Countering the Opioid Crisis: Time to Act Podcast

The response to the U.S. opioid crisis has been fractured, making it hard for experts to collaborate and share best practices. This approach has led to an abundance of policies and solutions, many of which target small portions of the crisis rather than taking a holistic view. To bring together experts from across industries, organizations, and specialties, the National Academy of Medicine and the Aspen Institute launched the Action Collaborative on Countering the U.S. Opioid Epidemic. Through convenings, publications, strategic partnerships, webinars, this podcast, and other outlets the experts who comprise the Action Collaborative aim to uplift established evidence, promote best practices, identify research gaps, and identify collaborative approaches to countering the opioid crisis.

In each episode of Countering the Opioid Crisis: Time to Act, Ruth Katz, Vice President and the Executive Director of the Health, Medicine, and Society Program at the Aspen Institute and co-chair of the NAM’s Action Collaborative, will host experts who will discuss critical aspects of the opioid crisis, the response, and research that is being conducted to better understand the disease of addiction and the management of chronic pain.

Episode Guide

Episode 3: Racism and the American Opioid Epidemic

Description

In this episode, Ruth Katz hosts Dr. Helena Hansen, professor, and chair of the research theme in translational social science and health equity at the University of California, Los Angeles, and Joy Rucker, the former executive director of the Texas Harm Reduction Alliance, to discuss the role of racism in America’s opioid epidemic. They explore the societal, health, and policy systems that contribute to disparities in care for people of color with opioid use disorder (OUD) and offer solutions to ensure better outcomes for Black and brown communities in the opioid epidemic. Joy breaks down how policy and public perceptions further inequitable systems within the opioid epidemic and the direct consequences those systems have on people of color. Helena offers insight into the two pathways of care divided along racial lines that we see available to those with OUD. One focuses on criminal-justice solutions and the other on public health. Listen to learn more about how we can reform systems of inequity in the opioid epidemic to increase access to treatment and provide better outcomes for Black and brown communities.

Transcript

Countering the Opioid Crisis: Time to Act Podcast — Download the PDF
Episode 3: Racism and the American Opioid Epidemic
Guests: Helena Hansen and Joy Rucker
Host: Ruth Katz

Narrator: Welcome to Countering the Opioid Crisis: Time to Act, from the National Academy of Medicine and the Aspen Institute. This podcast explores the most critical drivers of the opioid epidemic and key strategies to stem the crisis. Host Ruth Katz leads the Aspen Institute’s Health Medicine and Society Program and co-chairs the National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic. Here’s Ruth.

Ruth Katz: The opioid epidemic sits at the intersection of systemic racism, policy, and healthcare, Black and brown communities face higher overdose and fatality rates than their White peers, very often receive inferior care, and have fewer Black clinicians to treat and understand their care needs. Undoubtedly, the already severe health disparities for Black and brown communities have been exacerbated by the COVID pandemic. In 2020, the U.S. experienced the largest annual increase in drug-related deaths in 50 years and nearly 30% increase compared to 2019. That measure translates to 93,000 people who lost their lives to drug overdoses last year. The disproportionate risk minorities face in this epidemic is not new. The rates of fatal overdose among Black African-American, LatinX and American Indian, Alaska Native people have been rapidly rising since 2013. Today we’ll look at the opioid crisis and its impacts through the lens of structural racism and consider ways to redesign systems and policies to ensure appropriate and equitable care for opiate use disorder for all. With us is the University of California at Los Angeles, social science and health equity, professor Helena Hansen and Joy Rucker, former executive director of the Texas Harm Reduction Alliance. Helen, Joy, welcome.

It’s great to have you here.

Helena: Thank you

Joy: Thank you

Ruth: To start us off, help me, actually help all of us listening in here, to understand exactly what is meant by the concept or the term structural racism.

Joy: The more I think about the term structural racism, I think it’s more systematic than structural because if we look at the structure in its purity, like educational, medical, structure and its purity, there aren’t any biases in there. And then what happens is we create, uh, and make policies and vote on systems that create inequity. If we look at voting in its purest form is you have the right to vote. And now we have states that are now creating systems that are making it harder for people to vote. So, I’m starting to look at the difference between the structure and the systems that we create within the structure that create inequities

Helena: That’s really thought-provoking. In my world of studying structural determinants of health, I use the term systemic and structural racism interchangeably. I do that because it’s only possible for systems to persist because of the ways that they’re structured into our institutions and our policies. And so I’d have to think a little bit more Joy about that really, um, a provocative question about what this what’s the difference between structure and system, but certainly in this country, we have had centuries of institutions and policies that are specifically designed to preserve the racial hierarchy. Of course, that goes back to slavery, but, more recently, we’re all pretty familiar with the fact that the U.S. is incredibly racially segregated in terms of its housing, where people live, school systems as a result of that. And therefore the education people have access to since schools are funded by residential tax basis, rich and poor districts have rich and poor schools. And our health care system, that’s a very obvious place where we have persistent and serious segregation, by race and by class.

We definitely have at least two different tracks of health care, uh, the public safety net system, the place where people who are publicly insured, Medicaid, Medicare, or uninsured, end up. Versus the private healthcare system, people with private insurance or the ability to pay out of pocket, you get two vastly different worlds of care and response. And then as we’ll get into it a little bit, of course, there’s the very idea embedded into drug policy that certain people who use drugs should be treated medically and other people who use drugs should be treated as criminals within the criminal legal system and that largely plays out along racial lines. It’s actually intentionally built into our drug policies based on racial stereotypes about who uses the most dangerous drugs and who are the most dangerous drug users. And who is morally culpable and who’s more biologically prone. There are just so many ways that the public policies and the institutions that I think of as structures, they mediate systemic discrimination because they’re actually designed with that purpose in mind. I, I, you know, I don’t, I think we’re in a moment in U.S. history where we can just acknowledge that, that there is racial intent to the way that our policies are put together and our institutions are crafted.

Ruth: There’s another concept that we’re hearing a lot about these days and that’s the concept of health inequity as opposed to structural racism. And again, I want to focus how these concepts play out in the world of health and health care.

Let me give you three examples, and you guys may have better ones than I’ve come up with, that I hope can illustrate the difference between the two. Um, I suspect that many of our listeners are familiar with the Tuskegee syphilis study on Black males that took place between 1932 and 1972, and was actually sponsored by the U.S. government.

The study, as I understand, it was intended to observe the natural history of untreated syphilis. And as part of the study, researchers did not collect informed consent from participants and they didn’t offer treatment even after treatment was widely available.

Now, the other well-known case involves Henrietta lacks, a Black woman whose cancer cells have been the source of invaluable medical data for some 70 years. Now, back in 1951, as you both know, Lacks was the unwitting source of these cells from a tumor biopsy during treatment for her own cervical cancer at Johns Hopkins Hospital. And these cells were then cultured to create a cell line, a cancer cell line that is used today for medical research. As you also know, as was the practice, then no consent was required to culture. The cells obtained from Lacks as treatment and neither Henrietta nor her family was compensated for the cells extraction or use.

Those two cases are well-known. Let me give you one more: when residents that is doctors who were in training present their cases to supervising physicians or to their fellows and to their fellow residents. It’s been the practice to describe the patients they’re gonna see, by race, as well as by sex, age, and diagnosis. And that tradition in medicine seems to have set up certain biases among residents and training before they even have the opportunity to examine the patient.

Help us understand the difference between structural racism and health equity. Again, focused on health care in particular.

Helena:

So this is a unique moment in time because on the heels of a year of attention to racial inequalities in COVID testing treatment and outcomes, as well as the murder of George Floyd and all of the protests that unfolded after that, um, all of a sudden we’re seeing structural racism and systemic racism, those terms pop up in places where we’d never heard them before.

Prior to that, we spoke much more indirectly and passively about health inequalities about, um, health disparities in a kind of passive manner.

You know, we spoke about underserved patients, um, who lack access to care without really identifying well, why do they lack access to care? Like why are they underserved? So there was this kind of unspoken void when it came to the explanatory model. Somehow certain groups of people were just lacking. Um, and I think all of a sudden this year, we’re speaking much more openly in academic medicine about the fact that there are active processes that create these kinds of inequalities.

So that’s what I’m referring to when I talk about structural racism. And I want to point out that the reason for the emphasis on structure or even systems and Joy, I don’t want to dismiss the distinction you’re making, because I think that’s a really important point. But in my mind when I use either the term structural or systemic, what I’m trying to do is call attention to the ways that racism and healthcare work at a level that isn’t confined to the individual practitioner, because so much of what I was taught about racism as a source of inequalities in health and health care as a medical student revolved around, well, what are the attitudes of the individual doctor, right?

But if we think about these systems, if I’m a doctor practicing in a safety net setting, like a federally qualified health center, or, um, really underfunded public hospital in a low-income Black or brown neighborhood, I may have all the best intentions in the world for my individual patient, but I’m totally constrained by the policies of the institution, the policies at the state and federal levels that determine what gets paid for what doesn’t get paid for. What’s even possible for me to do in the exam room or in the operating room. That’s what I’m talking about. But these things have had a momentum that goes well beyond the intentions of the individual practitioner.

