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The Next Phase of the Opioid Crisis | Brown Dean of Public Health Dr. Francesca Beaudoin
9 Plays3 days ago
In this episode, Dr. Francesca Beaudoin - emergency physician, clinical epidemiologist, and Dean of the School of Public Health at Brown University - joins us to examine the next phase of the American opioid crisis.
We begin with her firsthand experience on the frontlines of emergency medicine, where she witnessed the shift from prescription opioids to a fentanyl-dominated drug supply, and how that transformation reshaped overdose care in real time. From there, Dr. Beaudoin shares why emergency departments represent a critical intervention window, and how mobile opioid treatment programs are expanding access to life-saving medications like methadone. We also explore the deeper structural drivers of addiction and why lasting recovery requires more than acute stabilization. Ultimately, this conversation reframes the opioid crisis not just as a public health emergency, but as a systems-level challenge that demands coordinated policy, clinical, and community solutions.
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Transcript
Introduction to Healthcare Theory Podcast
00:00:00
Speaker
Welcome to the Healthcare Theory Podcast. I'm your host, Nikhil Reddy, and every week we interview the entrepreneurs and thought leaders behind the future of healthcare care to see what's gone wrong with our system and how we can fix it.
Evolution of the Opioid Crisis
00:00:14
Speaker
Over the past two decades, the American opioid crisis has claimed more than a million lives, evolving from prescription painkillers to heroin to fentanyl-driven overdose epidemic that touches nearly every community in the country.
Meet Dr. Francesco Beaudoin
00:00:27
Speaker
Today, I'm joined by Dr. Francesco Beaudoin, an emergency physician, clinical epidemiologist, and now the Dean for Public Health at Brown University, who has spent her careers on the front lines of this crisis.
Rethinking Interventions in Addiction
00:00:39
Speaker
Her work bridges emergency medicine, addiction science and public health. And not only do we get into why this opioid crisis started in the first place, but how we can actually better rethink emergency departments and different interventions, getting through the community, EDs, and also building by understanding the biology behind substance use addiction.
00:00:59
Speaker
So thank you so much, Dr.
History of Pain Management and Opioid Epidemic
00:01:00
Speaker
Bowden, for being here today. Welcome to the health care theory. My pleasure. Of course. And before we get into your work today, I'd love to get onto your background. I think when you first started in this area, pain was still treated as a fifth vital sign. They thought of it as something that should be reduced at all costs. So the effort was focused on pain management. I'd love to hear what drew you personally or intellectually into studying substance use disorder, youop opioid and pain management in that time. What was it looking like from your perspective, especially given that you're also an epidemiologist and used to work in emergency medicine too?
00:01:33
Speaker
Yeah, thanks so much. So this really dates back my interest in pain management and substance use and addiction to the early days of my clinical practice. So I've been out in the field for about 20 years now. i finished my residency in 2010.
00:01:53
Speaker
and then in those early days, we were not thinking of the overdose crisis
Changing Perceptions of Opioid Risks
00:01:58
Speaker
like we were today. and in fact, you highlighted you know this idea that pain was the fifth vital sign. And so the things that I saw in my practice as a new emergency physician were a couple of things like one we were treating pain and much the same way that we had been treating pain for decades.
00:02:16
Speaker
Thinking about things like opioids, ibuprofen, Tylenol, so became very interested in like, why are we taking this one size approach fits all to pain? When there's different types of pain, you can have pain related to a trauma.
00:02:29
Speaker
You can have pain, neuropathic pain that we see sometimes with diabetes and other conditions. And i was really fascinated by like this, like the way that we approach pain and the lack of evidence behind it.
00:02:44
Speaker
At the same time that I became increasingly interested in the management of both acute and chronic pain, We saw an abundance of prescribing of pre prescription opioids. And then i watched like really in front of my eyes, I felt like the opioid epidemic takeoff and and to put it like in perspective. And this is like a story. It's an anecdote, but the data will like support my own perceptions. I went from it being rare to take care of somebody who had an overdose from an opioid, and at that time it was predominantly heroin, that to seeing patients with an overdose from prescription opioids, heroin, and then ultimately fentanyl, every shift that I worked. So like rare to sometimes like multiple patients at a shift coming in because they had nearly died as a consequence of opioid medications.
