Stigma – Addiction Treatment Forum

How OTPs Can Help Pain Patients With OUDS: SAMHSA

January 18, 2019

By Alison Knopf

Can opioid treatment programs (OTPs) help pain patients who no longer need opioids for pain? Absolutely, says Elinore F. McCance-Katz, MD, PhD, assistant secretary for mental health and substance use at the Department of Health and Human Services (HHS). “For overuse and misuse of pain medications over time, which may have been initiated for a pain condition—I definitely think there’s a role for OTPs in this,” she told AT Forum.

One barrier is that the patients themselves don’t want to be considered “addicted,” and certainly don’t want to go to a treatment program that advertises itself as treating “addicts.” Another is that pain physicians themselves sometimes don’t want to be associated with addiction—and don’t even want to get the waiver to prescribe buprenorphine for their patients who develop opioid use disorders (OUDs).

Stigma of “Addict”

As assistant secretary at HHS, Dr. McCance-Katz is also responsible for managing and directing the Substance Abuse and Mental Health Services Administration (SAMHSA), and for leading SAMHSA policy and program development. So Dr. McCance-Katz understands the barriers facing patients, physicians, and OTPs. She cited an example. “I think there’s a certain stigma to using the word addiction with someone who believes they have a legitimate painful condition for which they received opioid therapy,” she said.

My own approach with those patients is not to use the word ‘addiction’ or ‘addict,’ but to discuss with them how these opioids have affected their life in a negative way,” she said. “It’s not just about dependence—it’s about overuse to the extent that it’s medically dangerous.” For example, overuse of opioids can result in periods of respiratory depression or aspiration pneumonia that could lead to death, she said. Another problem is that people on long-term opioids for pain “are not very active, and don’t exercise their lungs,” further exacerbating the respiratory issues, she said.

To help these patients accept treatment in an OTP for their OUD—because that’s what people who overuse and misuse opioid painkillers have—it’s best not to “label” them, but to “get them to tell you themselves about some of the negative ways opioids have affected their life,” said Dr. McCance-Katz.

Comprehensive Care

As for helping people who are coming off high-dose long-term opioids get their lives back together, that’s exactly what OTPs do in providing comprehensive care, she said. “They have all the resources that are necessary to help that person.” And treating the OUD may not necessarily be with methadone—increasingly, OTPs are offering all three medications, said Dr. McCance-Katz: methadone, buprenorphine, and naltrexone.

“In my own clinical experience, so many people start out on opioids with pain, and legitimate pain,” said Dr. McCance-Katz. They were vulnerable to developing an OUD—and they did. “I talk to them about the positives and negatives, and they start to talk about the positives and negatives.”

Tapering

It may be that the patient’s own pain management physician needs to taper a patient’s opioid medications before the patient can start taking methadone, because most OTPs are not allowed to induce patients at doses above 20 or 30 milligrams. “Pain management may need to taper them to a point where they can safely transfer over to methadone or to buprenorphine,” said Dr. McCance-Katz. “There are protocols for doing that (specifically, for buprenorphine, she noted, although she added that it is easier to go from buprenorphine to methadone than from methadone to buprenorphine).

Unlike methadone given for OUDs, methadone for pain is given in multiple daily doses. “I don’t think we have all of the science” to understand why we give methadone once a day for OUD but not for analgesia, she said. Both methadone and buprenorphine are long-acting drugs.

How does a clinician know if a patient on long-term opioids for pain has an opioid disorder? It’s based on DSM-5 and behavioral manifestations—not just tolerance and withdrawal, which are not necessarily pathological, noted Dr. McCance-Katz.

“One of the key questions, when you get people who are on these large doses of opioids, and who meet criteria for an OUD, is, what do you do with them?” she said. “What you don’t do is cut them off. Too often that’s happening. Will they go through withdrawal? You bet, and that is wrong—in my opinion, it’s inhumane. We have to have protocols in place, that is part of the individualized relationship between a clinician and their patient.”

The federal Centers for Disease Control and Prevention, in their guidelines for long-term opioid use, did not recommend cutting patients off immediately, noted Dr. McCance-Katz. Yet, many pain physicians are doing that. OTPs have the resources and the pharmacological know-how to induce methadone and buprenorphine.