That’s what I mean by structural or systemic racism that, um, even though public policies and institutional practices are set they’re, they’re influenced by popular opinion particularly powerful groups like middle-class White voters. So their impressions of who’s addicted, who’s responsible for drug-related crime, who deserves treatment, those kinds of attitudes, for sure, at a group level, do support policies and institutional practices deriving from them that force individual practitioners into a certain predicament.

So I’m not saying that individual attitudes of practitioners aren’t important, but I’m saying that if we really want to address the source of these inequalities, we have to look at a level above the individual practitioner. We have to ask ourselves, what can we do to intervene at that level at the level of public policies and the ways that institutions are structured.

And then very quickly to get to the points about Tuskegee, the Tuskegee experiment and the example of Henrietta Lacks. Um, I think that those are excellent examples of how biomedical research is based on a racial hierarchy. This is a really good example of structural racism at play because, in the era of both Henrietta Lacks and the Tuskegee experiments, it was actually very, very well widely known and accepted that poor Black and brown people served as experimental subjects.

Affluent middle-class White people were the intended consumers of the medical knowledge that was generated from those experiments. Okay. So we’re talking about a racial system within biomedical research that was widely acknowledged. And after these, these two events in the midst of civil rights activism, Black power activism, you know, I just want to put in historical perspective that these things were not scandals in their own, right. They were perfectly consistent with the racial hierarchy that White Americans and especially, um, middle-class and affluent White Americans had already agreed upon, right? That it was fundamental our system of biomedical research, this racial hierarchy who would serve as subjects who would serve as consumers of the knowledge, but then in the midst of civil rights activism, which actually started to have a real toehold in the late sixties to early seventies, it was only then that these practices became scandalized, became the grounds for reforms, IRB protections, et cetera. And at least some, um, some facade or some, uh, attempt to look as though we’re working towards equity in terms of who gets to serve as research subjects and who benefits from that knowledge.

But to this day, if we really look carefully at who serves as research subjects and who serves us when it comes to dangerous research and who serves as consumers of the knowledge we’re seeing in the country, still a racial hierarchy, biomedical research centers that have a lot of clinical trials going, tend to be located in poor Black and brown neighborhoods. A very, very significant trend. Also, now that we’re in a global moment of pharmaceutical industry and biotech, it’s the low-income Black, brown, and Asian countries that often provide the experiment experimental subjects, so we still have a racial hierarchy. It’s just a little more hidden and there are a few more institutional protections designed to try to rectify them.

Ruth: How has structural racism impacted our health policy approaches to drug use. And what has been the resulting health inequities within Black, brown, and other minority communities let’s say in terms of, of overdose rates? Joy?

Joy: When the crack epidemic was happening, there was not the kind of attention focus, funding research in the African-American community, as there is now as it’s related to opiate overdoses. And that’s because the face of the overdose or the face of, uh, the drug issue has changed. As soon as it became young White Americans, there there’s a crisis. Following Helena’s point that in this country, we built a structure, a system that supports that people of color have never, never, never been treated equally. And so, we’re now at this point as a result of George Floyd’s death and all the other protests that are coming to light in this country of now looking at structural racism and how it impacts every level of people’s lives.

It’s always been there, but it’s only the result of George Floyd’s death and the number of protests and the issues, the worldwide attention to this. It’s like all of a sudden, we, as people of color have always known that, you know, if, if you’re a person of color, you’re going to be impacted on where you can buy a house, where you can get a loan. And as a result of that, that’s going to indicate what kind of health care you get, what kind of education your kids are going to get, what kind of neighborhood you’re going to be able to live in. Now we’re looking at, oh, this is a much larger issue than the physician’s attitude toward the patient. Racism just does not rear its ugly head, it’s voted on.

And, you know, that’s what Helena was saying in terms of the structure. And then we have the systems that, oh, now this is, this is an epidemic. So now we have to address it. And what, how did it become an epidemic? What, what made it an epidemic? Overdoses have been happening for years in Black and brown communities, but there has never been the documentation of it or the attention that is now focused on it. It just continues to play out the systematic racism that we’re, that we live in.

Ruth: Now that we have the attention of the public in a way that we did not before, now that we have the attention of policymakers, I would suggest in a way that we have not had before, you both have spoken to very troubling outcomes, very, very troubling, rates among minority communities.

What do we do in terms of systems and services to begin to reverse these very troubling outcomes that we’re seeing beyond just the opioid epidemic, drugs across the board? What do we do?

Helena: So, one thing that Joy was describing was that the very way that we frame something as a health crisis. as opposed to, for example, a crisis of crime in the inner cities, which is the way that the heroin problem and overdose problem in Black and brown inner cities facing very high unemployment in the sixties to eighties, that was the way it was framed, as a crime epidemic, not a public health epidemic. And it led to a further White flight from urban U.S. and disinvestment of public resources from the very cities that were already suffering from disinvestment. Um, and now all of a sudden we have a health crisis. And so I think what Joy was flagging was there is structural racism built into even how we identify a crisis, um, and it has to do with who’s affected, right. And what they’re supposed to role is in society.

Based on the White identity of the intended markets of Oxycontin and sister products in the nineties, because the White middle-class consumers, for which these products were geared, were not thought of as a high risk for addiction, right? And so there weren’t a lot of, there was not a lot of, um, skepticism or regulatory impulse there. And then once it became a very obvious problem in terms of rising overdoses, there was a need for a separate track from the drug war track, that had been structured for Black and brown Americans, of criminalization. There was a need for something even right, more, um, biomedical than methadone, which had it because it was introduced really to address a growing Black and brown, as well as Vietnam veteran-centered heroin problem. And then the sixties always carried this slightly kind of criminalized tone and was very, very highly regulated directly by the DEA. There was a need for something other, something it’d be quote, unquote appropriate. And here I’m taking from the congressional records, um, where buprenorphine legalization of office space, buprenorphine was being debated.

There was a need for a more appropriate intervention for Whites, well, suburban, youth, they used coded language like suburban youth that were being affected. this is where addiction medicine as a field got a huge boost. This is where 80 years of prohibition of private office-based maintenance treatment for opioid dependence with opioids. Eighty years of that kind of prohibition was reversed and it was, it became legal for medications like buprenorphine and opioids to be used in office settings because methadone and criminalizing approaches were not seen as appropriate for this quote-unquote new category of users.

Ruth: Let me just send her up for a second here. Suboxone, buprenorphine and methadone, all three are medications that are used to treat opioid use disorders. That, right?

Joy: Exactly.

Helena: Yes. And so not only did, um, addiction medicine get abused, but the very concept of addiction as a brain disease. So the national discourse began to swing from addiction as a moral scorge. We need not look any further than the nineties during the crack epidemic that Joy was mentioning, to see how incredibly stigmatizing and punitive and racialized the language about crack addiction was at that time.

We’re swaying from that to a really prominent, discourse of addiction as a brain disease requiring biomedical intervention. So what we have right now is a set of federal and also state and local policies that support buprenorphine and a biomedical approach to addiction, but it’s largely because of systemic racism playing out, for access for a White middle-class clientele, because it is private office-based within a health care system in which essentially White and largely middle-class consumers are the ones with primary care doctors, people that can prescribe people who would get certified to prescribe buprenorphine. And that’s well-documented that that’s, who’s getting access to buprenorphine. So we have a two-tier system right now where there’s a biomedical track that was created in response to the middle-class White opioid overdose problem, largely embodied in buprenorphine. And, uh, we continue to have a criminalizing track that is still concentrated in Black and brown neighborhoods and also poor White neighborhoods, a more complex story there, but in largely White states and White areas, like the Appalachian states, poor White people, essentially are being subject to drug war-style interventions. There’s almost a racialized discourse around poor White people. You know, they’re kind of standing in for Black and brown people in predominantly White states.

So we have these two tracks, a medicalized track, and then a criminalized track still. And my issue with the brain disease model, it sounds good to be promoting a biomedical approach, seemingly a nonjudgmental approach to addiction. But first, we have to look at well, how is it playing out? First of all, it’s restricted to certain segments of society. Second, what does it leave out? It leaves out the social determinants of health. And most importantly, the structural drivers, like the system, the structural and systemic forms of racism that Joy and I have been describing. Instead of confining ourselves to brain disease model and investing a lot of money into finding the new molecule, the new biotechnology or the next new pharmaceutical, we should instead be investing in addressing the root causes of social determinants and structural drivers.

Ruth: What are your ideas, Joy’s ideas as well, as to what we would have to do to change our services, change our systems. Again, I recognize this is over a long period of time to really get at the root problem here.