00:03:37
Speaker
And if you look at the kind of the overlap, I think we have we know pretty well that like these medications have high potential for addiction, abuse liability, and clearly like
Structural Factors and Policy Interventions
00:03:49
Speaker
fueled this epidemic. And so over time, my own interests then like shifted from what I was seeing in practice to a problem about pain management, which I think is still real it still exists.
00:03:59
Speaker
But that's what felt like a pressing crisis and how was I going to use my skills both as a physician and an epidemiologist like wearing my public health hat to help not just like the one person in front of me that was experiencing the overdose, but how could I help drive evidence and data to help lots of people and families who are all now suffering from this epidemic.
00:04:23
Speaker
Yeah, that's really interesting because I know data can sometimes be a lagging indicator. Sometimes it can predict things really well, but there's nothing really better than being there on the ground and understanding what's going on with your own eyes.
00:04:33
Speaker
So, I mean, I can imagine that must have been quite scary, surprising to see, especially as a newer physician. and I'd love to get into the infrastructure, just like prescribing pain and opioids. i mean, it hasn't really changed and it's getting much worse.
00:04:46
Speaker
I often, people often reduce the word of opioid crisis to overprescribing, but it seems like there's much more forces going on there. I'd love to hear from you. It's a huge question, but what the same structural drivers that have been driving the crisis over years? I know the angle has kind of changed, but what do we often misunderstand about the nature of the crisis?
Illicit Substances and Current Challenges
00:05:05
Speaker
Yeah, it is, you know, I i think... It's easy to look through things in the good old retrospective scope, you know, as they say, the hindsight is 20, 20. And I think now we understand things about exposure to pain medications that we didn't, you know, 20, 30 years ago.
00:05:28
Speaker
So there's like, you know, the the chemistry of how these medications work, increasingly potent pharmaceuticals. Now, i think a better understanding of like who is at risk to develop ah potential the potential of our opioid misuse and opioid use disorders in a way that we did not before.
00:05:46
Speaker
And then theyll and like the last piece then is the kind of both the early identification and the approaches to treatment in people who then ultimately did go on to develop opioid misuse and an opioid use disorder. I think we're doing much better now. We're not there yet.
00:06:02
Speaker
And the opioid crisis has shifted. We still in this country and the United States prescribe a lot of prescription opioids compared compared to peer countries.
Emergency Departments as Intervention Points
00:06:12
Speaker
But it's better. We prescribe less than we did at our at our peak.
00:06:16
Speaker
on But what we see now is really ah an overdose crisis has been fueled by illicit substances, largely illicitly manufactured fentanyl, but increasingly kind of poly drug situations where people are overdosing.
00:06:31
Speaker
and um and And so the factors that drove the initial like spikes in overdose-related deaths, deaths related to opioids, I think are different than they are now But then there are always these underlying like structural, social, economic factors that I that i think are contributors.
00:06:50
Speaker
One thing that I think would be like, just to put again, some data to it and put things in perspective at our peak of opioid prescribing, we were prescribing enough pain pills to give every man, woman and child in this country, roughly like enough Vicodin to take one pill every four hours for a month.
00:07:10
Speaker
And it's like wrap your head around that. That's a lot of pain pills. And these are also like needed medications. They help people. I would under no circumstances want pain meds, to not to not have prescription opioids to treat pain in people that need them, but we definitely had swung way too far. Now that pendulum has swung back, but we have new problems to deal with.
00:07:32
Speaker
And do you think it often starts from, because i know the prevailing theory was that it starts with you getting an injury on your leg, you get to prescription and the cascade starts from there. But you think that's changed also? Like where from the patients that you meet does this addiction crisis tend to start? I can imagine it's not just that one pathway, it's quite different from patient to patient, but what is the prevailing theory of where addiction and the bottlenecks start to occur?
00:07:56
Speaker
The drug supply now is dominated, particularly in the East Coast. Now, drug supply does vary geographically and in the the East Coast. So i live and practice in Rhode Island.
