Challenges in accessing best practices in addiction treatment
The story of one of the patients receiving substance abuse treatment from Sarah Wakeman reflects his view of the process and the obstacles he faces. Under the pseudonym Sandy, he first encountered opioids in high school on a doctor's prescription after an injury in sports.
«I got addicted to it and became addicted to opioids while still in college after experimenting with drugs with my roommate. Soon I was addicted to heroin» — Sandy says.
For several years his life was on the decline: debt, layoffs, non-payment of bills, arrests, constant trips to rehab and participation in a 12-step program.
Sandy joined Wakeman's practice several years ago. He is currently stable: he is taking buprenorphine, has a job, an apartment and even a new pet. But he described the difficulties and distrust he experienced from those around him, including those who were supposed to be helping him, such as doctors and psychiatrists. Even now, pharmacists are sometimes afraid to renew his prescription for buprenorphine, so he hides spare doses to avoid going without, and this, he noted, can be dangerous for someone with an addiction.
Social stigma further complicates the challenges Sandy faces with buprenorphine treatment. Although this medication is intended for long-term therapy, it is given in small doses that require refills every few days or weeks. If he were less motivated, he doubts he could succeed, or if he had less privilege — after all, Sandy, an educated white male in his early 30s, grew up in a family of medical professionals.
Barriers to treatment, including logistical and ideological ones, are partly related to those who suffer from addiction and are on the margins of society. Addiction is joined with other social problems such as homelessness, poverty, mental health disorders, untreated trauma, and the epidemic of loneliness that is unfolding across the country.
In 2020, the number of opioid overdoses increased significantly due to the COVID-19 pandemic, in part due to the isolation of people from each other and from treatment. Racism also plays a significant role in limiting access to treatment, as does mass incarceration. Especially in rural areas of the United States, there are not enough drug treatment specialists, making basic primary care inaccessible to all patients.
Until recently, about 60% of people living in rural areas lived in places where there were no doctors authorized to prescribe buprenorphine. That changed last year, however, after a law requiring special authorization to dispense the drug was repealed. In Madison, Wisconsin, where Dr. Elizabeth Afshar works with addicts, many patients travel long distances each day just to get an appointment that takes only 30 minutes. Salisbury-Afshar notes that people are forced to spend an entire day traveling to the clinic because of a lack of other options.
Dr. Afshar says that in rural areas, many primary care physicians who could be the first line of care for addicts are too overwhelmed to do so. She notes that there are not enough qualified professionals in the field to provide everyone with the treatment they need. This leads to a situation where many people are unable to access the medication they need or are unable to continue treatment.
Dr. Joudry of Pittsburgh says the U.S. health care system is not prepared to help drug addicts and other vulnerable groups. The focus on technological innovation sometimes distracts from the sociological and economic problems caused by the drug epidemic. It is important to remember that treatment itself, such as medical assisted therapy, does not always solve all the problems associated with addiction. The success of such treatment depends on a wide range of social and economic factors that may affect the patient.
Dr. Afshar says that in rural areas, many primary care physicians who could be the first line of care for addicts are too overwhelmed to do so. She notes that there are not enough qualified professionals in the field to provide everyone with the treatment they need. This leads to a situation where many people are unable to access the medication they need or are unable to continue treatment.
Dr. Joudry of Pittsburgh says the U.S. health care system is not prepared to help drug addicts and other vulnerable groups. The focus on technological innovation sometimes distracts from the sociological and economic problems caused by the drug epidemic. It is important to remember that treatment itself, such as medical assisted therapy, does not always solve all the problems associated with addiction. The success of such treatment depends on a wide range of social and economic factors that may affect the patient.
How can we make a difference?
This experience demonstrates the scientific need to create new treatments to reduce overdose deaths. Research has identified several promising approaches, including harm reduction interventions, which are already beginning to be widely used. Despite the long controversy surrounding the notion that harm reduction can contribute to drug abuse, this approach has gained acceptance among service providers and policy makers.
Decades of research in the US, as well as in countries such as Canada and Ukraine, shows that it both saves lives and saves money.
Despite slowing and uneven progress, a nationwide initiative to bring material health care support (MAT) programs into prisons and jails — spurred in part by ACLU litigation in several states — is gaining momentum.
This experience demonstrates the scientific need to create new treatments to reduce overdose deaths. Research has identified several promising approaches, including harm reduction interventions, which are already beginning to be widely used. Despite the long controversy surrounding the notion that harm reduction can contribute to drug abuse, this approach has gained acceptance among service providers and policy makers.