But tapering? That’s hard for anyone to do, said Dr. McCance-Katz. “I don’t think this is an area that gets a lot of emphasis in training programs,” she said. “Often clinicians aren’t aware of what all the downstream effects are, of tapering, and especially of cutting patients off of their opioids,” she said. “We know how to taper opioids. We need to make these protocols available.”

In fact, the federal government is working to get clearance to release tapering protocols to the field, said Dr. McCance-Katz. “As a field, as prescribers, we cannot absolve ourselves of responsibility when we are the ones who started these medications, usually without good evidence of their effectiveness.”

Emergency Departments

Some emergency physicians have suggested that if patients come in in withdrawal from opioids, all they need to give them is some opioid—any opioid—to stop the symptoms. “The problem with that approach is that within a few hours they’re going to be right back where they started from,” said Dr. McCance-Katz of these patients, noting the problem will be particularly bad if patients are giving short-term opioids, like Dilaudid.

“In fairness to emergency medicine colleagues, they are under intense time constraints, and this is not the kind of work that should be assigned to them,” she told AT Forum. “Increasingly, EDs are looking to do this kind of work, but it’s really very difficult to give the person the proper assessment, to determine if they’re a candidate for any opioid,” she said. The patient also needs to be able to move on to a clinic quickly where they can continue treatment. “If you just give them a dose of opioids, you’ve done nothing except put off the problem for a few hours or a few days.”

Long Stigmatized, Methadone Clinics Multiply in Some States

November 12, 2018

“While Congress and the Trump administration were promoting greater use of the addiction medication buprenorphine to quell the opioid epidemic, a handful of states were licensing new methadone clinics in dozens of the nation’s hardest-hit communities.

In fact, the methadone treatment industry, which began in the late 1960s, grew more in the past four years than it has in the past two decades, said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence Inc., which represents methadone treatment providers.

Between 2014 and 2018, the methadone industry added 254 new clinics, according to data from the Drug Enforcement Administration. In the two decades before that, increases in the number of programs were only incremental, Parrino said. “We haven’t seen such a dramatic increase in the industry since the 1970s.”

But despite a national drumbeat for more science-based treatment for people addicted to prescription painkillers, heroin and other illicit opioids, the opioid treatment industry’s expansion has mostly gone unheralded.”

Source: PewTrust.org – October 31, 2018

BAART Sues California City Over NIMBY Blocking Of Clinic

October 3, 2018

By Alison Knopf

This summer, Bay Area Addiction Research and Treatment (BAART) sued the city of Concord, California after a three-year effort to site its methadone clinic there. Amitai Schwartz represented BAART and BAART’s owner, BayMark Health Services.

It is a classic case; everything seemed to be moving forward (with some hitches, of course), and after a few years a site was located. Then the neighbors heard about it. They protested, and local officials caved to the popular pressure.

The lawsuit requests an injunction against the city and anyone succeeding or working with it from prohibiting the use of the location─2152-58 Solano Way─as a methadone treatment clinic. It also requests costs and attorneys’ fees.

Background

The city’s economic development office allowed the use of the facility at the location, and classified it as a medical office. However, city planners then reclassified it as a medical “clinic,” a use that is not allowed in a commercial and mixed-use zoning district.

BAART then went looking for other spots, found one that did allow a medical “clinic,” and began paying rent at the site in April. In November of 2017, however, NIMBY (not in my back yard) took over the official process, and residents didn’t want the facility near them. At the same time, the city’s economic development office decided the center should be a “social service facility,” which requires an additional permit.

BAART Appealed; Negotiations With the City Fell Apart

The lawsuit─like others involving NIMBY─is based on the state’s incorporation of the Americans with Disabilities Act (ADA). In the lawsuit, BAART charges the city with changing the classification of the facility, with the intention of violating the rights of people with disabilities. Under the ADA, patients seeking or in treatment at Opioid Treatment Programs (OTPs) have a protected disability.

BAART already has two other OTPs in Contra Costa County, where Concord is located. One of them, in Antioch, lost a legal fight to prevent the clinic from locating there in the 1990s.

The case was filed in United States District Court for the Northern District of California, and is called BAART Programs, Inc., BayMark Health services, Inc., and Addiction Research and Treatment, Inc. vs. City of Concord and Andrea Ouse (who changed the designation to “social services facility” after residents protested the siting).