00:08:08
Speaker
And before I answer your question, I'll actually highlight I don't practice emergency medicine really anymore. I'm still, yeah I am doing some addiction medicine, actually. So i work on a mobile a recovery unit, a mobile opioid treatment program that helps people who are suffering from of an opioid use disorder. So I actually aren't work on an um RV that's deployed to Woonsocket, Rhode Island, ah community that's been hard hit by the opioid epidemic. And so now I'm like truly really seeing firsthand the results of this of this crisis. And our local drug supply is heavily penetrated by fentanyl. I had a patient say to me, actually just this morning when I was there, they said something about themselves using heroin and then they said, ha ha ha, I'm really dating myself. Like there's no heroin anymore. And that's sort of true.
00:08:59
Speaker
And the other piece of it is, is that like how people have started using illicit fentanyl There is good data to suggest that 10, 15 years ago, 20 years ago even, that people started off typically using prescription opioids, things like oxycodone, Percocet, OxyContin, and then progressed along a pathway to using illicit heroin and then ultimately fentanyl.
00:09:27
Speaker
Now, and I'll just refer to what I see my own clinical practice, sometimes I'm i'm taking care of people who are now actually use it going straight to illicit substances, what sometimes people will call it like hard drugs, right? Like patients don't say that. I wouldn't say that in my clinical practice, but
Complexities of Treating Opioid Use Disorder
00:09:43
Speaker
I think for lay people, they sort of know what that means. They think of like, oh, fentanyl, cocaine, injection drugs. those ah And I am taking care of more and more people who haven't followed this other like pathway through I think you know when I was growing up as a kid, i had heard a lot about like gateway drugs and what does that mean. And now there are a lot of varied pathways to how people ultimately start using fentanyl. And so the crisis has, there are are behavioral pieces to the crisis that has shifted in a way that was very different than 15 to 20 years ago.
00:10:18
Speaker
And I think now we're starting to acknowledge that the addiction crisis is more than someone who got a leg injury and was on opioids for a while, then the cascade became worse and worse. They got addicted. Now it seems like there's much more different avenues for people to get addicted. From your perspective, um what are the main pathways and how has that been changing over time? I know it probably varies quite a lot between people.
00:10:41
Speaker
It's very heterogeneous. That scenario definitely still happens. I think we are doing a better job now about identifying potentially who is at risk of going on to develop a you know a problem with opioids or ultimately opioid use disorder after starting a prescription pain medication for you know a trauma, a broken bone after surgery. And a lot of states have actually tried to limit the number of the
00:11:14
Speaker
the days of prescribing after an episode of acute pain. In Rhode Island, the the practice is around three days of a supply of opioids. It's very different than before. So there's closer monitoring, early identification, more patient education.
00:11:29
Speaker
So I hope, and this may actually be one of the things that is driving decreases in overdose deaths over the past one to two years, is that we may have a less of like an at-risk population because we don't have as many people going on to develop an opioid use disorder.
00:11:47
Speaker
But that's not to say that people don't um don't develop an opioid use disorder via like other pathways as well. And it would be a mistake to categorize everybody as like, this is the unique experience for patients because it's not. And there's a lot of other things that that fuel somebody's substance use from like history of trauma, co-occurring mental health conditions, even things like poor sleep.
00:12:14
Speaker
And then all the social supports, lack of housing, unemployment. So it is really a complex problem. And it is hard to distill to like, these are like, if if we knew that these were like the clear things, right, we it would be much easier to do something about it.
00:12:28
Speaker
Yeah, that makes lots of sense. And I keep coming back to this tension in emergency medicine. On the one hand, you have The traditional role of the ED is to stabilize, you treat the overdose, manage the acute crisis, then you discharge. Discharge is the goal.
00:12:42
Speaker
But in the context of addiction, it seems like that opportunity is more, it could be almost like an inflection point. If someone survives an overdose, that could be the only time they interact with the healthcare system.
00:12:53
Speaker
So I'd love to hear what do you think of the ED as Is it a staable stabilization site? Is it a potential for a rare intervention window? I mean, what are the highest level tools, leverage tools we can deploy during that moment? I can imagine medication, peer recovery, housing, but in that brief encounter that's so short, what could we actually move the needle with? Should the ED be the one moving the needle?
