Addiction Is a Chronic Disease. Let’s Treat it That Way
Why does the United States persist in treating addiction like a moral failing? A look at a program that treats addiction like the chronic disease that it is.
In today’s special issue of MindSite News Daily we pose a critical question: Why does the United States persist in treating addiction like a moral failing? We’ll explore programs that treat addiction like the chronic disease that it is – at a time when overdoses have declined but are still claiming more than 80,000 lives a year.
Following is an excerpt of a recent piece on addiction treatment in primary care in California that I wrote for the Center for Care Innovations (CCI), a nonprofit that promotes innovations in healthcare:
“It’s All Hands On Deck”: A Southern California Clinic Goes All In for Addiction Treatment in Primary Care
Sean Brown remembers the first time he saved someone from dying of a fentanyl overdose.
The lead navigator for medications for addiction treatment (MAT) at the Central Neighborhood Health Foundation, a network of safety net health centers serving Los Angeles, he had just pulled up into an area called Alta Park when a patient knocked on his vehicle’s door shouting “Hey, this guy is suffering from a fentanyl overdose over here!” Luckily, Brown said, he was carrying Narcan – a lifesaving drug used to treat opioid overdose – and raced into the park to find a man lying on the ground and unresponsive.
“The guy was unconscious, he had eyes in the back of his head, grey lips and all the other signs of an overdose,” Brown recalls. He administered Narcan – inserting the nozzle inside the man’s nose and giving a quick squeeze – but nothing happened. Brown did chest compressions and CPR, including mouth-to-mouth resuscitation for two or three minutes. As he was working urgently to revive the patient, officers from the Los Angeles Police Department pulled up and piled out of their cars, but to Brown’s dismay, they didn’t help. Instead, they lined up to watch.
Getting no response from the comatose man, Brown administered another dose of Narcan. This time, the man finally began breathing. The LAPD officers, silent until that point, broke into a round of applause.
“Addiction has been treated as a social problem. It’s actually a chronic disease.”
Saving people on the brink of dying from a drug overdose may be the most dramatic way that Central Neighborhood Health Foundation is combating the opioid epidemic, but it’s just one part of a comprehensive strategy involving prevention, harm reduction, and addiction treatment, along with consistent health care and other services.
Sean Brown and his colleagues on the addiction treatment team are part of the fourth wave of Addiction Treatment Starts Here, or ATSH, a program from the Center for Care Innovations (CCI) to help curb the opioid epidemic in California. Brown’s training on how to use Narcan to save lives during an overdose, and the clinics’ well-stocked supply of Narcan itself, were supported by the program, which in turn is funded by the California Department of Health Services.
The goal of the latest round of the program is to promote equity and racial justice in addiction treatment and reach disinvested communities by partnering with community-based organizations that help clinics reach the community, serving as trusted messengers and sources of community expertise.
This wave of the now-completed ATSH programs also expanded access to FDA-approved medications that cut the craving for opioids and offered counseling and therapy. It also incorporated a comprehensive set of evidenced-based approaches to ensure that medication-assisted treatment (MAT) services were inclusive, caring and accessible.
“Stigma is a big component as to why treatment for addiction has suffered,” said ATSH faculty member Joe Sepulveda, an addiction psychiatrist at the Family Health Centers of UC San Diego. “Addiction has traditionally been treated as a social problem, not a health problem. But the reality is that it’s actually a chronic disease.”
“We’re not here to judge you”
At the Central Neighborhood Health Foundation, addiction treatment work took off quickly. The ATSH grant from CCI provided the funds to assemble a team devoted to addiction medicine, with Brown and other team members training under physician David Asher, the health center’s addiction medicine specialist. After a year and a half in the ATSH program, the program expanded from a handful of MAT patients to 600, with a new behavioral health substance use disorder center opening in Long Beach.
But it didn’t happen overnight. To help build up the ATSH-funded program, Brown and Central Neighborhood MAT supervisor Cravon Charles scoured communities, fields, shelters, encampments and freeway underpasses on foot to explain the MAT program and offer services.
