A Helper's Reflection: Barriers & Solutions After Supporting 1000's of Opioid Overdose Survivors

Rates of overdose deaths exceeding 100,000 in the past year, driven by synthetic opioids, has been daunting for communities at large (CDC,2021 ). The Guardian Angel program (GAP) is a health education and intervention-based initiative, part of Aetna, a CVS Health Company's multi-pronged strategy to combat the overdose epidemic. We leverage claims data and predictive analytics to proactively outreach overdose survivors and those at high risk for an overdose. GAP has successfully supported thousands of opioid overdose survivors since 2018. In 2022, we've eagerly expanded to support people surviving other drug overdoses as well.

As a psychotherapist with a specialty in addiction recovery, I have been honored to personally support hundreds of overdose survivors for the past 4 years with GAP. Over the years, we have encountered several thematic barriers to this population's recovery, among gratefully finding solutions to help these wonderful people lead the successful lives they deserve. These shared experiences and anecdotes aren't necessarily unique or specifically aimed for didactic purposes. However, my hope is they may improve understanding and invigorate an optimistic outlook toward those living with a Substance Use Disorder (SUD) and experiencing overdose. Also, to provide a reminder that even simple interventions can catalyze the recovery of a complex condition and enable transformation.

*Pseudonyms have been used to further protect information*

Lack of Access

Whether people are living in treatment deserts, unaware of therapy options, or restricted from certain modalities; many struggling with Opioid Use Disorder (OUD) have an easier time accessing illicit opioids rather than accessing effective care. Following up with overdose survivors to provide education on evidenced based treatment, such as Medication Assisted Treatment (MAT) and harm reduction strategies such as Naloxone, position them to make healthier and safer choices. Receiving treatment is made easier for people by providing a hands-on approach and linking them with specialty healthcare services. Moreover, advocating for those recovering in restricted treatment environments, to have the option to be evaluated for MAT, has been critical for some people's success.

Mark, a 57-year-old man from Florida, was prescribed opioids after being in a serious vehicular accident eight years ago. Mark developed a dependency on prescription opioids over the years and one day was abruptly tapered off. He was going through agonizing withdrawal and no longer able to receive his opioid medication but did have an easy time finding opioids on the street to mitigate his pain. He soon couldn't afford un-prescribed opioid pills and found himself "desperate enough" to use heroin. Mark was overwhelmed, as he expressed, "There's no help out there for me." For months he had been searching for a Buprenorphine certified physician that accepted his insurance and who was also accepting new patients. We took over this stressful process for Mark, by using treatment locating tools, calling each office, and then scheduling Mark for the first available appointment. His gratitude was touching and referred to the outreach as a "Godsend." Mark has been compliant with treatment and confidently recovering for months.

Stigma

The vilifying view attached to those suffering with SUD has long been a barrier to people vocalizing their struggle and seeking help. Stigma pervades through most aspects of life for those living with SUD. Survivors, in many cases, are inundated with shame and guilt after overdosing. Often influenced by hearing: “you’re choosing to do this to yourself.” This destructive message causes many people with SUD to hide in the shadows and to be reticent about their disease. Another deleterious message, entangled with MAT, the gold standard of OUD treatment, is: “you're replacing one drug for another.” These inaccurate perspectives prevent openness with professionals who can help, and these messages hinder receptiveness to lifesaving treatment. We found it essential to focus on connecting with the person behind the label of SUD. To establish a rapport, we convey understanding and compassion to those who are succumbed by stigma. When humanizing their experience and developing a non-judgmental and trusting relationship, we saw people become increasingly receptive to evidence-based education and effective treatment options.

? Kevin, a 51-year-old from Illinois, struggled with OUD and alcohol use for many years of his life. His usage began as an attempt to self-medicate for chronic back pain and depression. As a result, Kevin has survived multiple opioid overdoses. Kevin expressed, “I don't have good luck with professionals,” with shame in his voice. He described often feeling judged, pressured, and bad after speaking with them about his use of substances. We developed a rapport with a person-centered approach, that empowered Kevin to direct the discussion at his own pace. After multiple conversations of employing empathy and validation toward his life circumstances, he became comfortable and opened up. He expressed a common misunderstanding of Medication Assisted Treatment: “it’s just like heroin." Kevin was educated on the differences between MAT and heroin use. Such as the vast difference between mortality and life interference when someone is using MAT as a tool for recovery verses using heroin. He became increasingly interested in this treatment option and scheduled an appointment for evaluation. Kevin has been compliant with MAT and surpassed early remission in his recovery. He has been able to return to work, improve his marriage, and gratefully reconnected with his terminally ill mother.

Transient Treatment

?A misperception continues to exist regarding the length of treatment that is necessary to successfully manage SUD. People may believe if they go into detox for a week or residential treatment for a few weeks, that treatment is finished. This misunderstanding that: "short-term treatment is enough treatment," precipitates cycles of multiple inpatient treatment stays. Often resulting in relapse and repeat overdoses. People grow impatient and discouraged with the process of recovery, and even more damaging at times, so do their families. Naturally, people will become hopeless about treatment when thinking long-term recovery should occur after transient attempts. And greatly benefit from a helper instilling hope back into the power of treatment. Providing education on the biological basis of SUD and normalizing the need for ongoing support to effectively manage a chronic disease, is of paramount importance.