00:13:19
Speaker
Yeah, this is my own bias. And as an emergency physician and wearing my public health hat, I think that for problems, not just substance use and opioid use disorders. Emergency departments are a perfect place to do public health interventions. For some people, it's the only place they're going to interact with the healthcare care system or see a doctor potentially.
00:13:41
Speaker
um We could have a whole another, probably, you could do a whole another episode and maybe you will about primary care access and challenges with access and affordability with the rest of the healthcare care system. But we know when someone steps foot in an emergency department, we do have to think about the whole patient. And often people are spending hours in an emergency department waiting for diagnostic tests, even just waiting periods in the waiting room. And so I always like the idea of thinking of like, what is, what are, what can we do during those periods of time when someone is going to be there anyway, to take better care of that person and also to provide better population health.
00:14:22
Speaker
Emergency departments, I think, have really stepped up in a very meaningful way as it relates to the overdose crisis. And because and I think specifically for this vulnerable population,
Integrating Care in Emergency Settings
00:14:34
Speaker
sometimes an emergency department may only be may be the only window to link somebody.
00:14:41
Speaker
to care, to start them on a recovery pathway. And even though they're like acute life threatening condition may be resolved, maybe their overdose was treated and they're stable and they're okay, that person's life is still in threat.
00:14:54
Speaker
And I think there's an obligation to continue to care for that person. And um emergency departments have, I think, been quite innovative in bringing in medications, peer recovery support specialists, community health workers, and thinking about not just that time the person is in an emergency department, but the the days, weeks, months, maybe years to follow. And are some of the ways you think this could be delivered? Like I can imagine peer approaches are important. And we kind of hinted at some of the others too. I mean, what are some of the best ways that we can get involved in the ED to start this early?
00:15:31
Speaker
Partly this is a health systems problem. It's incentivizing health systems to, to um do things that aren't always related to like care in that moment. And that is going to require getting policymakers at the table, leaders of health systems, payers to put the right incentives in place. And I i would say that falls under kind of this general bucket of doing a public health interventions and printing preventative care. And so this is a case example of that. But i think we absolutely need to have
00:16:06
Speaker
better integration along the spectrum of care and high need in the in the behavioral health space. on You know, we need more resources, we need more ease of of transition of care to the outpatient setting, and to reduce barriers for people to to get into care. And we've been fortunate in Rhode Island, because it is a small state, to integrate some of those things in a way that I think is difficult in other states. And even beyond the health system setting, I'll take you to like our carceral settings and the criminal legal system. We have fortunately access to to better care than a lot of other states because we've inter integrated things like medications for opioid use disorder treatment in our prison and jail systems and have handoffs and transitions to care post-carceral relief. And so it's thinking about like all the places that someone with a chronic health condition, a chronic disease of which addiction is one of where that person like
00:17:08
Speaker
might like interact and have healthcare needs.
Street Medicine and Community Partnerships
00:17:12
Speaker
And an emergency department is only one of those places. Often it's the entry entry point. But, you know, we, this is like really it requires a health system as approach and doing things in a way that are different than we've currently been doing them because like we've been putting a lot of band-aids on things, but the fix isn't there. So I hope like you have some listeners that are still like in training and coming up the pipeline that want to kind of like blow the lid off some of this stuff and do things in and do a new and different way because it's much needed.
00:17:41
Speaker
And at the same time, I can imagine some pushback. Hospitals are already overburdened. There's this concern about mission creep expanding the role of the ED beyond what it was designed to do. when you talk about long-term addiction care and emergency settings, like what are the real barriers for that? You kind of hinted it's a little bit of a policy issue, maybe reimbursement problem. or um I I'm just curious, what is the primary bottleneck to implementing this broader intervention model? there There are definitely policy levers to be pulled, but it's not purely a policy solution. And I Part of this is like resources, capacity, workforce development.
00:18:17
Speaker
There are lots of places that we can think about you know improving this problem. And and you know emergency department is, again, an access point, a starting point. And um I would actually like to give a shout out to my colleagues who practice at Brown University Health and um specifically Rhode Island Hospital. They've actually...