This ‘boots on the ground’ approach was also reflected in the team’s work with mobile units and their outreach to schools and to unhoused people.
“Coming from a strong mental health background, you learn a different type of language, how to speak to people,” said Charles. “Being of urban descent, we can relate to (our patients) and get them to understand the importance of MAT and its benefits. We were able to build a strong presence and a rapport with people to know that hey, we’re here to assist you. We’re not here to judge you, and we’ll come back as often as we need to make sure that we can assist you.”
One of their key challenges was the stigma of addiction — and addiction treatment itself.
“That stigma still plays its part when patients are standoffish or defensive, even though they’re getting the help they need,” said Joanna Bellinger, director of operations for the behavioral health and addiction medicine program of Central Neighborhood. She and other employees often leave a reminder message on a private line about an appointment for substance use disorder, she said, in case people need transportation or help setting up an online appointment. “And sometimes people get offended and call back upset and say don’t leave all that on my voicemail message – you don’t know who might hear my voicemail.”
Brown, who has 30 years of experience in the mental health field, agrees stigma is a challenge. “Addictions have no color, have no race, they have no boundaries,” he said. “You see people that live under the bridge using the same type of drugs that a millionaire uses. The stigma is definitely high, so we try to be as sweet as possible.”
The team is also working hard to level the playing field in addiction treatment. The urban neighborhoods served by Central Neighborhood have a high percentage of low-income Black, Latino and other people of color, many of whom have been caught up in the legal system’s approach to addiction, including incarceration, with little access to substance use disorder treatment. The Anti-Drug Act of 1986, for example, enacted prison sentences 100-fold greater for inexpensive “crack” cocaine than for high-priced powder cocaine, the latter used more often by white people.
Black communities also tend to be prescribed methadone for opioid use disorder at higher rates than white communities, which have better access to newer treatments like buprenorphine, which can be prescribed by primary clinics. The result is that they have far less access to evidence-based treatments like buprenorphine and to overdose reversal drugs like naloxone. And despite a legal obligation to provide healthcare to American Indians and Alaskan Natives, addiction treatment and other healthcare to these communities lags far behind other groups.
Ultimately, white patients have also suffered from our country’s disparate racial drug policies, which granted them “the ‘privilege’ of unparalleled access to prescription opioids,” according to UCLA psychiatrist and anthropologist Helena Hansen.
But no matter the community, people who use drugs still struggle to overcome the stigma that has prevented many patients from receiving addiction treatment in primary care. During its six-year campaign to help curb the opioid epidemic, CCI’s Addiction Treatment Starts Here program helped more than 100 primary care clinics in California build or expand medications for addiction programs. It’s an urgent undertaking: In the last 25 years, more than one million Americans have died from overdoses during the opioid epidemic.
The 20 California clinics in the latest wave of the ATSH program, including Brown’s, made significant improvements in reach and effectiveness, according to a state-funded evaluation by a team led by Mark McGovern, a Stanford University professor of psychiatry and behavioral sciences. The work also reduced disparities in access to MAT.
The secret to this cohort’s success? Seeking more employees and new hires with lived experience, people who spoke the language of the community and could empathize with their patients, as well as assigning more employees to doing street medicine. Also key: lowering the barriers to service by making it easy to get treatment.
“A lot of times, patients who use drugs or have substance use disorders do not get treated well in the healthcare setting, whether it’s emergency care visits or primary care settings,” said family medicine doctor Caleb Lusk of Harbor Community Health Centers in San Pedro, California, who has also participated in CCI’s ATSH program. “A lot of the patients gave us feedback and said, ‘This is the first time I’ve been treated like a human being. This is the first time I’ve actually had a connection with somebody who’s in healthcare. And now I feel this is my medical home, and I’m here.’”
Combating stigma with the BLINK Project Collaboration
One way that Central Neighborhood is spreading equity in addiction medicine and combating stigma is with the Blink Project Collaboration, a prevention program for teens in school, which covers mental health, sex education, HIV education, drugs and domestic violence.