Joy: My understanding is that medical professions only have eight hours, 10 hours of education around addiction and yet and still, they are a gatekeeper for people that need services a lot of times. So I would expand that, in the same way, that their medical students have to have more, more education around addiction and working with people that use drugs than they currently do now. And the other is that you know, this is to make, um, medicated assisted treatment readily available for anyone that needs it. And that does not mean just in an office setting. You know, like Helena was saying how we have this structure around methadone that is really, punitive, but we have this medicated assisted treatment where, you know, you could go to the pharmacy and pick up your own, um, medicated assisted treatment and take it home.

Ruth: That’s what we have or that’s what we should have.

Joy: Well, we do, we have, we have both. And, and what I’m saying is that we should move away from, the punitive and move toward the medicated assisted model because that’s, what’s humane. If you look at the structure around methadone, like I have to be there at five o’clock in the morning, I have a few hours that I have to dose between. And then I have to have these behaviors that indicate that I can have take home. If I’m on Suboxone, all I have to do is go to the pharmacy and get a prescription. What, why is there a difference if we’re going to say that, oh, this is a brain disease, then what makes the distinction that this should be treated differently?

Helena: That is such a good point. That it’s the way even that these medications are dispensed, the settings in which they’re dispensed, what goes along with that, that makes all the difference. And, um, as a counterexample to the private office-based model that we have, I mean, I just want to point out that when it comes to buprenorphine, our most recent nationally representative data is that White Americans are three to four times as likely as Black Americans with opioid use disorder to get buprenorphine that the most common payment method by far is out of pocket for a very expensive drug. The next payment, most common payment method is private insurance. And very far down on that list is Medicaid. So that tells you the race and class background of the people getting buprenorphine. And that’s by design. I mean, buprenorphine was legislated, um, you know, approved legally approved and marketed for that clientele. It’s the system that we live in.

If we look to other countries that have done a much better job in terms of disseminating evidence-based medications, I’ll take France, which a lot of buprenorphine advocates in the U.S. like to point to because it was introduced early in 1996, it was, um, dispensed by general practitioners without a certification requirement, just taken for granted as a part of the armamentarium that any physician should have and went along with an 80% decline in overdose rates in the first, first five years.

Sounds terrific. But what we don’t learn in this country is everything that went along with that buprenorphine. So it’s not only that buprenorphine was disseminated by general practitioners. It was that France has a universal health care system, France engaged people who use drugs, people with lived experience in designing a system of community-based centers where people can go not only for buprenorphine and increasingly for methadone, they have a choice of medical treatments. They also go for comprehensive health care, social services, including housing placement, employment placement, harm reduction.

I’m a buprenorphine certified provider, I worked in a methadone clinic. So I believe in these medications, however, I also can see that people get on medications and they go on them, go off of them. They need a lot of support. They need harm reduction at many critical junctures. So offering syringes, offering safe injection facilities, which are legal in France alongside the medication, so that you can meet people where they are, and having peer support, peer workers on site, all of those things were combined in France.

So there’s such a wraparound in France that we’re entirely lacking in this country. And that’s where we can really learn a lot. Just that one example of how do you successfully use these medications, even that it points to you have to build around the medication, an institutional system and a set of policies that provide social supports, social services for the many needs that people have that you have to meet in order to support their recovery. Also a way to engage people who use drugs in their own futures. So the activism and the advocacy and the peer support, that’s all really critical. So just in that one example, I think is embedded the things that we would need to build in besides simply marketing new pharmaceuticals.

Ruth: If HHS Secretary Becerra is listening in, and I hope he is because this has been a terrific conversation, what is the one thing each of you would advise him to do right now, to turn the tide of the opioid epidemic, especially with regard to minority communities who have been hit so terribly hard?

Joy: Well, I would say, um, support, harm reduction, the entire continuum of harm reduction. Since I can answer more than one, one suggestion. And so whatever is on that continuum and have a base in communities where people can access them.

Ruth: Have them available and make them easily accessible.

Joy: Exactly

Helena: I totally endorsed with Joy is saying, and I do have a suggestion for how to go about it. So taking our lessons from the aids pandemic. I would say let’s really look carefully at the Ryan White Care Act and the way that it mandated community-based councils’ decision-making bodies.

Ruth: The Ryan care act was enacted by Congress. Ooh, I’m going to say about 30 years ago, which provided community-based services for individuals with HIV AIDs. It was named after Ryan White, a young boy who died of AIDs.

Helena: The thing that really interests me about Ryan White Care Act is that the way that they made decisions about how many will be spent is handled, people, it mandates that people who are HIV positive, directly affected by HIV participate on decision local decision-making councils that allot the funding and what these councils have ended up doing has really, um, supported a lot of innovation. For example, peer support funding, peer support as a part of treatment funding, housing as a part of treatment. So basically when you take people who are directly affected, not only are you enhancing the democracy of our country, and, um, that’s very necessary for addressing racial inequalities because what we’re seeing is a lack of democratic voice when it comes to communities of color. So you’re addressing people, having a voice in their own health care number one, but what you actually see from that of innovations that are directly responsive, responsive to the experiences of people on the ground, which have a lot to do with social needs and structural drivers. So what’s happened in the hands of Ryan White Care Act bodies is that they’ve introduced all these really interesting innovations that probably apply equally well to opioid use disorders and preventing overdose. So addressing housing and basic social needs, addressing social support, building that in as a line item financially using healthcare dollars as a part of that, to get actually savings on the other end through better outcomes. So that’s, that’s what I would propose looking very carefully at how something like that could be adapted to the overdose crisis.

Ruth: Well, this has really been a terrific and very insightful discussion. I’m sure we’ve given our listeners a ton of stuff to look at as we consider how to create equitable and actionable solutions to combat the opioid crisis. Helena, Joy. Thank you so much for joining us for a very terrific conversation.

Helena: Thank you.

Joy: Thank you

Ruth: Helen, Dr. Helena Hansen is a professor and the chair of the research theme in translational social science and health equity at the University of California, Los Angeles, and Joy Rucker is the former executive director of the Texas harm reduction Alliance. Both are also participants in the National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic.

In our upcoming episode of Countering the Opioid Crisis: Time to Act, we’ll review the latest overdose statistics from the Centers for Disease Control and Prevention, especially as those numbers relate to the opioid epidemic. So be sure to follow us in your favorite podcast app and make it easier for others to find this podcast by giving us a rating in Apple podcast. I’m your host, Ruth Katz be well and stay safe.

Narrator: Ruth Katz is Vice President and the Executive Director of the Aspen Institute’s Health Medicine and Society Program. She Co-Chairs the National Academy of Medicine’s Action Collaborative Countering the U.S. Opioid Epidemic.

The conversations in this podcast build on the ongoing work of the NAM Action Collaborative. The Action Collaborative is committed to developing, curating, and disseminating multi-sector solutions designed to reduce opioid misuse and improve outcomes for all who are impacted by the opioid crisis.

To learn more about the Action Collaborative, please visit nam.edu/opioidcollaborative

Our theme song was composed by Benjamin Learner and Joshua Sherman and recorded at Old Mill Road Recording in East Arlington, Vermont. The Aspen Institute’s Pearl Mak created our logo. Our podcast editor and producer is Shanna Lewis. Special thanks to the Aspen Institute and The National Academy of Medicine.

Episode 2: Stigma, Addiction, and Health Care

Description

In this episode, Ruth Katz hosts health information technology expert Edna Boone and Dr. Charlene Dewey, a professor at Vanderbilt University Medical Center to understand the role of stigma in the U.S. opioid epidemic. They dive into how the disease of substance use disorder became stigmatized, the ways in which stigma presents itself in the treatment and recovery journey, and what can be done to move past stigma, so individuals can seek accessible and effective health care without judgment. Edna shares the toll stigma can take on an individual, after seeing first-hand how family members were treated while seeking help for opioid use disorder (OUD). And Charlene offers insight into how the health care community is attempting to reduce the harm caused by stigma in both health education and clinical settings. Listen to learn more about how addressing stigma reduces barriers to treatment and recovery and improves the quality of care for individuals with OUD.

Transcript

Countering the Opioid Crisis: Time to Act Podcast — Download the PDF
Episode 2:
Stigma, Addiction, and Health Care
Guests: Edna Boone and Dr. Charlene Dewey
Host: Ruth Katz

Narrator: Welcome to Countering the Opioid Crisis: Time to Act, from the National Academy of Medicine and the Aspen Institute. This podcast explores the most critical drivers of the opioid epidemic and key strategies to stem the crisis. Host Ruth Katz leads the Aspen Institute’s Health Medicine and Society Program and co-chairs the National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic. Here’s Ruth.

Ruth Katz: Addiction is often viewed as a moral failing or weakness rather than what it is—a chronic relapsing disease. More than 3 million people across the United States have an opioid use disorder, and four out of five of them go untreated. Why is that?

Among many reasons for this huge gap in care—perhaps one of the most impactful and least talked about—is stigma. People with substance use disorders may be stigmatized by their family, their friends, their healthcare providers; and they might even stigmatize themselves. To get people with addiction the care they need, we must focus on removing stigma as a barrier.

With us today is Edna Boone, a health information technology expert whose family has experienced addiction and stigma up front, and Dr. Charlene Dewey, a professor of medical education and administration and professor of medicine at Vanderbilt University Medical Center. Both are members of the National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic.