Decades of research in the US, as well as in countries such as Canada and Ukraine, shows that it both saves lives and saves money.
Despite slowing and uneven progress, a nationwide initiative to bring material health care support (MAT) programs into prisons and jails — spurred in part by ACLU litigation in several states — is gaining momentum.
This becomes urgent given that deaths from drug or alcohol overdoses increased more than 600% in state prisons from 2001 to 2018, according to the Bureau of Justice Statistics, which found that in 2009 (the most recent year with national data), the rate was nearly 2%. One-third of inmates suffer from substance use disorders. A 2015 North Carolina study found that those recently released from prison had a 40 times higher risk of overdose than residents of other states.
In 2014, Massachusetts General Hospital in Boston, where Wakeman works, opened one of the first «bridge clinics» in the country, aimed at bridging the gap between a patient's admission from the emergency department (e.g., after an overdose) and long-term treatment. Wakeman noted that the addiction treatment period is a crucial time when the risk of relapse or overdose is high.
Patients can visit the bridge clinic without an appointment — the same day after discharge from the emergency room or right off the street — and begin buprenorphine treatment. They can also receive psychiatric counseling, participation in a recovery program and medical care, and use harm reduction if they are still using drugs. Wakeman noted that those who want to can just sit, have a cup of coffee and relax here if they need a place to be safe.
In 2014, Massachusetts General Hospital in Boston, where Wakeman works, opened one of the first «bridge clinics» in the country, aimed at bridging the gap between a patient's admission from the emergency department (e.g., after an overdose) and long-term treatment. Wakeman noted that the addiction treatment period is a crucial time when the risk of relapse or overdose is high.
Patients can visit the bridge clinic without an appointment — the same day after discharge from the emergency room or right off the street — and begin buprenorphine treatment. They can also receive psychiatric counseling, participation in a recovery program and medical care, and use harm reduction if they are still using drugs. Wakeman noted that those who want to can just sit, have a cup of coffee and relax here if they need a place to be safe.
Bridge clinics are opening in other locations, including several dozen in California alone, and early data show that they have led to promising indicators of MAT treatment and linked patients to long-term addiction treatment. These effects may extend to other parts of the hospital.
One study by researchers from Syracuse, N.Y., found that emergency room visits decreased by 42% in the six months after the bridge clinic opened. Studies also show that bridge clinics help fill a gap in care for patients with «clinically complex» cases: patients with co-occurring substance abuse, serious mental illness, homelessness, and infections such as HIV or hepatitis.
In cases where primary care physicians are limited, nurse practitioners can be key to ensuring access to care.
As of 2016, federal regulations allow nurse practitioners and physician assistants (PAs) to prescribe buprenorphine, but this remains unavailable in some states, including those hard hit by the overdose crisis, due to regulatory restrictions.
One study by researchers from Syracuse, N.Y., found that emergency room visits decreased by 42% in the six months after the bridge clinic opened. Studies also show that bridge clinics help fill a gap in care for patients with «clinically complex» cases: patients with co-occurring substance abuse, serious mental illness, homelessness, and infections such as HIV or hepatitis.
In cases where primary care physicians are limited, nurse practitioners can be key to ensuring access to care.
As of 2016, federal regulations allow nurse practitioners and physician assistants (PAs) to prescribe buprenorphine, but this remains unavailable in some states, including those hard hit by the overdose crisis, due to regulatory restrictions.
For example, the state of Tennessee strictly prohibits nurses and medical professionals from prescribing buprenorphine, which means they cannot fully utilize their education and qualifications. Matthew, a psychiatric nurse practitioner and clinical professor at the University of California, San Francisco, who directs the medical aspects of substance use management at UCSF Health, notes that advanced practice nurses, especially in mental health, have the education and experience necessary to effectively treat substance use disorders.
With the introduction of prescriptive authority for nurses and federal health care providers, nurses and health care providers have submitted more applications for licensure than physicians, reflecting their readiness and willingness to take a more active role in providing care.
Extending methadone care into regular health care settings, as in other countries, would be a significant step in ensuring accessibility. At the beginning of the Covid pandemic, methadone clinics relaxed their rules by allowing more take-home doses and allowing family members to pick up medications for quarantined patients, showing possible changes for the future.
With the introduction of prescriptive authority for nurses and federal health care providers, nurses and health care providers have submitted more applications for licensure than physicians, reflecting their readiness and willingness to take a more active role in providing care.