00:18:37
Speaker
come come out of the emergency department setting and have started a street medicine program and are now actually like reaching out to people before they even hit the emergency department. So thinking like one step before someone comes into an emergency department setting. And I think that's a way of thinking creatively and differently about how we've reached people to provide care.
00:19:01
Speaker
And we've seen, um i think that's interesting because we've seen in medicine becoming increasingly predictive in that way. um so it's kind of it's kind of cool. I mean, biomarkers, assist models, machine learning, but it doesn't seem like it's as neat an addiction. So how were they able to actually go about doing that?
00:19:20
Speaker
um I can imagine maybe it was just being in the community or something like that. But Um, what's it this like street level engagement or do you think there was more room for technology to get involved here? i mean, what actually worked when they, um, were building this tools out?
00:19:34
Speaker
Yeah. The, it's a ah lot of community engagement. so speaking with people who really have a pulse on what's happening with the population of people who use drugs and people in recovery. and then i think, you know, support from.
00:19:53
Speaker
health systems, the state community partners to to support these programs. I will say like when I first started working on the mobile unit that I'm on, um it when it was new to the community and new to the area that we were, so I've been there for ah going on five years now, when that first went there, I started off actually with one of our nurses who was on the unit with me and we basically walked up and down like the street and we went to tent encampments and we went to shelters and we went to mobile showering units to to promote that we were there, we were available if people were interested in and treatment or if they needed other access to harm reduction supplies like naloxone, safe injection kits, things like that. And it really was just kind of like some good old like sweat equity outreach in the beginning, as well as promoting the program from like an organizational level. So I work for Kodak Behavioral Healthcare. They've been a very dynamic partner. And so Kodak did a very good job of doing also outreach and partnership with community organizations who could create awareness of our program with when they interacted with with people that would potentially benefit. And so it requires really like a very much of a grassroots effort. And, you know, for the street medicine program, same thing. It's it's it's successful. because it is it is closely aligned with community partners. So true community engagement.
00:21:29
Speaker
Academics talk a ton about doing community engagement, but there is a way to do it correctly. And engagement's probably not the right word, it's partnership.
Methadone Treatment and Access Barriers
00:21:39
Speaker
Yeah, I mean, I'd love to hear a little bit more about that. I mean, we see three parts of this, the prevention side, getting like just preventing the start of the addiction, then getting access to patients, and then finally, um being able to intervene with biologically or psychologically.
00:21:54
Speaker
And I think often it's second part that's quite confusing is how we can access patients, as you mentioned. Usually it has to be through the ED, but we're just not there yet in terms of building interventions there. So Kodak Behavioral Health Care and these mobile methadone clinics, or recovery clinics, I know you've worked with quite a few. What does that actually look like? Where do they come into play and how do they flip the script from instead of waiting for patients to come to them, the system goes to them?
00:22:19
Speaker
I guess. Before even getting to that, I'd love for your listeners to understand a little bit more about methadone specifically. So medications are definitely a mainstay of treatment, and there are three FDA approved medications to treat opioid use disorder or MOUD.
00:22:38
Speaker
Two of the three have a good weight of evidence behind them, methadone and suboxone or buprenorphine. methadone is highly highly regulated it is probably the most regulated medication that we have in the u.s healthcare care system and when bed if methadone is used for the treatment of addiction or opioid use disorder it has to be dispensed in a facility that's licensed by the drug enforcement agency overseen by um by samsa another federal agency and what methadone looks like for most is hard to fathom for most people so
00:23:15
Speaker
when methadone was in its most tightly regulated form, People had to go to have to go to clinics every single day to get dispensed methadone. They have to line up in a clinic, they get poured a liquid form of methadone, they have to be observed taking it in front of a nurse.
00:23:32
Speaker
And i always like challenge people to think about what other their chronic health condition would we ever make people like line up every day to get life-saving medication? It's pretty crazy. And you can actually get methadone at a pharmacy when it's prescribed for the treatment of chronic pain. So if I was giving somebody methadone for chronic pain, they could go pick it up a month supply at their pharmacy and pill form and take it in the comfort of their own home.
