Hard Cases: What Can We Learn From an Epidemic?

This article is part of LinkedIn's Hard Cases series, where healthcare professionals share the toughest challenges they've faced in their careers. You can read more about it here and follow along using hashtag #HardCases.

In 1995, I was a resident in the emergency room at San Francisco General Hospital, providing treatment to patients who had overdosed on heroin. At that time, it was our job to give them naloxone, ensure that they were breathing — in other words, save their lives — and send them out the door.

At the same time, we were treating the mostly young men who were filling hospital and hospice beds throughout San Francisco as they battled AIDS. 

By the end of my residency in 1998, the hospice beds were almost empty. The ER was not.

Most of the hospice patients, thankfully, had been sent home to receive antiretroviral treatment. Research and care had progressed so much so that the HIV/AIDS epidemic was in decline. Patients were getting starting to get the treatment they needed, and we were tackling the stigma that was associated with the diagnosis.

During my residency, I witnessed the impact of one epidemic — the HIV/AIDS crisis — and the very beginning of another, as opioid addiction was starting to take hold nationwide. How we dealt with the earlier provided lessons that can inform our work to address the other.

Today, our nation is in the throes of the opioid epidemic. 130 Americans die every day from an opioid overdose, and two out of every three drug overdose deaths involve an opioid. According to the Substance Abuse and Mental Health Administration (SAMHSA), just over 12% of the 21 million people aged 12 or over who needed treatment for a substance use disorder (SUD) in 2017 actually received that treatment.

In the face of the HIV/AIDS epidemic, the academic medicine community invested in and advanced research, leading to new and effective treatment that was then delivered to the patients who needed it. We are starting to do that today in the face of the opioid crisis, but we can do more.

Research conducted at Yale New Haven Hospital shows that if patients are introduced to medication-assisted treatment (MAT) in the emergency department, on average, they stay in treatment longer. This has started to result in new care protocols at teaching hospitals across the nation. For example, the department of emergency medicine at the Jacobs School of Medicine and Biomedical Sciences at the University of Buffalo in New York created an innovative network model for initiating MAT in patients presenting with opioid overdoses, with secure handoffs to treatment agencies within 24 hours and then transitions from maintenance care to primary care physicians.

The federal government — through the National Institutes of Health and other agencies — is also investing in more research into addiction and pain management, much of it taking place at medical schools and teaching hospitals. Our knowledge base is expanding, and these institutions are developing nonaddictive treatments for pain as well as new, more effective ways of delivering naloxone. We are teaching the next generation of doctors about this new research, the latest care protocols, and how to balance providing patients with access to pain medications when clinically appropriate while minimizing the potential for misuse.

But we need more doctors to provide those treatments and we need to work on stigma. The data from SAMHSA shows it: The overwhelming majority of people who need treatment for an SUD aren’t getting it.

One issue is the physician workforce shortage. There is an overall shortage predicted in the future supply of physicians as our population grows and ages. Even today, the Health Resource and Services Administration has designated over 5,000 areas in the United States as mental health professional shortage areas, meaning there aren’t enough providers to meet the mental health needs of large parts of the country. To address this, there is bipartisan legislation that, if passed, would focus on training more providers in pain management, addiction medicine, and addiction psychiatry. There’s also a bill to train more doctors writ large, which would have a positive effect on the mental health and pain management workforces. Yet even if patients are able to find a doctor to provide the treatment they need, the stigma can be so great that it is a barrier to making use of that care.

The good news is that the discussion at the recent AAMC National Workshop to Advance Medical Education to Combat Opioid Misuse focused a lot on language, stigma, and bias. Physicians have, for a long time, been uncomfortable discussing substance use and addiction. This needs to change.

I’ll give you an example—a friend of mine is a retired internist and refers to himself as “an alcoholic and addict” (I’ll admit that those terms are even uncomfortable for me to type). At the top of his “problem list” that he hands to the physicians who treat him, he has “substance use disorder” listed before his cardiac and other problems. Yet every doctor he sees skips over the “SUD” and starts discussing his other conditions. They just don’t know how to ask about it or talk about it. 

As clinicians, we have to learn to discuss these diseases in order to end the stigma associated with them. We need to do our part to change the conversation and stop blaming patients for their suffering. Leaders in medical education need to continue to set the example.

Through continuing to advance research and patient care, training the future and current health care workforce, expanding access to treatment, and reducing the stigma, we can do for those battling SUDs and dealing with chronic pain what we did for those young men we treated in the hospices of San Francisco nearly three decades ago. But first, we need to be able to talk about it.