“Under California law it is unlawful to discriminate because of disability or the perception that a person is disabled,” the lawsuit states. “The patients who would be treated at the BAART clinic are disabled within the meaning” of state code.

For a Contra Costa County report that found more treatment is needed, go to http://www.cc-courts.org/civil/docs/grandjury/1806_The_Opioid_Crisis.pdf.

4 Factors That Add To Stigma Surrounding Opioid-Use Disorder

September 17, 2018

“Even as America’s opioid epidemic has increased, the stigma surrounding substance-use disorders continues to be a major barrier to wider implementation of effective treatments that prevent overdoses and deaths.

The AMA Opioid Task Force offers a wealth of educational tools and practice resources to aid physicians in removing stigma surrounding opioid-use disorder and effective treatment for the condition.

Among them is a JAMA Viewpoint essay, “Confronting the Stigma of Opioid Use Disorder—and Its Treatment,” that provides insight on the harmful effects of stigma with medication-assisted treatment of opioid-use disorder.

The essay’s co-authors—Yngvild Olsen, MD, MPH, and Joshua M. Sharfstein, MD—describe four factors that contribute to stigma on opioid-use disorder and offer guidance on how they can be overcome.

The understanding of opioid-use disorder as a medical illness is still overshadowed by its misconception as a moral weakness or a willful choice.
The separation of opioid-use disorder treatment has meant clinicians overlook other health issues.
Loaded language furthers stigma associated with the condition.
The criminal justice system’s unwillingness to yield to medical judgment in the treatment of opioid-use disorders..

Source: AMA-ASSN.org – September 13, 2018

States Are Legalizing Nonprescription Syringe Sales in Pharmacies; How Well Is That Working?

June 18, 2018

By Barbara Goodheart, ELS

Nonprescription sales of syringes in pharmacies are being met with some enthusiasm, some resistance, and a tinge of stigma. But they offer an accessible, affordable, reliable way to lower the risks of HIV/AIDS and infectious hepatitis, and, if managed well, they can help control health care costs and save lives.

Attitudes—and Consequences

Some people sincerely question the wisdom of selling syringes (cylinders with hollow needles attached) to people who inject drugs (PWIDs). They see it as granting permission to continue misuse. Others think that people who misuse drugs “should suffer the consequences.” Those consequences are substantial; they include blood-borne infections and painful illnesses. As the data below show, they also include soaring medical costs—clearly impacting society as well.

Greatly boosting the medical costs are the sheer numbers involved. CDC data show that at least 3.5 million people in the U.S. are infected with hepatitis C virus (HCV). The C. Everett Koop Institute estimates the total lifetime costs for those currently infected with HCV could reach $9 billion. But if 80% develop chronic liver disease, the total costs over a lifetime would be “a staggering $360 billion in today’s dollars.” Adding medical costs, and all costs for other types of infectious hepatitis, along with costs for HIV/AIDS, boosts total expenditures to unbelievable levels.

Beyond those costs are other serious consequences that cannot be measured—broken ties with loved ones, untimely tragedies. Most of us know of a young person who had much to offer, but instead tragically succumbed to a drug overdose.

Stigma: The Not-So-Good News

Local stigma is a common problem, and California is no exception. California pharmacies have been selling nonprescription syringes since 2012—and The New York Times has identified areas where PWIDs face severely limited treatment options. An official blames local stigma— “county supervisors who don’t want a treatment program located in their area.”

Syringes for Diabetic Patients—But Not for PWIDs

A study in the International Journal of Drug Policy points to areas of stigma in California’s Central Valley. A purchase trial found that only one in five PWIDs were able to buy syringes, despite legalization. The study also found that only about 29% of pharmacists and staff would sell to PWIDs—but 79% would sell to patients with diabetes.

Pharmacists turned down people they thought might be PWIDs, based on appearance. Some participants donned conservative clothes and covered their injection scars, but were refused syringes nevertheless. Their attempts to buy, they said, were “embarrassing and stigmatizing,” and “forced them to ‘out’ themselves as drug users.” Some PWIDs who heard these reports didn’t even bother to try purchasing syringes.