00:23:57
Speaker
So that introduces like all these issues and challenges with an access to methadone plus all of the stigma, right? Like if you are waiting in line to get methadone, like, you know, everybody knows why you're there. You know why everybody else is there.
00:24:11
Speaker
And very recently we have done, um, the rules around methadone and being able to take methadone home or quote take home doses ah just over over a year ago were relaxed so that that patients were allowed to take more quantities of methadone home to be administered in their in their own home, but still in like in a little bottle in liquid form.
Policy Challenges in Methadone Access
00:24:34
Speaker
And the most stable patients now can get up to a month of methadone to take home And these are people and who are stable in long-term recovery and not actively using fentanyl, things like that.
00:24:47
Speaker
And that has been a game changer for a lot of people, but it's still very, very regulated and it's hard for people to get access to. And it's a medication that works. Suboxone, on the other hand, can be picked up at pharmacies. It can be prescribed by primary care doctors. There's been some relaxing of the rules around Suboxone as well. But both of these medications, only a fraction of the people that would benefit from them can get access to them.
00:25:12
Speaker
And so it's one thing to know like who would benefit from the medications, and and it's another thing to have people actually taking medications. And then again, there's all the like stigma and social layers, and that's not even then scratching the surface of all the other things that people need to be have um be successful in recovery, like housing and a source of income and social supports. you know So medications are a piece of that. So when you talk about access, it's really challenged with the current system. There was recent legislation that was ah that was proposed, Moda, Modernizing Opioid Treatment Act, and that was proposing to allow pharmacies to dispense methadone and potentially even to widen the tent of like who can prescribe methadone
00:26:07
Speaker
to give more people access. There was bipartisan support. It's currently, my understanding, is stalled out. And there was a lot of controversy among current opioid treatment treatment providers and um you know professional societies about like the best practices and the way to roll this out. And so it just like hasn't happened. But that appetite exists and is a huge, huge access issue.
Balancing Safety and Accessibility in Treatment
00:26:33
Speaker
Yeah, of course. And I can imagine that. So it's the i mean I can imagine, first of all, with with methadone, instead of the trade-offs, you usually would have, um there's this deep tension where it's highly controlled, but there's limited access. Because if you increase access too much, it's a little bit dangerous. You might worsen the crisis. If you restrict it too much, then of course the addiction gets worse. The crisis gets worse because you can't settle these addictions. So there's a weird trade-off here between safety and accessibility.
00:27:00
Speaker
um i would love to hear, man, what does, the right kind of balance look like in this area, especially with behavioral clinics and CODA coming into play? um What does this look like within the larger landscape of methadone still not being dispensed by pharmacies?
00:27:15
Speaker
I think a lot of people, for example, stigmatize these interventions, and that's something needs to be dispelled, too. It's kind of that not-in-my-neighborhood energy. But what's standing in front of health care being delivered? Mobile units have actually, i think, been a unique solution to this idea of like that, you know, the NIMBYism, not in my backyard. Right. Because it's very hard to stand up a new brick and mortar facility at a location. There is typically a you know, a long process to get community buy-in if you ultimately get community buy-in. And so what the mobile units do is it it allows, you know, the ah RV that I work on, it is able to be deployed, um to the parking lot of a community partner. it functions, it serves as an OTP, and then at the end of its dispensing hours, um, which are typically early in the morning, another another inconvenience of methadone. A lot of, quote, methadone clinics have very early morning hours.
00:28:11
Speaker
But when it's done functioning in that capacity, it leaves. And so it doesn't stay at the site, and it goes back to its parent site. It can also then do outreach in the afternoon. So it can, when it doesn't have methadone on it, again, methadone being this like highly regulated medication, um But the unit itself can also serve in other roles and so meet some flexible needs.
00:28:35
Speaker
There are challenges with mobile units. It's a vehicle. We just had a blizzard. We had to make preparations. when We knew the blizzard was coming because the um RV was not going to roll out on Monday um you know in the middle of February when Rhode Island saw historic snowfall.
00:28:50
Speaker
And in other parts of the countries, mobile units have been thought of as a fix for rural health care access. But you might have an RV needing to drive long distances, three, four, five, six hours.