Edna and Charlene, welcome. It’s great to have you here.

Charlene Dewey: Thank you Ruth. It’s great to be here.

Edna Boone: Thanks, I’m happy to be here.

Ruth Katz: I want to start by hopefully getting us pretty much on the same page here, and that’s with trying to get a basic understanding by what we mean with the concept of stigma. How would you guys define that, and how do people experience it?

Charlene Dewey: I’ll take that one first, Ruth. First, we think about stigma in the basic definition of something like a mark or shame, or some form of discredit—like a stain, so to say. Basic definitions would say that it’s like a diagnosis of a disease. It’s something that people put on another individual, thinking something untoward toward them. And addiction is a chronic relapsing disease. It’s not really a moral failing or something that people view as a personality deficit, so to say, but that is where the root of stigma actually comes from.

There are probably several different misconceptions around substance use. These can result from a number of different factors. Some of them might be rooted in the historical and racial precedents of the war on drugs that was set way back in the 70s, when it was more of a criminal kind of process. We still see addiction or substance use disorder as a criminal act for many individuals, and that’s a form of stigma.

Addiction isn’t really a choice. This is a process that happens when someone has a genetic predisposition, and they try a substance, and then their brain adapts to it. So it really is not a choice, even though people see it as a choice. “Oh, they can just stop that. They should just stop using that substance.” That’s not really what it’s about. People might have a predisposed risk, but it’s really a process that they end up developing. Sadly, it’s when they’re struggling the most, when they have an addiction or substance use disorder, when they’re treated the most poorly. Rather than giving them the help that they need, often they find out that they’re being chastised or stigmatized because of the condition that they have, which is a chronic, relapsing brain condition and not one of a stain or mark on who they are as an individual.

Ruth Katz: So, Charlene, is there more to it than that? You used the word behavior. Are their stigmatizing behaviors in addition to stigmatizing language that we need to be looking out for as well?

Charlene Dewey: Yes, Ruth, absolutely. We think about language being one of the major components for sure, but there are behaviors and attitudes that are manifested in a variety of different ways. Sometimes they’re conscious, sometimes they’re unconscious, and there are those biases that people develop over time. In the healthcare arena, so to say, if someone is stigmatized because they feel like the healthcare provider says that they can’t really be competent or make their own decisions because they’re using a substance, then that is a behavioral kind of approach. There are definitely behaviors, there are definitely attitudes.

Again, using some of the terminologies that we have used in the past—and I think a lot of people are growing out of these but they still exist right—like “dirty” if they’re still using a substance or “staying clean” when it seems like somebody might be in recovery. All of those are attitudes, words, behaviors, and actions that subconsciously or consciously contribute to stigma, which are negatively impacting our patients who are trying to deal with a substance use disorder.

Ruth Katz: Charlene you just mentioned, and I mentioned in my opening comments that health professionals themselves may engage in stigmatizing types of activities. You would think health professionals and health workers would know better. Why would they do that?

Charlene Dewey: Well, first, I have to say that healthcare professionals are normal people. They all grew up in society, just like we did, and their experiences might influence how they’re going to actually engage with someone who has a substance use disorder. When they go to medical school, they might already have preconceived notions about what substance use disorders are. Those are going to be due to social depictions within media, cultural conversations that they’ve had, or maybe the lack of conversations that they’ve had around what substance use disorders actually are. And so, when they go into training, we actually have to somewhat untrain them first and then retrain them into understanding and appreciating substance use disorder as a medical condition that actually needs treatments and interventions.

What we also know is that they’re going to have experiences. Depending on who’s teaching them, they might have negative experiences or positive experiences. If we have healthcare professionals who are training them who they, themselves, have had positive experiences, then they’re more likely to demonstrate those positive experiences with the students that they’re teaching, whether it’s physicians, nurses, PAs, whatever.

But if the students also experience negative experiences from faculty that use a stigma, or maybe they see negative examples of the outcomes of treating substance use disorder—those can all be impacted because there aren’t enough treatment centers, enough good treatment programs or people who can treat them like addiction-medicine doctors—if all of those really start to develop more of a negative, compared to a positive, experience for that student, then by the time they get to residency program, or by the time they finish residency program, they, themselves, will only reinforce the stigmatizing beliefs that they came into medical school or nursing school with. They might also have even worsening negative attitudes, biases, or stigma around substance use disorder because of those experiences. And of course, we know that’s going to end up leading to negative impacts like reduced access and quality of care for the patients and delayed detection and referral and early treatments.

Ruth Katz: Edna, let me ask you this question. Charlene has just described, in general, the kinds of behaviors we might see, the kind of language that people might experience, and what health professionals learn in medical school that may even set them up for this kind of behavior. You and your family know all about stigma firsthand, both stigmatizing language and stigmatizing behavior. What was that like for your family? Talk a little bit about your own experience.

Edna Boone: Sure. You know I go back to the definition of stigma and think about that “mark of shame,” “discredit,” “a stain.” My family was hit pretty hard by this several years ago. We lost two young men; that was really difficult to go through. It’s difficult sometimes to talk about. I think about the anonymity of both myself and the people in my family. I have to also look inward and say, okay, I’ve got my own stigmatizing language and behavior.

I’ve experienced the shame of stigma even just talking about this. Even in a closed meeting of the NAM’s Opioid Action Collaborative I felt real pressure to change my language—to use the term opioid addiction rather than saying heroin or fentanyl addiction—and then to make sure that folks knew that the folks in my family that were afflicted had gone to college and had graduate degrees. This behavior, this is the language that we use around this disease. It’s definitely clouded my frame of reference, and I know that when I speak about it.

Then I think about, okay, in my healthcare career, what have I experienced? I remember early on, when we had electronic health records that I worked on, we started to realize that we can use the data in these systems to prevent medical harm and try to help patients. What we started to do is watch the patients that come to the emergency room and those that come to urgent care centers that are seeking pain prescriptions, and we wanted to flag their medical records on the computer so that we wouldn’t write any new prescription. This was kind of like, we’re going to stop the drug traffickers. I thought about it the way we treat shoplifters when they’re being followed around a store.

Our ultimate goal was to not harm the patients by providing more medication. The focus and the behavior ended up being trying to catch someone and blame that patient rather than the focus of an opportunity that they need care and we can get them into the system and treat them. Instead, again, this shames and discredits those in behavior and in language.

I do want to get back to language, because one of the things that we talk about, and this is a mouthful, but there’s this pivot to person-first, recovery-centered language. Words matter. They reflect our attitudes toward people that have this disorder, and if we use stigmatizing language or behavior, we can interrupt them from seeking the care they need. Or, we can cause them to have worse outcomes just because they are perceiving, perhaps, that their peers who have cancer experience thoughtful, considerate care. It’s more than just getting your feelings hurt; it’s a serious problem, and we need to treat it seriously.

Ruth Katz: It can have a real detrimental effect. Back in the day, I can remember when growing up that my parents, certainly my grandparents, if there was a diagnosis of cancer in the family or even among friends, nobody would say the word. They would refer to it as, “She’s been diagnosed with the ‘big C,’” which was stigmatizing in its own way.

Addiction, of course, as both of you have spoken about, that’s a disease too. But there seems to be a different sense of how we think of cancer than how we think of addiction. I want to get into that in terms of the stigmatizing effects, but before we go any deeper into that problem and think about potential solutions, can we step back just a little bit and talk about how we actually got to this point?

Charlene, you mentioned the war on drugs, some of the other activities or issues that have been around for a long time. How did we get to the point that the medical condition of addiction has in essence become a mark of disgrace? How did we get there? Edna, can you start us off on that?

Edna Boone: Sure. One of the things we have to look at is how do we structure care and health care? We have separated addiction care, and really mental health care as well, as a silo. So much so that healthcare professionals don’t necessarily feel it’s their responsibility to treat or even consider treating people that have these ailments. These silos have further perpetuated the stigmatizing language, behavior, and everything that we’ve been talking about.

We also have separate regulations around prescription medications for opioid use disorder from “normal” prescriptions. You need to have formal training and waivers to prescribe medication for opioid use disorder, but no formal training, no waivers to prescribe opioids. It’s this topsy-turvy, how did we get here, and how do we get ourselves out?

Ruth Katz: Let me ask you both this question. Does race, poverty, or even wealth also somehow impact or play a role in SUD stigma?

Charlene Dewey: Yes.

What’s interesting is if we go back again—like we talked about the historical aspects of the war on drugs and how patients were seen as derelicts of society because they were using substances, or couldn’t hold down jobs, or things like that—they were criminalized. It was taken through the process of being tough on them, getting them into jail, so that they can get off of substances and everything like that. That is where we started. What we need to think about over time is, where have we come?

Early on, even in history, we just didn’t have really good understanding, Ruth. There’s plenty of people who will still say the word addiction all the time. I tend to actually use substance use disorder, because the DSM-5 only lists substance use disorder. It doesn’t…

Ruth Katz: Charlene, let me interrupt. What’s the DSM-5?