Methadone Stigma

Stigma is no stranger to people taking methadone, participants learned. Methadone treatment was even “more stigmatized than injecting drugs,” they said, noting that many local sober living homes barred methadone patients.

Amanda, a study participant, said:

. . . if you get on methadone, you are just as bad as any junkie heroin addict, so you might as well just do the heroin because then nobody knows you are at a methadone clinic . . .

[We] hated people who were on methadone and talked crap about them, because, for whatever reason, we thought we were so much better.

Amanda and her husband eventually enrolled in methadone treatment, but she wished they’d done so sooner, instead of letting their daughter live elsewhere, “because she had heroin addicts her whole life as parents.”

Choices

What motivates some PWIDs to head for a pharmacy to purchase syringes, instead of sharing or reusing syringes on hand—their own, or others’—as many PWIDs do?

Perhaps they are aware of their risks, and ready to accept advice and help. Some may be standing on the brink—almost ready for treatment—waiting for someone to offer a hand.

The Pharmacist Is In

Enter the pharmacist. He or she is among the most trusted and knowledgeable sources patients approach for health care information.

In some states it’s standard to require pharmacists to provide information to people buying syringes. Pharmacists in California are called upon to offer guidance about testing and treatment for HIV and hepatitis, and to provide safe disposal of sharps. Some pharmacy programs give links to support groups and detailed help about entering treatment programs.

To date, more than half the states offer nonprescription sales of syringes in pharmacies. Some states have a counseling agreement resembling California’s.

The Bottom Line

The pharmacy staff’s interactions with customers can have far-reaching effects. Pharmacists who are nonjudgmental and understanding can do much more than provide helpful information and safe syringes; they can help PWIDs take those difficult first steps, perhaps even opening the door to treatment.

A Note To Our Readers—

This article certainly isn’t meant to encourage readers to use illicit drugs. But we do want to spread the word that, for drug users not in treatment, access to clean syringes can lower the risk of contracting or spreading HIV and viral hepatitis. Moreover, the opportunity to contact a pharmacist or other health care provider for advice may increase the likelihood that a person who is using drugs will consider treatment.

Sue Emerson, Publisher, Addiction Treatment

References

Edlin BR, Eckhardt BJ, Shu MA, et al. Toward a more accurate estimate of the prevalence of hepatitis C in the United States. Hepatology. 2015;62(5):1353-1363. (Free PMC Article.) doi: 10.1002/hep.27978.

The C. Everett Koop Institute. Dartmouth Medical School. Hepatitis C: The Facts: The Epidemic: Associated Health Costs—United States. http://www.epidemic.org/thefacts/theEpidemic/USHealthCareCosts.

Del Real JA. Needle by needle, a heroin crisis grips California’s rural north. The New York Times. May 8, 2018. https://www.nytimes.com/2018/05/08/us/california-heroin-opioid.html.

Paquette CE, Syvertsen JL, Pollini RA. Stigma at every turn: Health services experiences among people who inject drugs. Int J Drug Policy. 2018;(57)104-

Resources

Meyerson BE, Davis A, Agley JD, et al. Predicting pharmacy syringe sales to people who inject drugs: Policy, practice and perceptions. Int J Drug Policy. 2018;56:46-53.

HIV and Injection Drug Use. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. November 2016. https://www.cdc.gov/hiv/pdf/risk/cdc-hiv-idu-fact-sheet.pdf.

A New Study Shows Stigma Is Hurting Our Response to the Opioid Epidemic

June 11, 2018

“When it comes to combating opioid misuse and addiction, needle exchanges and safe injection sites have decades of evidence behind them. Yet a new study published in Preventive Medicine found that a majority of Americans oppose both — and stigmatizing attitudes toward people with addiction appear to be to blame.

For the study, researchers conducted a survey of more than 1,000 Americans asking about their attitudes on needle exchanges, safe injection sites, and addiction more broadly. They found that about 39 percent of Americans support needle exchanges, while around 29 percent back safe injection sites.

The survey also measured respondents’ stigmatizing attitudes toward addiction, putting together a composite of questions — whether they’d be willing to have a person who is using opioids marry into their family or start working closely with them on a job, and their overall feelings of people who use opioids.