00:29:02
Speaker
What about in a place like Alaska? you know And there, I think we have to think a little bit more creatively about what mobile means.
Chronic Disease Framework for Addiction
00:29:10
Speaker
I was recently looking at a program in Vermont that is actually using more virtual medicine, telemedicine um to do video observed methadone dispensing. can it be, is mobile like actually remote? And is there a way to satisfy the rules and regulations that go along with methadone with technology and thinking about some of these things? So there's probably policy levers and then there are probably like technological advances, which it will allow us to satisfy it.
00:29:44
Speaker
you know, some of these things because these, these medications work. Um, there is excellent data to show that these medications work. They reduce overdose risk. They promote wellbeing, they promote recovery.
00:29:55
Speaker
um and i see it every day. i see people who benefit from by being on these medications. Um, so access is definitely, definitely, you know, front of mind for me. Um, when I think about medications.
00:30:08
Speaker
Yeah, it's quite interesting to me. um You have the patient access side and usually you want patients who have access to drugs and innovation, but here you want to have access to the patient too, which is kind of a unique dynamic in this scenario.
00:30:20
Speaker
um Usually it's the other way around. For example, in oncology or psychiatry, is not necessarily as hard to get access to patient dealing with cancer. um They might come to you first, but here now we have a little bit of a bi-directional demand situation. So I'd love to hear a little bit more about that in these types of interventions.
00:30:37
Speaker
What is the overall landscape of treatments beyond these methadone clinics? I mean, there's biological, psychological, social interventions, but um which of them, um can you talk about the landscape these different interventions, how they come into play, and when do we decide on each?
00:30:54
Speaker
Yeah, absolutely. And I think this is like a chronic disease framework, right? We could have the same conversation about diabetes and there are medications to treat diabetes as a range of medications and some, you know, medications work better for some people than others. And there are also behavioral and dietary interventions that are needed with diabetes. There are social supports. They're the same barriers of transportation, medication costs, things like that. and And so when we're thinking about chronic disease, we need to be thinking about the whole person and the different, you know and again, that wraparound treatment, which is often coupled like pharmacologic with you know bio biopsychosocial interventions.
00:31:37
Speaker
when we're talking about opioid use disorders or addiction, medications are a piece of it. And I've emphasized medications a lot because i think there's still a lot of stigma around these medications. A thing I hear time and time again, even from the patients I take care of is that they view it as another drug. And so I spend a lot of time educating people and families and partners about you know they not thinking of it in that way.
00:32:03
Speaker
And medications are, they help with like the brain chemistry piece. And just in like a lay way that I describe it to patients is like you are helping, you know, almost like letting your brain
Holistic Approach to Addiction Treatment
00:32:18
Speaker
heal. You've been on this like roller coaster of different spikes of different chemicals in your brain for potentially years. And these medications are are letting things kind of like level set and and letting brain recovery happen.
00:32:35
Speaker
That does not fix all of the other pieces that go along with addiction. There are behavioral aspects. I have patients who have trouble stopping using kind of that last bit of fentanyl, not because they're having cravings anymore, not because they're having physical withdrawal. The medications have helped with those things. But because it's habit, they inject fentanyl every time that they want to go to sleep. And if they don't do it, they have like raging insomnia. And it's not rooted necessarily like in ah in a chemical, like physical, like biological place. But there is there is this habit that has and this behavior that's been ingrained over time. and So it's doing that part of, you know, of work and engaging in behavioral therapy. And for some people, that's peer support and group therapy.
00:33:21
Speaker
And then there's the all of the other like things that go along, like are do people have underlying mental health conditions that have not been addressed? Is there you know underlying trauma? Are they getting trauma informed care and trauma informed therapy? Are there you know social things that need to be addressed?
00:33:41
Speaker
Does the person have stable housing? and So there's transportation. can do they They want to work, but do they have the skills and can they get a job? Do they have a history of incarceration? What kind of barrier does that exist there?
00:33:56
Speaker
So I think it's um there's a lot and it requires wraparound support and coordination and recognition of those things. And you know we have to do better in that way. We have to do better. I think housing is a huge, huge one for people. like I often get asked of like, what is the like was the thing that I would, if I had a magic wand that that I could wave?