Charlene Dewey: That’s the diagnosis-management diseases for psychiatry and all the mental health conditions, in which it lists substance use disorder, or an opioid use disorder, an alcohol use disorder…

Ruth Katz: So it’s the bible that lists various diseases and conditions and explains it, and substance use disorder is included as one of those.

Charlene Dewey: Exactly.

Ruth Katz: Got it.

Charlene Dewey: It doesn’t even use the word addiction in there, and so I actually have learned to stay away from that.

If I use myself as an example here as the history: I’ve been in medicine for over 30 years now. When I first started, I actually started off by helping smoking cessation because of it being a part of a modifiable perspective for cardiovascular diseases, or like heart attacks, strokes, things like that. Over time, as I had experience with other patients who had different substance use disorders or with great addiction medicine or general internal medicine doctors who took care of patients with addiction disorders, then we learned over time what to do better.

Where we are today as far as definitions, as far as treatment, as far as access and resources, it’s very different than what we had back in the 70s. We’re kind of trying to untie that knot. We got into it for maybe some of the best intentions, but it didn’t last that way and it’s evolving.

What we get back to now with the race and the socioeconomic status is that earlier on, what we saw was more socially disadvantaged patients, or minorities, or ethnically diverse individuals being more criminalized for substance use versus when it became more of an epidemic when a Caucasian population started having complications or side effects from opioid use and or inadvertent deaths. You can see just how, from lowest socioeconomic to higher socioeconomic, or racial background from minorities to majorities, it made a difference in how people looked at it.

Ruth Katz: And, of course, now we refer to the opioid situation as a crisis, whereas we didn’t refer to some of these other addiction problems earlier as a crisis.

Following up on that, race and poverty can affect stigma, as in this case. What about in terms of ages? I assume that stigma is experienced by people of all ages, but do people of different ages experience stigma differently? Edna, I’m going to ask you to jump in here because, again, reflecting on your own experience—Can you give us any sense if there’s a difference in how young people versus old people may experience stigma?

Edna Boone: Well, sure. There’s some of the obvious: Cognitively, you don’t have a mature person. You’ve got emotional, psychological peer pressure. They’re adolescents, and young adults are really vulnerable to substance use. When does it cross over to substance use disorder? They might be predisposed.

What is available to them? And there’s a lot of issues around confidentiality. Can they talk to their healthcare providers about this, with their counselors or their family? Are people going to refer them to treatment, or are they going to be ostracized? Again, we get back to some of the communities of color, and we get back to criminal, legal issues with police. Then there’s the whole concept of consent when we think about the prescriptions of opioids; a lot of times you hear about sports injuries, and these young men now in their late 20s and 30s started in high school. These are the things that are with us.

And then it’s not always recognized. I mean, I think we’re doing a better job than we were, but it’s still out there. It’s not as easy for them to get help as it is for those that might be of legal age.

Ruth Katz: Charlene, you’re a clinician. What’s your experience with old vs young, if you will?

Charlene Dewey: That’s where the silos start to come in again. We have young people being taken care of by pediatricians. I’m a general internist, so I don’t see anybody unless they’re considered an adult. You have that chiasm of what happens when someone, as Edna just said, who maybe had a sports injury and started using an opioid for a very legitimate medical reason, becomes dependent on it or develops an iatrogenic dependency. Then, they’re transferring over from their adolescent years into their adult years. That’s the most vulnerable population for opioid use disorder, actually—the adolescents and the young adults. In the older patient population, while it still exists, it’s almost minimal.

What we know is that younger people, either from their predisposition genetically, from their cognitive development that aren’t ready to handle certain decisions yet, or are experimenting in an appropriate way but are predisposed, that is the population that’s most vulnerable.

Like Edna said, their access is different. They might have stigma, and fear, and friends saying one thing, parents saying another thing, school programs saying one thing. They can’t access care, unless their parents are with them if they’re under the age of 18, as an adult. So they can’t make decisions on their own, but yet they might be using substances. It becomes a little bit of a variety of different things that pose as barriers for those young individuals to get into help and get the help if they need it.

Ruth Katz: Stigma can affect people of all ages. We’ve talked about race and poverty; those things may experience stigma differently as well. And health professionals themselves may use stigmatizing language or exhibit stigmatizing behavior.

Edna, what do you think about this?

Edna Boone: I think about is the patchwork. The reality is—you’ve got this expertise at Vanderbilt, and I think at many other health systems that are looking at this, who are really trying to move the needle—but the reality is we have this patchwork in middle America. And where there’s rural America, we have huge gaps. This is where we have some of the needs.

What’s the experience of someone who’s experienced that several different times? It’s that even within the recovery community there’s a disparity, not just in terms of language but in what treatments are being offered. My own family experienced this. You go in, and some treatment centers will say they will offer the medication listed for opioid use disorder and some don’t.

There is a body of scientific evidence that says we should be doing this, and we’ve got insurance companies in the mix, and we’ve got stigma. And some of that does come from the providers: “I’m not ready and I’m not comfortable to use this prescription on this patient that needs it.” You’ve got some of the academic centers working through this, and then you’ve got the reality on the ground. Again, I think stigma is at the root of many of these things.

Ruth Katz: Yes, you often hear that health professionals will say, “If I provide this kind of help, I’m just furthering the addiction problem.” Charlene, you started say something. I’m sorry I interrupted you.

Charlene Dewey: I was going to say to Edna, of course my heart goes out to her and to anyone else who’s been in that same predicament. She’s absolutely right, because there are gaping holes in training and resources.

The medications for opioid use disorder or medical assisted treatment, unfortunately, right now we have  process that physicians actually have to go through a special training in order to prescribe buprenorphine or treatments for opioid use disorders and there’s a criteria that they have to meet in order to prescribe it.

But that’s one of those things that actually becomes a barrier and almost becomes the stigma with it. If we as healthcare providers can’t actually prescribe the medicines to help those individuals who actually need it, and can’t get the training to help them understand why and how… As healthcare providers, we can and should be helping these individuals.

Edna Boone: I’ll throw one more thing on that. I know we’re talking about more healthcare providers, but then let’s make sure the insurance companies are covering it. If it’s not covered, people are not getting the care they need.

Charlene Dewey: Absolutely.

Ruth Katz: Of course, that’s stigma of a different sort, the decision not to cover it. You guys have given us a really good idea of the nature of the problem that is stigma itself: what it is, how we got here, and how it works today.

Let’s turn for a moment to look at big picture solutions. Can you give us some examples of how stigma has been successfully dealt with within the context of health care?

Before you both jump in, let me go back to a comment that I made earlier about the “big C.” We used to talk about cancer as the big C; we don’t do that anymore. We talk about cancer, and we even talk about the treatments, and having real discussion about it. Are there other examples out there that you can share with us of how to deal with stigma successfully? Either one of you, jump in.

Edna Boone: I feel like probably the most obvious one is AIDS and HIV. I’m sure listeners remember, but individuals, including healthcare professionals—because I know, I was working in hospitals when this was happening—they were afraid to touch people that had AIDS or HIV. They felt they might catch it. Even though the science taught us otherwise, the facts were not enough to change the public opinion. Once AIDS was stigmatized that you might get it, it really took this huge tide to turn. We had organizations like Act Up; the AIDS quilt came into DC; you had people like princess Diana who visited AIDS patients in the hospital; Rock Hudson from a totally different generation, it came out that he had had AIDS; and then you have Ryan White from the youth, just fighting to attend.

Ruth Katz: A reminder for our viewers, Ryan White was a young boy who contracted AIDS, and as Edna said, wasn’t allowed to go to school. He was completely shunned and ultimately died of the disease. There’s a major piece of legislation in Congress that’s named after him, the Ryan White Act.

Edna Boone: The collective actions, they created a seismic shift around AIDS. We saw that. There was systemic change. We don’t talk about AIDS in that fashion anymore. It’s time; we got to now make that same kind of shift around the way we stigmatize substance abuse disorder.

Ruth Katz: Charlene, are there are other examples? HIV, AIDS is a good one.

Charlene Dewey: Mental health in general, sexually transmitted diseases, which we now actually call sexually transmitted infections, and like you said, cancer. Those are all really good examples.

As a community, we have to look at those things that we do that give good messages or messages that help humanize things, as opposed to letting people wallow in fear or bias about something like mental health or cancer or sexually transmitted diseases.

I think it’s certainly a place where we can start recognizing that substance use disorder is a chronic disease process. It’s a process within the brain; there’s a genetic basis for it. If we start with that, maybe we can start to shift some of the stigma that people are experiencing because of the lack of understanding or fear around substance use disorders in general.