The researchers concluded: “Individuals with higher stigma toward people who use opioids were less likely to support legalization of safe consumption sites … or syringe services programs.”

Source: Vox.com – June 7, 2018

Blog: Reversing Stigma Is Key to Stemming the Opioid Epidemic

May 9, 2018

“After two years of bitterly partisan debate on health reform, Congress appears poised to unite on a response to the opioid epidemic. Leaders in both parties should add one essential ingredient to the developing bills: a multiyear, comprehensive public education campaign to reduce the stigma around addiction.

I know our lawmakers are keenly aware of this agonizing issue. On a visit to Washington recently, days before the Senate Health, Education, Labor and Pensions Committee approved the “Opioid Crisis Response Act” last week, I was struck by how many members of Congress shared their feelings with me about the stigma tormenting substance users in their communities.”

Source: TheHill.com – May 4, 2018

Nursing Homes Routinely Refuse People on Addiction Treatment — Which Some Experts Say Is Illegal

April 25, 2018

“Nursing facilities routinely turn away patients seeking post-hospital care if they are taking medicine to treat opioid addiction, a practice that legal experts say violates the Americans with Disabilities Act.

After discharge from the hospital, many patients require further nursing care, whether for a short course of intravenous antibiotics, or for a longer stay, such as to rehabilitate after a stroke. But STAT has found that many nursing facilities around the country refuse to accept such patients, often because of stigma, gaps in staff training, and the widespread misconception that abstinence is superior to medications for treating addiction.”

Source: StatNews.com – April 17, 2018

AATOD Conference Recap: Field Has Funding, Now Needs Infrastructure

April 17, 2018

By Alison Knopf

There were more than 2,000 attendees at the 2018 conference of the American Association for the Treatment of Opioid Dependence (AATOD), held at the Marriott Marquis in New York City in March.

The five-day meeting was full of presentations, workshops, and formal and informal gatherings, where leaders and staffers in the field of treatment of opioid use disorders exchanged knowledge and experience.

Open Board Meeting: Concerns About STR Funding

The open board meeting, which took place March 10, was an important time to share concerns about funding and regulatory matters with federal agencies. Board members had many questions for the Substance Abuse and Mental Health Services Administration (SAMHSA). The questions were related to the State Targeted Response (STR) to the Opioid Crisis grant program, which added $1 billion to the opioid treatment landscape via state funds.

SAMHSA’s Onaje Salim, EdD, conducted his agency’s presentation at the open board meeting. He was confronted by questions about why so much of the STR funding was going to pay for buprenorphine, naloxone kits, and prevention messages, but relatively few contracts with opioid treatment programs (OTPs) were being funded, to expand treatment in a more comprehensive way.

Dr. Salim was very sympathetic to the concerns of the AATOD board members. Formerly the administrator of an OTP in Atlanta, Dr. Salim was the first Georgia delegate to the AATOD board of directors. Later he became the Single State Authority for Georgia, before going on to SAMHSA.

But concern persisted at the board meeting: Would the STR funding be used for the same projects in year 2 as in year 1? And how would SAMHSA be able to guarantee that the funds were being put to good use? “How do you give the same level of funding if you don’t understand if it worked the first year?” as AATOD president Mark Parrino, MPA, put it.

OTPs’ Missed Opportunity

The time for OTPs to have made their case, however, was back in December of 2016 when the STR grants were announced. States prepared their applications then, and although a new federal administration was coming in, the funding process was underway. OTPs needed to go to the states at that time to present their arguments.

“I did say to my board members and provider colleagues that if you guys want to get these funds, you have to plant yourselves in the state offices,” Mr. Parrino told AT Forum.

On the other hand, states also have an obligation to use federal funds judiciously and to reach out to the appropriate partners, including OTPs, said Mr. Parrino. If states are not including OTPs as part of their treatment expansion strategies, then that needs to be explained as well. While a number of federal and state agencies are moving quickly to increase access to treatment, it is also important to be accountable in how these funds are spent.

And it is up to SAMHSA to hold states accountable for their use of STR funds, said Mr. Parrino. “SAMHSA should be holding the states’ feet to the fire. This is a straightforward issue.”

Buprenorphine Data 2000 Prescribers—Where Are Comprehensive Services?