Extending methadone care into regular health care settings, as in other countries, would be a significant step in ensuring accessibility. At the beginning of the Covid pandemic, methadone clinics relaxed their rules by allowing more take-home doses and allowing family members to pick up medications for quarantined patients, showing possible changes for the future.
The Modernizing Opioid Treatment Access (MOTA) bill being considered by Congress would allow addiction medicine and psychiatry doctors to prescribe methadone. Studies demonstrate that patients reduce their risk of overdose or abuse if they are able to take more of the drug with them.
Opinions on MOTA vary among addiction specialists: some believe the bill goes too far by increasing the risk of overdose, while others believe it doesn't expand access enough. Rachel Simon, a physician at the methadone clinic at Bellevue Hospital in New York City, sees MOTA as an important first step toward reducing barriers to treatment. «Methadone is an effective medication. The time for change is now» — she says.
What if we removed treatment from sterile medical facilities?
For some patients, it may help to separate drug treatment from formal health care settings. Context matters, and making treatment more culturally authentic can succeed where other approaches fail.
Opinions on MOTA vary among addiction specialists: some believe the bill goes too far by increasing the risk of overdose, while others believe it doesn't expand access enough. Rachel Simon, a physician at the methadone clinic at Bellevue Hospital in New York City, sees MOTA as an important first step toward reducing barriers to treatment. «Methadone is an effective medication. The time for change is now» — she says.
What if we removed treatment from sterile medical facilities?
For some patients, it may help to separate drug treatment from formal health care settings. Context matters, and making treatment more culturally authentic can succeed where other approaches fail.
https://portal.ct.gov/DMHAS/Newsworthy/News-Items/The-Imani-Breakthrough-Project
The Connecticut-based Imani Breakthrough Project, launched in 2017, offers addiction treatment in black and Latino churches as a way to address racial disparities in treatment. The program, developed by Yale addiction psychiatrists Ayana Jordan and Chirell Bellamy, («Imani» means «fait» in Swahili) consists of weekly peer support and recovery sessions, as well as individual coaching and cognitive-behavioral therapy, held in churches.
The project was actually born out of a dire need — at a time when black and Latino overdose deaths were on the rise, but the media was primarily focused on white rural victims of the epidemic.
For as long as this program was being developed, the overwhelming message was that people didn't want to seek traditional help. They didn't feel safe. Black Americans in particular often distrust the medical establishment — and there's a good historical reason for that.
For many patients, spirituality is important to recovery, so the church itself represents a form of intervention: a sacred and familiar space where the people of the community felt known.
The program was originally located in eight churches across Connecticut, but has recently expanded to Rhode Island and New Orleans, with plans to open in Boston and New York City.
The project was actually born out of a dire need — at a time when black and Latino overdose deaths were on the rise, but the media was primarily focused on white rural victims of the epidemic.
For as long as this program was being developed, the overwhelming message was that people didn't want to seek traditional help. They didn't feel safe. Black Americans in particular often distrust the medical establishment — and there's a good historical reason for that.
For many patients, spirituality is important to recovery, so the church itself represents a form of intervention: a sacred and familiar space where the people of the community felt known.
The program was originally located in eight churches across Connecticut, but has recently expanded to Rhode Island and New Orleans, with plans to open in Boston and New York City.
A new version of the Imani program was launched in 2021 as a five-year NIH-funded project, where participants can consult with black or Latino psychiatrists via telemedicine to start MAT at their church. The ultimate goal is to implement the Imani model nationwide.
According to a study of Imani's first three years, an astounding 42% of participants remained in the program after 12 weeks.
There is no perfect comparison to treatment in standard medical settings, but an analysis of 2016 drug treatment data showed that 20% of black patients and 15% of Hispanic patients completed their programs, compared to 60% of white patients. Participants also improved their scores on tests assessing health and community citizenship.
Project creators have seen excellent results in terms of complete cessation or reduction of substance use.
The project's founders claim it's the first time they've seen an environment where black or Latino sovereignty is really clear. In a country where the dual identity of a person of color with addiction means that «you are completely thrown away», this project has a place where church members are there for people who look like you, welcome you, and integrate medical care.
The project's founders claim it's the first time they've seen an environment where black or Latino sovereignty is really clear. In a country where the dual identity of a person of color with addiction means that «you are completely thrown away», this project has a place where church members are there for people who look like you, welcome you, and integrate medical care.