Ruth Katz: I don’t want to let you go without asking one final question to really help our listeners. Because it seems to me each one of us has a role to play here in trying to address the problem. Let me ask each of you, in closing, what is the one suggestion or idea that you would tell our listeners that each one of them could do in their everyday lives to prevent the stigmatization of individuals with substance use disorder? What’s the one thing

Edna Boone: Oh, for me, it’s just people speaking out. I think it can make a huge difference in spreading awareness to friends, family, and certainly health colleagues about using person-centered language when we talk about addiction. If you think about a loved one that you might be stigmatizing right now, everyone needs to speak with care and thoughtfulness. We need to change that language and our behavior now.

Ruth Katz: Charlene.

Charlene Dewey: So for me, I think I’m going to address healthcare providers in general to think about embracing a reflective position, asking themselves what is there that I can do that’s going to be different by not placing judgment, good or bad, on individuals who have substance use disorders. How can we as healthcare providers actually find better ways of helping our patients in the success of managing a substance use disorder, and really all conditions. It definitely starts with us as an individual, reflective practice. I have this saying that says, “Be part of the solution and not part of the problem.”

Ruth Katz: Thank you Charlene. Thanks Edna. It’s great to have you here.

Edna Boone: Great to be here.

Charlene Dewey: Thank you, Ruth.

Ruth Katz: Edna Boone is the health information technology expert and Dr. Charlene Dewey is a professor of medical education and administration at Vanderbilt University Medical Center. They are both members of the National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic.

If you’re interested in diving deeper into identifying and addressing stigma surrounding opioid treatment in the United States, register for the virtual Stigma of Addiction Summit coming up on June 10. There’s a link in this episode’s description to that program.

In upcoming episodes of Countering the Opioid Crisis: Time to Act, we’ll explore racism’s role in the opioid epidemic and the changing nature of pain management. Be sure to follow us in your favorite podcast app. And make it easier for others to find this podcast by giving us a rating on Apple Podcasts.

Thanks for joining us. I’m your host, Ruth Katz. Be well and stay safe.

Narrator: Ruth Katz is Vice President and the Executive Director of the Aspen Institute’s Health Medicine and Society Program. She Co-Chairs the National Academy of Medicine’s Action Collaborative Countering the U.S. Opioid Epidemic.

The conversations in this podcast build on the ongoing work of the NAM Action Collaborative. The Action Collaborative is committed to developing, curating, and disseminating multi-sector solutions designed to reduce opioid misuse and improve outcomes for all who are impacted by the opioid crisis.

To learn more about the Action Collaborative, please visit nam.edu/opioidcollaborative

Our theme song was composed by Benjamin Learner and Joshua Sherman and recorded at Old Mill Road Recording in East Arlington, Vermont. The Aspen Institute’s Pearl Mak created our logo. Our podcast editor and producer is Shanna Lewis. Special thanks to the Aspen Institute and The National Academy of Medicine.

Episode 1: An Epidemic Within a Pandemic

Description

In this episode, Ruth Katz hosts addiction medicine specialist Dr. Kelly Clark and community paramedic Daniel Sledge to understand how the COVID-19 pandemic has impacted the response to the opioid epidemic and treatment for individuals with substance use disorders in the United States. They discuss the barriers and opportunities at the individual, first-responder, clinician, and systems level while offering insight into changes in the national response, resources, and tools since the onset of the pandemic. Kelly and Daniel also share their experiences working to support those with opioid use disorder and offer advice on the tools, policies, and multi-sector collaboration needed to combat the U.S. opioid crisis. Listen for more on how treatment providers evaluate the response to the opioid epidemic within the COVID-19 pandemic.

Transcript

Countering the Opioid Crisis: Time to Act Podcast — Download the PDF
Episode 1: An Epidemic Within a Pandemic
Guests: Dr. Kelly Clark and Daniel Sledge
Host: Ruth Katz

Narrator: Welcome to Countering the Opioid Crisis: Time to Act, from the National Academy of Medicine and the Aspen Institute. This podcast explores the most critical drivers of the opioid epidemic and key strategies to stem the crisis. Host Ruth Katz leads the Aspen Institute’s Health Medicine and Society Program and co-chairs the National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic. Here’s Ruth.

Ruth Katz: COVID-19 is making the opioid epidemic worse, and the opioid epidemic makes COVID-19 more deadly. The American Society of Addiction Medicine’s past president, Dr. Kelly Clark, says the pandemic makes it difficult, and sometimes impossible for people with substance use disorders, or SUDs, to get treatment.

Kelly Clark: People who have opiate use disorder who get COVID have a higher risk of dying than people who get COVID who don’t have opiate use disorder. This is a population that is at risk for succumbing to serious side effects or death from COVID.

Ruth Katz: The number of new and worsening SUDs is rising as people look for ways to cope with the pandemic. Daniel Sledge works with the Williamson County mobile outreach team in Georgetown, Texas. He responds to opioid-related mental health crises.

Daniel Sledge: When you’re talking to some of these folks, it’s like yeah, the stress of everything – I lost my job, I lost my healthcare, I’m losing my housing, I don’t know how I’m going to pay for food or where I’m going to sleep tonight. All of this sort of came crashing down at once.

Ruth Katz: People are trying to deal with this unprecedented situation and the extreme levels of stress that come with it. More than 40 states have reported increases in fatal overdoses since the pandemic began. It’s time to take a close look at what’s going on and what needs to change. Kelly, Daniel, welcome. Great to have you here.

Kelly Clark: Thanks. It’s great to be here.

Ruth Katz: Let’s start by really beginning to set the stage. You’ve both been involved in responding to the opioid epidemic for years, actually, way, way, way before the emergence of COVID-19.

Daniel, let me start with you. Describe for us what it’s been like for you since the emergence of the pandemic.

Daniel Sledge: Sure. So, I’ll answer this in terms of our response on the outreach team and doing peri- and post-overdose follow up. Before COVID, the biggest thing is that, you know, we had a much larger menu of options for somebody who wanted to engage in treatment to choose from. That was the biggest difference. Afterward, several places, at first, just closed down. Or you know, some of the inpatient detox centers or respite centers were not able to logistically make enough space to have, you know, single-person rooms or anything like that. So a lot of places closed in that menu, kind of shrunk down to almost nothing. So we had to get really creative in terms of connecting people to services.

The other thing that was a stark difference is that our call volume as part of the crisis team, our call volume went way, way up post-COVID, and on top of that our staff went down, because some of them were reassigned to COVID-specific roles. So, we kind of had this double challenge, and I feel like for a while there we were just running around doing damage control just trying to put out fires. You know, a lot of people were accessing social services for the first time ever, and had become you know food insecure and housing unstable or unhoused for the first time, and kind of all at the same time. So those are some of the biggest challenges that we’ve seen. A lot of people fell down kind of to the bottom level of Maslow’s pyramid and were just trying to get access to food and shelter, much less medications that they may have been on for a while.

Ruth Katz: So what were some of the options they had before COVID that they lost out on once COVID emerged?

Daniel Sledge: There was an office-based opioid treatment that stopped taking new patients. One of the inpatient detoxes closed. Another one eventually went out of business, post the onset of COVID. And then I think there were fewer options for new patients to access office-based care, especially at first, when you know, so much was unknown.

So, thankfully, with some of the new provisions by SAMHSA and DEA, we were able to get people access to care, just by telemed visits.

Ruth Katz: SAMHSA is the Substance Abuse and Mental Health Services Administration and DEA is the Drug Enforcement Administration. Both are federal agencies. So, basically, people have fewer places to go.

Daniel Sledge: Fewer places to go. So, if somebody said hey, you know what, I do want XYZ service. Then it was like, all right, normally they would be taking people, and we would be able to get you in in a reasonable amount of time. But that’s not an option right now.

Ruth Katz: Fewer places to go and longer waits to get in.

Kelly, what about you, how would you compare your pre- and post-COVID experiences?

Kelly Clark: I think that Daniel did a really great job of doing that sort of bottom-up approach to what’s happened. Before COVID-19 we still had a problem with an adequate number of evidence-based treatment providers in every community in the country, really. But what happened with COVID is a number of things: people who are providing care can get COVID, and the understanding of what needed to happen for staff and employees to be able to function in the healthcare environment without sufficient PPE was rapid and somewhat devastating.  

A lot of organizations that do treatment for addiction don’t really come from a medical standpoint, and they didn’t know how to do infection mitigation, etc. And large numbers of them, as Daniel said, treatment providers did in fact close down or were repurposed in a general medical area to be general medical beds.

One of the things that was really impressive, I think, about the initial response was how quickly some parts of the federal government relaxed some rules. The rules about doing telemedicine to get started on medication, basically everything but methadone, were relaxed at a federal level. In my state, which is Kentucky, they worked very quickly to relax the requirements as well at a state level for providing treatment for people with pain as well as people with addiction. The payers moved very quickly to pay for telemedicine, so that was a really rapid and important shift to some of the telemedicine.

Ruth Katz: Now that you’re both in the middle of this, what would you describe as your biggest and most difficult challenges that you and those with whom you work are now facing in trying to do the jobs you do, and do so well?

Kelly, what would you say are the two or three biggest challenges that you face?