The challenge from DATA 2000 practices—buprenorphine prescribers who do not necessarily provide comprehensive services—is felt keenly by the OTP community.

SAMHSA is invested in quality treatment services. Still, how this need for quality is implemented in DATA 2000 practices “is going to be a mystery,” said Mr. Parrino. While Elinore McCance-Katz, MD, PhD, who heads SAMHSA, says she wants coordinated services, how does this apply to DATA 2000 practices, which only have to prescribe buprenorphine and not provide any other care?

It is also true that there are many DATA 2000 practices that are offering excellent care. There should be some consideration in identifying treatment providers who do provide excellent treatment utilizing evidence-base practices, said Mr. Parrino. This issue will take on greater importance as insurance companies use a number of strategies to identify providers, which should be part of their network.

AATOD supports all three medications approved to treat opioid use disorder, but, like Dr. McCance-Katz, it endorses treatment that is comprehensive, not just restricted to prescribing and dispensing medication.

Mobile Vans Haven’t Yet Hit the Road

The Drug Enforcement Administration’s Jim Arnold, section chief of the liaison and policy section, explained to the AATOD board that mobile vans are not a reality yet because of President Trump’s executive order calling for eliminating two regulations for every new one. He said that the DEA was trying, however, and had sent it to the general counsel, but got it back with 70 requested modifications.

“So it’s slowed down,” said Mr. Parrino. “It’s not that anyone is saying ‘We don’t want to do this,’ because the DEA does want to do it,” he said.

The holdup is a problem in the way states use the STR money, as well. For example,

Molly Carney, executive director of Evergreen Treatment Services, wanted to use Washington’s STR grant for 2017 to get two new vans. She couldn’t, because of the DEA.

Awards Banquet: Former New Jersey Governor Attacks Stigma

If there were any questions as to why Chris Christie was chosen for the Friend of the Field award, the passionate acceptance speech by the former governor of New Jersey answered them. He attacked stigma directly, as the main reason for access problems for patients seeking methadone and buprenorphine treatment.

The Nyswander/Dole “Marie” awards at the banquet, which was sponsored by Mallinckrodt Pharmaceuticals, went to:

Gloria Baciewicz, MD (a psychiatrist based in Rochester, New York, who broke ground 25 years ago in getting upstate communities to start to accept methadone);
Hope Bolger, RPh (among many other credits, she has been the State Opioid Treatment Authority for Virginia, where the number of opioid treatment programs tripled during her tenure);
Jonas Coatsworth, MA, LPC, CAC-II (a leader in methadone and recovery in South Carolina);
Gabriele Fischer, MD (an Austria-based psychiatrist who has promoted methadone maintenance through the World Health Organization and the United Nations Office on Drugs and Crime);
Kathleen Maurer, MD (the medical director of Connecticut’s Department of Correction, where she instituted methadone maintenance treatment in prisons);
Stacey Pearce, CAS (treatment program director and methadone treatment advocate in Georgia); and
Vickie L. Walters, LCSW-C (a treatment advocate based in Maryland).

The Richard Lane/Robert Holden Patient Advocacy Award went to Paul Bowman, CMA, Boston National Alliance for Medication Assisted Recovery chapter director, patient advisor to Habit OPCO, consultant to residency programs, and more.

Connectivity and Importance of Staff

The conference itself was a chance for OTP staff from around the country to get together. Looking over the history of the conference programs, it’s easy to see trends in the field. Mr. Parrino believes the conferences promote “connectivity,” so that stakeholders and conference attendees can understand how their work is related to regulatory changes and other moves on the state and federal levels.

Now that the field has the money—from the STR grant program, with new funding expected—the question is, do OTPs have the infrastructure? Programs are opening, and in some states, the growth is dramatic. “In Ohio, it’s like the gold rush,” said Mr. Parrino. But, as he said at the open board meeting, as OTPs expand, they must be sure that they have the workforce to do this properly, and that they have the money to support the workforce.

“There’s a connection between retaining staff and retaining patients,” said Mr. Parrino. Success in treatment is driven by the characteristics of the treatment program, not the characteristics of the patient, as the John Ball study showed (see citation, below).