“When you’re in high school, you don’t want people to know your business,” said Cravon Charles. “We have real interaction with these kids and build a rapport where they can say, ’You know what, I don’t feel comfortable talking to my mom and dad if I’m struggling with any of this.’” In those cases, the team counsels them, offers them handouts with real-life strategies on prevention and invites them to call them at the clinic if they need to. “We want the students to know we’re here for you,’” said Charles. “We encourage them to reach out anytime, that we’re in the trenches with you.’”
Charles recalls one teen who called Brown at home to tell him his dad had a huge substance and drug problem. The son didn’t know what to do, so he asked Brown if he could reach out to his dad “because he don’t know how much he is hurting our family.”
The team called the father, who was initially worried. “ He was like, ‘hey, how did you get my number?”’ Charles said. “And we didn’t want to say your son threw you under the bus, but we let him know his son said we should reach out to him. We told him what we could provide and that it was all without judgment. Now he and his son are in therapy together and the father is seeing a doctor monthly for MAT services and doing exceedingly well – all because his son reached out to us.”
Keeping their eyes on the prize
With the alarming changes in the opioid epidemic, including the problem of high-potency synthetics and fentanyl contamination of other drugs, the team welcomed being able to talk with other clinicians at an in-person ATSH convening in Los Angeles.
The program, which Brown, Charles, Bellinger and Lusk all attended, incorporated several indigenous traditions taught by ATSH faculty member Dr. Melanie Goodchild, a member of the Anishinaabe (Ojibway), moose clan, and a design and innovation strategist. One of the featured activities was systems mapping, which has long been practiced by First Nations communities.. It’s a practice intended to help bring clarity to thorny challenges such as addiction by helping people discover patterns and interconnectedness. In MAT programs, systems mapping often uncovers underlying patterns that are preventing endurable, sustainable change as well as unlocking help from unexpected sources.
Team members also participated in the Kaswenta (Two Row Wampum Belt) and the tobacco ties ritual exchange, two other indigenous rituals, with the purpose of bringing a spirit of healing, openness and gratitude into the program. The wampum belt stresses friendship, peace and respect between countries and people, while the tobacco or prayer ties are an exchange of gratitude, which involves a traditional sacred bundle of tobacco that’s imbued with the giver’s best wishes, prayers, intentions and especially their thanks.
Bellinger of Central Neighborhood remembers the in-person gathering and ceremonies as “awesome,” and Charles found the program’s in-person gatherings essential to his work, adding, “Nothing can replace meeting people face-to-face.”
In the meantime, the Central Neighborhood team is keeping their eyes on the prize: eliminating substance use disorder inequities. Charles and the team reported that they matched clients with collaborating shelters if they needed housing overnight. They linked patients to detox facilities to start their recovery. They’re working at schools and seeing clients with a mobile clinic, hoping to purchase a mobile van of their own. They’re working on harm reduction and letting patients know that no matter whether they are using or getting treatment, they are there to help.
“I think the way we approach people, in a compassionate type of manner, has shown that we really are here for the people,” said Charles. “It’s about servicing. The biggest thing that we try to do is stay consistent with some of the locations that we service. We do that faithfully, whether they use the service or not. Because at least the people know every Wednesday, 12 o’clock, Sean and Cravon will be here.”
For a look at other effective approaches to addiction and culture-based care, read the entire CCI article here.
The name “MindSite News” is used with the express permission of Mindsight Institute, an educational organization offering online learning and in-person workshops in the field of mental health and wellbeing. MindSite News and Mindsight Institute are separate, unaffiliated entities that are aligned in making science accessible and promoting mental health globally.
Author
Related Articles
In Teens, Social Anxiety Often Looks Like Anger
A study finds that some teens’ aggressive behavior may be due to social anxiety, not straightforward reactivity.
Expert Calls for Harm Reduction, Not Punishment, to Resolve Our Overdose Crisis
As the Trump administration pulls funding from harm reduction, an expert on the overdose crisis says it’s the best way to save lives.
The Trump Administration Continues to Fail Epstein’s Victims
The millions of Epstein files included thousands of mentions of Donald Trump as well as identifying information about Epstein’s victims.