Kelly Clark: Well, our biggest challenges are always around regulation and payment. Those have been in place before, but they’re also in place during COVID, because what I mentioned before, about the changes that have been allowed, those could change back in a heartbeat. Literally with the stroke of a pen, and all of that’s being allowed with telemedicine could go away. So that is a huge issue for us.

Another one of the big issues is around how we’re dealing with people, as Daniel said before, who now struggling at a more basic level – being unemployed, not knowing how they’re going to make their rent, how to get their food, people who are at home with their children, without childcare, trying to work. The resources that are available for them, just given the entire changing society, are inadequate and are going to stay that way.

So, the other thing that that’s really important for us is to try to keep people connected. That goes back to telemedicine, but things around support groups and mutual help groups and groups that aren’t just for people who have been diagnosed with a substance use disorder but people with lots of different kinds of stressful issues. One of the things that’s been really impactful for us as addiction doctors is trying to get information out to people on how to gather safely. How to do it in support groups and how some of this treatment can proceed.

One of the things that I would say is if any treatment providers or people who are trying to figure out how to do mutual help groups, they can google ASAM, like the American Society of Addiction Medicine and COVID. We’ve put up, I don’t know, 15 or 18 pieces of guidance around this. That material is available for people. So just google that for some more information. Hopefully, that’ll help.

Ruth Katz: Daniel, what would you say that one or two of the biggest challenges that you and the folks you work with are now facing in addressing this problem?

Daniel Sledge: You know, the biggest challenge has been the stark uptake in call volume. We need more staff.

So, right after COVID came into our area, I might be on outreach at an extended stay motel or something, I’ll be in the parking lot with someone, and then 3, 4, 5 other people might come up and say, hey, I don’t have food. I don’t have XYZ medication, or I need help paying for another week at the motel. So, we just need we need more staff, more access to resources.

Health care resources are finite. And I think that’s been one of the biggest challenges. Overall, just in general, responding to this overdose and drug poisoning crisis in the context of the pandemic.

Ruth Katz: You’ve both spoken to the issues that you face doing your own jobs. Let me turn to the challenges faced by patients – those individuals with substance use disorders.

Kelly, you and your team provide treatment to those with SUDs. What specific challenges has the pandemic created for these people, and how are they navigating throughout the pandemic?

Kelly Clark: Actually, people who have opioid use disorder and who get COVID have a higher risk of dying than people who get COVID that don’t have opiate use disorder. We’re really seeing that this is a population that is at risk for succumbing to serious side effects or death due to COVID. The problems that have been facing people with addictive diseases now are just more acute than they have been.

Our basic issue is that we have never had, in this country, any kind of coherent or cohesive or comprehensive construct of a treatment system. We need to build directly to Daniel’s point, and build actual treatment infrastructure that’s based on evidence-based care. Because right now, if a patient says hey, I want help, there’s no way for that patient to know or their family to know, or even their primary care doctor to know if a treatment program boundary or in the next city over that is providing appropriate evidence-based care or care that could even be harmful. So, the very baseline pieces are difficult for folks.

So, just getting into the appropriate kinds of treatment, knowing what to expect, getting the appropriate follow up, every piece of the way is problematic – it’s just now also more acute with COVID.

Ruth Katz: You mentioned earlier, about stress levels going up, in addition to the things you’ve just talked about. I assume the pandemic has created lots of stress among those you treat, higher than normal, I suspect. Can you give us some examples of the role stress is playing in all of this?

Kelly Clark: Let me give you just one thing to think about. As a culture, we’ve taken a lot of things like Valium, benzodiazepines, Xanax, Klonopin, over time, those are sedative drugs that we use for anxiety. But for the last 10 years, in the U.S., there’s been less and less and less prescriptions for Valium and those kinds of drugs, for 10 years, going down. From March [2020] on, our rates of prescribing for those, across the country, for those kinds of drugs, are up over 30%, for those types of sedative drugs that we use for anxiety.

Ruth Katz: And you’re talking about it across the board now.

Kelly Clark: Across the board. Just that kind of sedative. The amount that people are drinking right now has been astonishing. I hear from colleagues all around the country that they can’t even grasp that 20-something-year-olds are coming in with liver failure from drinking at rates that we just have not ever seen before.

People are isolating. They’re without their social structure of having to get up and go to work. Structure is really important for people, to have an external structure. And they’re not out interacting with their clergy, going to their doctor, just taking care of routine health things. All of those pieces have kind of fallen down and so, you know, gosh, what I would say to people, is make those connections back again.

You can see your doctor, even on your telephone in a lot of areas. You can go to a support group and reach out to your clergy by telephone, get those connections going because the more connections we all have, the better we all do as individuals and communities.

Ruth Katz: What about the stress level stress levels among health providers, including paramedics? Daniel, what’s happened in terms of the stress levels with those with whom you work?

Daniel Sledge: I mean, obviously, it’s shot sky-high. When COVID first came into our area, there were vacation callbacks and a moratorium on taking time off.

And so much at first was unknown. And so you’re unsure what you’re walking into when you make contact with somebody in direct care. And there’s this level of anxiety, like, okay, is this next scene or this next call the one where somebody is going to be pre-symptomatic for COVID.

There’s a hyper-vigilance, I think, among providers, like I can’t get lax about anything, about masks, goggles, hand cleaning, anything like that, because the one time you do will be the time that something will get past the barrier. So, yeah, I just think a lot of heighted anxiety among providers, and the other anxiety among providers is not wanting to bring something home to our families. So, yeah, stress levels are definitely way up.

Ruth Katz: I mean, what about some examples among physicians and nurses and others you work with?

Kelly Clark: So, let’s just be really, really clear. Medical personnel are dying of COVID and are also seeing that large numbers of the general population refusing to wear masks. This has been beyond demoralizing to doctors and nurses and EMTs and paramedics and respiratory therapists and the wide variety of medical providers that I work with. There’s now a feeling that they are front-line cannon fodder and are no longer being respected. The burnout that has been occurring in medical professions for several years now, with increasing suicide rates, particularly among physicians – there is no sign that that’s going down with COVID, but rather that is going up. General thoughts about suicide have gone up in the general population, and we’re hearing lots of reports from colleagues about this across the country.

Ruth Katz: So let me ask you both this. Looking at both the impact on providers, the impact on patients with SUDs – can you speak to the impact that all of this has had, overall, in confronting the country’s opioid crisis? What I mean by is are we somehow just holding on? Has progress that we might have been making slowed, or have we really lost ground in combating this national epidemic?

Kelly Clark: We’ve lost ground.

Daniel Sledge: Absolutely. We’ve lost ground. I think that pre-COVID, the status quo left a lot of room for improvement. We’ve got a long way to go.  

Kelly Clark: We’ve got this epidemic of overdose deaths that’s been overshadowed by our pandemic of COVID, which we rightly need to focus on. But overdoses have gone up substantially since COVID, and by the way, they hadn’t been trending down, even immediately before COVID. So they’ve gone up since COVID, and that’s superimposed on our endemic. We have drug use and misuse at very high levels in our society, even before the overdose rates, but our overdoses are going up and we are not going to be able to get a handle on COVID, we’re not going to be able to get a handle on our society until we deal with our opioid and other addiction problems in this country.

Ruth Katz: Despite all the challenges you have just discussed, and even setbacks – when I said have we lost progress, have we lost ground, you both immediately said yes.

Despite the setbacks, it does seem the pandemic has brought about at least some unintended benefits, if you will, such as Kelly suggested, the relaxation of rules and regulations that have allowed easier access to addiction treatment.

Daniel, do you agree, first of all, with that some of the relaxation of rules and regulations have made a difference in easier access and, if so, can you give us some examples.

Daniel Sledge: I absolutely agree. I know there were a lot of advocacy folks who worked incredibly hard to get those changes and especially in as timely a manner as they were for DEA and SAMHSA to relax some of the restrictions on methadone or buprenorphine. For example, going out and making contact with participants who say hey, I heard about this program from someone who wanted to get started on buprenorphine, we want to start Suboxone. Suboxone is a branded version of buprenorphine, and then there’s methadone, these are medications used to treat opioid use disorder.  

And so, you know, looking at that menu that’s now shrunk. And we’re having to say okay, well, this place is not accepting new patients. This place is closed, this place went out of business, you know, and on and on. The provision for telemedicine opened up kind of a whole new item on the menu, if you will.

We partnered with this awesome addiction medicine doctor in Austin. I met these folks, the participants, in a park, at a picnic table, two meters away, of course. And I set up a hotspot on my phone, set up the laptop, made sure there was a good connection, and the doctor was able to have a face-to-face via technology with these folks, and then was able to prescribe the medication. I picked it up from the pharmacy, delivered it to them, and they were able to be on this medicine that otherwise they probably would not be able to access.

Ruth Katz: What about Narcan or naloxone, the nasal spray that can help reverse an opioid overdose – have we made that easier for people to get access to?  