Currently, there are about 1,600 OTPs in the United States. By October of 2019, when the next AATOD conference takes place in Orlando, that number will be 1,800, Mr. Parrino told AT Forum. “I’d like it to be 2,000,” he said. “But remember, the number must be reflected in the ability to open and staff the programs.”

Reference

Ball JC, Lange WR, Myers CP, Friedman SR. Reducing the risk of AIDS through methadone maintenance treatment. J Health Soc Behav. 1988;Sep;29(3):214-226.

How OTPs Can Help Reduce Stigma: The Boston Experience

February 11, 2018

By Alison Knopf

Boston is not the only city with a powerful push by academics and providers for medication-assisted treatment (MAT), but it’s definitely one with a high profile. We talked with Janice F. Kauffman, RN, MPH, and Sarah Wakeman, MD, about how opioid treatment programs (OTPs), specifically, can help fight stigma against MAT.

Education is important, but by itself won’t work because of pre-existing bias, said Ms. Kauffman, who is vice president of Addiction Treatment Services for North Charles Foundation, Inc., director of addictions consultation for the Department of Psychiatry, Cambridge Health Alliance, and assistant professor of Psychiatry, Harvard Medical School. “I spend a good amount of my time talking to community members, talking to police, trying to educate people in the community,” Ms. Kauffman told AT Forum. “But I don’t think education is as helpful as we hope it will be, because people come with pre-existing opinions.”

In other words, if someone is predisposed to believe methadone is “trading one addiction for another,” that person will believe it, regardless of the information they are given.

Teaching Police

“I often teach police officers,” said Ms. Kauffman. “And I’m impressed that I can spend an hour giving them information—in particular, about the efficacy of methadone maintenance. But at the end of the day there are many who maintain that you should be off the medication, that this isn’t really a disease like other diseases.”

One problem is that substance use disorders are still conflated with crime, in the mind of many in law enforcement. Those people don’t need to be educated about cancer, dental caries, or other diseases. Perhaps it’s too much of a stress to even try to educate them about addiction—but, in fact, many police officers, especially in Massachusetts, the home of PAARI (Police Assisted Addiction and Recovery Initiative), would rather help people get treatment than arrest them. The question is, what kind of treatment? Massachusetts currently has an initiative focused on getting residential treatment for people with opioid use disorders, and favoring antagonist treatment with Vivitrol instead of buprenorphine or methadone. This is also true for people under civil commitment—a process that falls in line with many beliefs of law enforcement.

The Media

Janice F. Kauffman, RN, MPH

Ms. Kauffman also said that OTPs need to do a better job of educating the media, which is in general not well informed about methadone maintenance, a treatment that’s proven efficacious for decades. “The media does not do us justice,” she said. “Their stories have focused on people who don’t do well.” She added that some stories look at people in the community who are not doing well, mostly because of benzodiazepines and other drugs of misuse. “This is what happened in the Boston area, with stories about what the media dubbed ‘Methadone Mile.’ Even when behavior doesn’t involve methadone, the media automatically connect it. They think that neighborhoods with OTPs are places people deal drugs—but people deal drugs everywhere.”

It would help for successful patients to come forward, but they’re afraid to, because of the effects on their jobs and lives and families, said Ms. Kauffman. “I’ve been doing this work since the early 1970s. I’ve lived this stigma for a long time, and I’ve watched our patients suffer from it.”

Employers

So, what is the solution? Perhaps OTPs should ask employers to publicly support methadone maintenance—“especially employers who are willing to come forward, and who know that their patients are in methadone treatment and doing well. That would be better than putting it on the backs of patients,” said Ms. Kauffman. “Employers could say, ‘Some people who are working for me are methadone patients, and they’re doing very well,’” said Ms. Kauffman. “This would show that people are willing to employ our patients, who have a disease like any other disease.”

The North Charles Foundation produced “Waking Up: A Story in Four Parts,” a short film on its program, specifically designed to address stigma, as part of a grant. In a narrative therapy group in the film, patients told how they got into trouble with drugs, and what methadone treatment was like. (The grant was from Johnson and Johnson, the Harvard Medical School’s division on addictions, and a private family foundation.) “We showed the film to over 100 medical, social-service and substance use treatment providers in the greater Boston area, for a pre-test and a post-test,” said Ms. Kauffman. Before they saw the film, viewers were biased against methadone. After they saw it, their feelings changed. “They were struck by how the patients suffered, and what happened privately in their lives. They were also impressed with how the patients got better, and became contributing members of society.”

