotine, OCD, schizoaffective disorder, any of these combinations, they come in the door and that same team can do it all.
There continues to be just a real stigma within the community about not just mental health but particularly addiction in general. And so I think it’s important for people to realize that the treatments that we have to offer both medication and psychotherapy really do go hand in hand in, do help people reach long-term goals of recovery and healthy functioning in society.
There’s no, there’s no need to be afraid of those kind of interventions and there’s no need to marginalize them. We really should be embracing both the medication assisted treatment and even harm reduction strategies like needle exchanges because these are tools that help move people toward a healthier lifestyle and a healthy recovery.
Over the season, we had a few guests mention something called harm reduction. What that means is reducing the impact or harms that drug use may inflict on a given person. Needle exchange programs, which are often called syringe services now, are a harm reduction tool because they reduce the likelihood of contracting hepatitis C or HIV from sharing dirty needles.
Joan Duwve talked to us about syringe services back in episode 9, and how they can not just reduce harm for patients, but ready them for recovery.
So syringe services programs. Really it’s how we like to describe them because they do so much more than give people needles and I think when we call them needle exchange programs, we really start focusing on the needle and on the one to one, so we do have laws that, that sort of prevent that one to one exchange. But if we focus on the syringe services program, all the services that are provided by these harm reduction programs, I think we start to see the benefits in terms of humanizing individuals, providing them access to care, meeting them where they are, and walking with them through their journey until they’re ready to get into recovery.
Keeping them alive, keeping them well, not only is beneficial to the individual, but it’s beneficial to the society as a whole. And that happens in so many ways, right? So even the simple fact of giving, giving people clean needles, we all understand that that prevents ongoing transmission of HIV and Hepatitis C. It also prevents infectious diseases, abscesses or endocarditis or heart valve infections. And what that does is it keeps levels of those infections, lower in communities. And it’s going to protect other people in the community, but there’s also a huge economic benefit to a community to keep people healthy every time you have somebody with HIV in a community that means that there’s a lifetime of treatment costs that go along with that. And the same thing with Hepatitis C, it’s an expensive disease to treat. Hospitalization for heart valve infections is really costly.
So we provide social benefit to the community. We provide benefit to the individual and we provide this huge economic benefit as well. But certain services programs do much more than that. So we’re already at a, at a positive, um, balanced socially and economically and in certain services programs. Actually the immunized individuals. So for example, we have a hepatitis a outbreak now in Indiana, in that hepatitis a outbreak has particularly impacted individuals who use drugs and individuals who are homeless. In communities with syringe services programs, the majority of individuals who meet those definitions are already immunized against hepatitis A. So in communities surrounding Scott County, for example, that don’t have harm reduction programs, there are hundreds of individuals who’ve been infected with hepatitis a and that can spread really, really quickly throughout a community. In Scott County, there have been five. That’s because the syringe services program meets people where they are, provides them with services in a safe space for those individuals, individuals don’t feel judged, so they’re ready to walk through the door, they’re ready to accept help.
To drill down on something that Dr. Duwve said there, we heard over and over again this season that we desperately need to reduce the stigma associated with addiction. Here’s a little more from Jim McClelland on how that can happen.
FSSSA last year launched what they refer to as a humanizing campaign, which is basically an anti stigma effort, called Know the O facts, to try to educate people that, number one, an opioid use disorder is a chronic disease. It has affected the structure of the brain. It has affected your ability to make what the rest of us would consider a rational decisions. And the longer you’re on it, the more difficult it can become to get off.
But the good news is it is treatable and recovery is possible. So this is the basic message that FSSA launched, last year. there’s a link to it on the next level recovery website, in.gov/recovery. It’s also on FSSA’s website. And we know that several thousands of people have access to that. We know there is some improvement in the way people are viewing this as a chronic disease rather than simply a moral failure.
Remember Shane Hardwick, our EMT from episode 7? Here’s how building relationships with his neighborhood has impacted his work.
At the end of the day, we’re building a relationship with these folks, and we’re kind of showing them that someone does actually care about their wellbeing.