00:34:19
Speaker
Affordable housing is probably like pretty close to the top of of the list. Affordable housing or just housing in general. If you are living in a tent and you have no money and you are doing whatever it takes to, you know, get fentanyl or other illicit substances for a whole host of reasons. Like that is a pretty big hole to be in.
00:34:44
Speaker
And what are we doing as a society to get to help people get
The Role of Community Health Workers
00:34:48
Speaker
out of that hole? I often reflect if I was in that situation, would I like have the capacity to like, you know, it is not a matter of like, like just like willpower, right? Like there's strong, like biological things happening, but there are then these just like enormous, like structural barriers that we have to be able to help people.
00:35:09
Speaker
more than we are. Yeah, it's just very easy to, or difficult to form empathy, especially with all the stigmatization you see.
00:35:19
Speaker
For example, the addiction and dopamine pathways that embed the biological side of this addiction, it's what most people think of. And I think there's much more to it. Not only is that incredibly strong, but for many people, they're not going home to a family of five. And it's hard to empathize with not just the addiction, but the entire scenario someone lives in, which there's so much to fix, but you pose all these different questions. So they like, do they have housing?
00:35:44
Speaker
Which intervention works for them? What is the social situation, trauma, et cetera. But who actually asked these questions? um It's an important question because I think you don't actually have one person to really reorient this care or be there for a person's care journey, even though there maybe should just be one person or just one entity.
00:36:03
Speaker
um For Kodak and new organizations organizations that are developing now, maybe they're changing things. What does it actually look like? Can we create... one single path of care and rerun to treatment? And who really has a full contextual picture of anybody throughout this?
00:36:17
Speaker
If it's really just the EDs doing the heavy work? Yeah, it's a great question. And it's this idea of like integrating, you know, other resources ba beside and not just thinking about kind of medical care in the moment you mentioned the emergency department, a lot of emergency departments are starting to so staff with community health workers. Often these are people who are duly trained as peer recovery support specialists and community health workers so they can help people with complex chronic health conditions, often you know substance use disorders and and co-occurring mental health conditions, but also sometimes other medical problems and who can help somebody kind of follow them, you know take the hand off after an emergency department visit and
00:37:06
Speaker
and work with them, partner with them along their continuum of care. And we need probably more of that as well as the capacity to kind of handle those those follow-up visits. And there are models, that I think those is from a research standpoint, we're still evaluating the effectiveness of those of those programs, because if you're going to put a lot of resources into something, you want to know that it works.
00:37:31
Speaker
So there is a real opportunity here to both be trying new things in real time in clinical practice while making sure that we evaluate them so that as a society and as taxpayers that we're we're investing in the things that work.
Reducing Stigma and Improving Empathy
00:37:48
Speaker
I think that makes sense. And it's difficult, but it's it's very interesting. And I think that I want to end off. I know you've been asked the magic wand question before, but I'd love to kind of factor in based on what what could we can actually accomplish. Like, what do you think are the most important things we're hoping to change or see change the next five to 10 years, given the landscape we're today?
00:38:06
Speaker
ah course, we're still miles ahead of where we were 10 years ago and many miles away from our perfect solution. But what do you hope that you'll see change in the future? And what are you working today at Brown too?
00:38:17
Speaker
I'll give you a pie in the sky one. I hope that we can get rid of stigma related to substance use disorders and and more broadly mental health conditions. Stigma is a huge barrier both for an individual patient thinking about engaging in treatment to their families, to the neighborhoods, the communities, to health systems and policymakers.
00:38:40
Speaker
That is, that's hard to change, but you know, so that's why i'll I'll reserve my magic, magic wand that you've given me to get rid of SEMA.
00:38:51
Speaker
Yeah, that makes that makes a lot of sense. I know it's a huge part of this journey is to get that tackled and just build empathy for others. But um I really appreciate the time. I mean, I think we can all learn that addiction is more than just a biological or social problem. There's so much more to it through getting access to patients and delivering better interventions. So thank you so much for coming on and just walking through your overall care journey and journey through health care.
00:39:14
Speaker
Yeah, thanks. Great chatting with you.