Daniel Sledge: We give out a ton of Narcan, and one of the difficulties is just that people are scared to engage with healthcare for several reasons. One of them, though, having to do with COVID, is that they don’t want to get sick. I’ve seen abscesses or cellulitis, skin infections, that might have gone on longer unattended or longer without someone having gone to the emergency department because they’re worried about, okay, if I go to the ER, I’m going to get COVID there, so I’m just going to not go or I’m going to try and ride this out as long as I can.

Anyone that we make contact with, we get them naloxone, and as much as they can get out into the community as well, so that’s the one thing that we’ve continued to push, especially in our area after we’ve seen a huge spike in overdoses related to press pills or counterfeit pills containing fentanyl.

Ruth Katz: Kelly, you mentioned earlier telemedicine. That seems to be an unintended benefit, if you will, of the pandemic. And again, as you mentioned, the use of this technology has just skyrocketed across the board.

It has been helpful, I think, in dealing with the treatment of people with SUDs. Can you tell us a little more about it, are there other benefits or improvements, with other technologies dealing with ongoing treatment options that have really had this unintended benefit as well – can you give us some other examples?

Kelly Clark: Sure. So what telemedicine used to be before COVID is that a patient would go into a medical center? They would see somebody as staff there, they would go into a room with their telemedicine equipment, their audio and visual, they would get their blood pressure taken or whatever, the person would sit in the room with them and they would dial up basically the doctor who would be at a different location and then they would have their session there, and the person would leave their healthcare situation and go back home.

But what’s happened now, the relaxation that happened with COVID is that the patient doesn’t have to go into that health care center anymore. They can literally, from their home, engage in a telehealth and telemedicine interaction with their doctor or other health care provider, and that’s a big change. But let me be clear – that is a temporary change that is a federal change and is around particularly Medicare payments. There’s some states that still have problems with this and when the public health emergency runs out, we are not at all sure that we are going to be able to continue to do exactly what Daniel said because it requires changing a law or regulation in DC to continue to do this.

So this has been incredibly helpful and moved things much faster than they had been moving for several years, but we need to stand back and solidify those gains in order to make sure we don’t lose those going forward.

Ruth Katz: That’s a perfect segue to my next question and that’s about lessons learned and lessons that we’re still learning, both about what has gone wrong and what has gone at least somewhat right and addressing this opioid epidemic within the COVID pandemic.

Going forward, because I think we’d all agree the opioid epidemic will continue long past the time we hope the COVID pandemic is under control. Going forward, are there are things we should do differently than the way we’ve been doing them in the past in terms of both practice and policy?

What would you like to see being done Kelly, what would you recommend. Actually, let me put it this way. What would you tell the administration?

Kelly Clark: Oh, this is not a hard one. I would tell the administration that we will not be able to meet any of their policy goals unless we look very clearly at our drug misuse and addiction problem in the US. We cannot get people employed if they can’t pass a drug test. And I will tell you that’s a problem in my community where an employer repatriated 2,000 jobs and then immediately had to think about sending those jobs back overseas because literally, people couldn’t pass a drug test.

If we don’t help employers know how to deal with people when they get an addictive disease and how to get them back to work and keep them back at work; if we don’t have appropriate childcare for people and understand that drug use and addiction is also a women’s issue because we’ve got a lot of single parents out there – this is an issue beyond public health and public safety. This is an issue of our justice system and our social service system.

You know there was a school in Eastern Kentucky with 300 kids and 30 dead parents. I mean, we don’t have parent-child days, we have caregiver-child days because so many parents are dead, in rehab, or incarcerated. Our foster care, our social services are totally overwhelmed.

What we need to do is to look at our drug problem from an issue of building an actual treatment system, that’s evidence-based. Stop paying for what doesn’t work, pay for what does work.  Engage all of these different stakeholder groups, including the people that are in charge of insurance and the department of labor, all together to look at this from a comprehensive three-dimensional approach and then we can pull the right levers to get done what we must get done.

Ruth Katz: Let me press you a little bit. All those things are important and I think many people would agree, need to be addressed to take on this problem. But they also take a long time to implement. They’re not going to happen overnight. Are there some things based upon the experience that we’ve had that you have seen that have really made a difference. Like the example, you’ve given with telemedicine that you said we want to make that permanent, or some other examples that you would say immediately we should put those into effect, and that could make a difference. Daniel jump in here, if you’ve got some ideas as well.

Daniel Sledge: I think that continuing the provisions for telemedicine and continuing the provisions for take homes for methadone would be a good start. I feel that we should deregulate buprenorphine and methadone as well. These need to be medicines that are left between a patient and a prescriber to decide what is best for him or her.

Other changes I’d like to see – harm reduction workers are essential health care workers. They should be treated as such. There needs to be more funding. If we could tap into some of the lawsuit money from some of the makers of some of these opioid medications and then route that funding toward harm reduction coalitions, I think that’s a change I would like to see as well.

In terms of deregulating these medicines. I know that it’s controversial, but the DEA should not be in health care.  I would not ask my doctor for legal advice, we should not be going to law enforcement agents for medical advice.

Kelly Clark: Daniel, I think what you mean is to take away the regulations that methadone to treat addiction must only be used in a licensed methadone clinic and buprenorphine has to have training, by the clinician has to have. There’s a certain cap – we can’t treat more than 275 patients, even when we’re experts, at a time. Is that what you meant by deregulate?

Daniel Sledge: Yes.

Ruth Katz: And that’s all, that’s all current law?

Kelly Clark: Yes, that’s current law.

Ruth Katz: And all of those are still in place?

Kelly Clark: The things that Daniel just said, those are still in place.

But the other things that you mentioned we could do very quickly. We could do Medicaid reentry. This is incredibly important because where we see people are at most risk for dying is when they’re coming out of incarceration, a jail setting, prison setting. Or coming out of rehab, where they have not been given appropriate medication to take as they leave, which would be you know methadone or buprenorphine, potentially naltrexone. And when they’re leaving they are at very high risk of dying. And we know that if we give people their choice when they’re leaving a jail, two-thirds of them will take methadone, a third will take buprenorphine. Their rates of dying go down so low.

I mean, they did this in Rhode Island and it decreased the entire state’s overdose death rate. So something that you could do fast, and it would be incredibly impactful, would be to do that – get people into their medication treatment and turn on their Medicaid as they are leaving incarceration as well.

Ruth Katz: Kelly, Daniel, any parting thoughts?

Daniel Sledge: We talk about stigma and countering stigma. This is one of the chief barriers to accessing care for our folks. I feel that sometimes we use the word stigma when we are actually talking about discrimination, and the fact that it took this respiratory virus for there to be changes so that people with opioid use disorder could easier access proven treatment to save lives. The fact that it took this respiratory virus and not the ongoing crisis of people we have lost to overdose – to me that is the epitome of discrimination.

Kelly Clark: As we focus on COVID, which we need to focus on COVID, we cannot take our eye off the increasing number of deaths we are experiencing due to our drug problem in the U.S. The problem isn’t just opioids – its opioids and stimulants, and opioids and stimulants and sedatives, like those Valium types of drugs, and it’s alcohol mixed in with opioids and sedatives. We are really hurting in communities by this problem. Before COVID, during COVID it’s worse, and after COVID we are going to have to pick up these pieces, and it’s going to be worse if we don’t start doing it now.

Ruth Katz: Kelly, Daniel, you’ve given us an awful lot to think about as a nation continues to confront this epidemic within the pandemic. Thank you both so much.

Dr. Kelly Clark specializes in addictive disease medicine, evidence-informed behavioral health care and payment reform. She founded Addiction Crisis Solutions and has provided expertise about the opioid crisis to many federal agencies. She’s also the immediate past president of the American Society of Addiction Medicine.

Daniel Sledge is a community paramedic with the Williamson County mobile outreach team responding to mental health crisis calls. He provides follow-up after opioid overdoses to train patients and their loved ones on administering naloxone and connect them to treatment and recovery resources.

Upcoming episodes of Countering the Opioid Crisis: Time to Act we’ll explore the role of racism and the opioid epidemic, the stigma of addiction, and the changing nature of pain management. So, don’t forget to subscribe and make it easier for others to find this podcast by giving us a rating on Apple Podcasts.

I’m your host, Ruth Katz. Thanks for joining us. I hope you’re staying safe and healthy.

Narrator: Ruth Katz is Vice President and the Executive Director of the Aspen Institute’s Health Medicine and Society Program. She Co-Chairs the National Academy of Medicine’s Action Collaborative Countering the U.S. Opioid Epidemic.

The conversations in this podcast build on the ongoing work of the NAM Action Collaborative. The Action Collaborative is committed to developing, curating, and disseminating multi-sector solutions designed to reduce opioid misuse and improve outcomes for all who are impacted by the opioid crisis.

To learn more about the Action Collaborative, please visit nam.edu/opioidcollaborative.

Our theme song was composed by Benjamin Learner and Joshua Sherman and recorded at Old Mill Road Recording in East Arlington, Vermont. The Aspen Institute’s Pearl Mak created our logo. Our podcast editor and producer is Shanna Lewis. Special thanks to the Aspen Institute and The National Academy of Medicine.


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