Ms. Kauffman uses this film when she teaches doctors training in hospitals as residents. “It’s powerful,” she said.

One Day at a Time

There’s a commonly held notion that methadone maintenance is forever, which can be daunting, creating a stigma of its own. It’s similar to what happens when people with alcohol use disorders are overwhelmed by the idea that they can never drink again. “We have lots of patients who come to treatment saying they want methadone only for a certain period,” said Ms. Kauffman. “I would never say ‘no,’ to that. We say, ‘Let’s get you stabilized, let’s help you look at this.’” Often it’s the stigma that makes patients want to leave treatment quickly.

“If you have to deal with the notion of needing to do this for the rest of your life—that’s hard for patients to wrap their minds around,” she said. But OTPs help new patients normalize their lives as soon as possible, and most patients see that they can have normal, good lives without giving up their medication, and without switching medications.

Sarah Wakeman, MD

Language Counts

Dr. Wakeman, who is medical director of the Substance Use Disorder Initiative and the Addiction Consult Team at Massachusetts General Hospital, co-chair of the Mass General Opioid Task Force, and an assistant professor in medicine at Harvard Medical School, is a big proponent of using proper language to reduce stigma.

“One of the greatest struggles we have is reducing stigma, not just about addiction but about treatment,” she said. “If we change our language, using medically appropriate terminology just as we do for other illnesses, we can change how the rest of the world thinks of treatment.”

A very simple but necessary change is to stop using the terms “clean” and “dirty,” she said. “You can say a toxicology test was positive or negative, or you can say the results are appropriate or inappropriate.” The point is not just to switch the words, it’s to stop being judgmental. “When I talk with a patient about diabetes testing, I refer to results as being within range or out of range. OTP counselors telling patients about a positive drug test can begin by saying, “There were unexpected findings in your toxicology report,” she said. “Stay away from judgement-laden language.”

This isn’t just a matter of being politically correct, said Dr. Wakeman. If treatment programs convey this kind of stigma against patients, how are people supposed to avoid it?

Dr. Wakeman also points out that “dependence” should not be confused with addiction. Being dependent on a medication is not the same as being addicted—it’s not pathological. “If someone is taking long-term opioids appropriately for pain, that person is dependent,” she said. “If someone is taking methadone for addiction, that person is dependent.”

Involving OTPs in the General Medical System

“The more we can engage OTPs in the general medical system, the better for patients,” said Dr. Wakeman. Her facility does not have its own OTP, but works closely with OTPs, she said. “We have agreements with OTPs. It’s important to have these agreements with OTPs as a hospital system,” she said. “That way we can link patients directly into ongoing care. It’s been great for us to work with OTPs.”

In deciding whether to refer a patient to an OTP or to office-based opioid treatment (OBOT) with buprenorphine, Dr. Wakeman said the most important factor is “what the patient wants and what the patient thinks will be effective.” Most patients prefer to start with buprenorphine, said Dr. Wakeman. “But if the patient reports having done well on methadone in the past, we go that way. If someone has tried both in the past, if they’ve done well on one but not the other, that helps us decide.”

Legacy for Methadone

For methadone, Dr. Wakeman uses a 1965 New Yorker profile of Marie Nywswander, MD, who, with Vincent Dole, MD, developed methadone maintenance treatment. Called “The Treatment of Patients,” the profile, by Nat Hentoff, explains how methadone works. “I still use this now, in 2018,” said Dr. Wakeman. “A molecule of methadone is no more problematic than a molecule of insulin.”

Dr. Wakeman has patients who work at Harvard or Mass General and are taking methadone. “You wouldn’t know it,” she said. “These people are doing well and going about their business and living their lives.

“We need to make addiction treatment seem scientific and a part of the medical mainstream,” she said. “And we need to hold them to the same standards and expectations we use for any other treatment provider.”

It would be beneficial to hear more patient narratives of recovery on MAT, said Dr. Wakeman, who agreed with Ms. Kauffman that the media promotes some stigma. “We need to hear from patients on MAT saying, ‘This is how much better my health and my life are now.’”