What sort of an impact do you think that makes? Do you think that that’s a thing that people get all the time?
No, I don’t. I don’t think that’s something that people get all the time, and one of the things that I think we’ve become keenly aware of on the job that we have is that loneliness is part of that epidemic. It’s not just the addiction, but you know, what’s the root cause… and to have people that are otherwise strangers that are pouring into these folks’ lives, I think it does have a profound impact. And to know that there’s someone out there that truly cares about you and your wellbeing is, um, that’s a pretty darn empowering thing.
Reducing the stigma associated with addiction is built on empathy and trust. That trust can be a powerful tool to help patients avoid potentially addictive drugs. Here’s a segment from our conversation with Marianne Matthias from episode 2. In it, she talks about tapering patients off of opioids onto safer alternatives.
if patients could be given some input into even like the rate of tapering, how fast their doses go down, patients and providers felt better about it because it gave them some control and some sense of ownership of their own health in their own treatment. Another thing we learned from that study is that patients really needed to know that they weren’t going to be abandoned by their providers. So they needed to know that their providers weren’t just going to cut their opioids and then leave. And we observed a lot of cases both in the clinic visits and in the interviews of providers, especially reassuring their patients, you know, I’m, I’m not leaving, I’m not going anywhere. It’s not going to happen. I’m going to be here with you through the whole time.
So those types of things we found were just, they helped facilitate, I think, smoother tapering because the patients really felt supported and they felt like they were, you know, in it with their provider and that they were, they were working as a team
But reducing that stigma is so important – remember, Robbie, our guest from episode 8, knew he could recover when he was in a place where he felt safe and respected. I want to close out the season with a reminder of the conversation we had with him. After all, at the heart of all of our efforts, it all comes down to people overcoming addiction and living well again.
This guy took me out in the hallway. I’m bawling. Crying is, I know what to do, man. I, and he told me, he said, man, just stay here today. Stay here tonight, just cool down. If you want to leave tomorrow, then leave tomorrow, so just don’t leave tonight.
My life ain’t pain anymore. You know, I don’t wake up hating life anymore. I don’t need to escape anything anymore. You know, I want to wake up in the morning, I want to live my life, y’know?
It starts with a plant, but how does it end?
There’s no silver bullet to the crisis. The misuse of opioids is deeply entrenched in our society, wrapped up in so many distinct factors.
What’s more, while the opioid crisis is, of course, an issue of pharmaceuticals, to call it simply a medical crisis is missing the point. So is, for that matter, calling it a mental health issue, or a policy issue. It’s not just a problem in any of those areas, it’s a problem in all of them.
And that’s not a handwave or a dismissal. Because if we acknowledge the complexity of the issue, then something interesting happens. When we acknowledge that the problem isn’t just confined to one discipline, or even one industry, then we have to confront the possibility that it might be a responsibility that all of us share.
It starts with a plant, but it ends with research. It ends with conversations about healing. More than anything, it ends with efforts from people across disciplines and industries, fighting together to stop The Problem.
That’s it for the first season of The Problem. We really hope you’ve enjoyed it.
We’ll be taking a break for a little while to plot out the next season, which will feature an all-new, all-different complex issue centered in healthcare. If you’re not already following Regenstrief on Twitter or Facebook, make sure you do to stay up to date for an announcement coming soon.
Music this episode was from Everlone and Broke for Free. Our theme, and additional musical cues were written and performed, as always, by Some Guy.
The Problem is produced at studio 132 in the Regenstrief Institute in Indianapolis, Indiana, where we connect and innovate to provide better care and better health. Learn more about our work and how you can get involved at Regenstrief.org, and see bonus content from this episode, including sources, pictures and more, at Regenstrief.org/theproblem
The Problem is written, hosted, edited and produced by me, Phil Lofton with additional editing by Andi Anibal, John Erickson, and Jen Walker. Web design and graphics are by Andi Anibal, and Social Media Marketing is done by Jen Walker. Special thanks to the Regenstrief Foundation, and Sam and Myrtie Regenstrief for their vision of a better future with better care and better health for all.