Corie, a 24-year-old from Colorado, struggled with clinical depression since her childhood and attempted to cope with substances as a teenager. Her opioid use began seven years ago when she realized that it was the one thing that allowed her to feel "happiness." The usage quickly went from her outlet of happiness, to feeling as she needed opioids to survive. Corie was soft spoken and self-deprecating stating, “I am a druggie loser, and I can’t get clean to save my life.” She felt discouraged about treatment as many brief attempts were ineffective for her continued sobriety and strong residual cravings precipitated relapse and overdoses. Corie felt hopeless that the people she cared about were growing impatient and doubtful about her recovery. We educated her and the family on brain changes inflicted from opioid misuse. We also instilled hope by normalizing ongoing treatment being imperative for long-term recovery and saw improvement in the family's ability to empathize and show care. With continued MAT and psychosocial support, Corie has achieved remission and is proud to announce the length of her sobriety. For the first time, she's feeling close with her family, starting to date, and gained full-time employment.

Ambivalence

Change is not all or nothing, but a step-by-step process.?Individuals with SUD may not be taking action steps toward change, but nonetheless, experience thoughts and feelings congruent with recovery. The outlook of waiting to support people struggling with SUD until they’re completely ready to take action for positive change, may enable them to not receive the chance to recover. We found it advantageous not to wait, but to align with the person, at the step they’re at in the process of change. Meeting the person where they're at, allows a working alliance to develop and the opportunity to utilize motivational enhancing techniques. Evoking and expanding the person’s thoughts and feelings congruent with recovery, facilitates them to take the next necessary step for healthy change. Also, it’s important to optimize the person’s pro-treatment mentality, by scheduling them for treatment as they're verbalizing readiness. We found providing follow up calls is necessary to reinforce the person's own reasons for initiating treatment and improves the outcome of attendance and retention.

Corbin, a 28-year-old from California experienced ambivalence toward treatment. He has struggled with Bipolar Disorder and paranoia since his early teenage years. Corbin explained how opioids created an inner calm. Allowing sleep and distraction from being overly worried that someone would try to harm him. We illuminated the function opioids had for him and validated his conflicted feelings of giving up something that felt helpful. ?This eventually opened the door to him being more expressive about the negative consequences' opioids had in his life and became more vocal about his desire to recover. We collaboratively maximized the pros of positive change while identifying barriers such as withdrawal, cravings, and inadequate support. Leading to treatment as the solution. As Corbin’s readiness increased, he was scheduled for treatment the same day his mentality was ready. We provided longitudinal support to assist with maintaining his commitment toward treatment and recovery. Corbin is several months sober, allowing him to become employed and afford a home.?His remission has also permitted him to focus on reconnecting with his daughter and be able to feel like "life has a purpose.”

Untreated Comorbidity

Many people struggle with SUD and mental health conditions simultaneously. Individuals with comorbid conditions require treatment that can address and provide support to both diagnoses. ?During assessment, we identified people with both SUD and a mental health diagnosis, receiving exclusive treatment for only one of their conditions. The untreated comorbidity was a barrier to the individual being successful in their recovery. The patient and their families were under the impression if the primary diagnosis was treated, then the other condition would automatically subside.?Providing education on the interaction and yet independence of both conditions was critical. Among emphasizing the importance of dual diagnosis treatment, permitted individuals to receive holistic care.

Lilly, a 24-year-old from New York, received limited care and struggled to recover for years. As a child, she went through traumatic experiences, and in her early teens learned that substances could numb her emotional and psychological pain. Lilly received treatment for PTSD which helped her work through and cope with trauma. However, after a month of abstaining, she would relapse on opioids, and eventually resulted in an overdose. Lily was frustrated and desperate as she explained, "I feel like I am coping with my past, but I still can't figure out how to stop using." We helped her and the family understand that although her trauma could trigger the use of opioids, the cravings alone were sufficient to cause relapse. They were provided education on dual diagnosis treatment and on the efficacy of MAT for the management of OUD. Lilly was scheduled for dual diagnosis services, facilitating many months of recovery. She reports feeling the healthiest she's ever been. Lilly was able to enroll in a graduate school program and started a professional internship.

Although these types of barriers have been consistent over the years, the stories we hear continue to vary in how people transform their lives with treatment. It's been heartwarming to be alongside so many people's successful recovery. However, when helping humans living with a chronic disease, inevitably you will encounter death. Burnout is a well-known concern when working in the field of addiction and can cause even the brightest professionals to develop pessimistic views. Patients and helpers can become discouraged from the multitude of barriers to recovery for SUD. However, it’s important to also recognize the passion and glory that only comes when being a part of overcoming such a tenacious challenge. Supporting numerous overdose survivors has encouraged an optimistic prognosis for people living with SUD: (1) People unable to find specialty care can live a healthier life with a mere helping hand. (2) Working through stigma can give people opportunity to live their life fully. (3) Chronic challenges are effectively treated with chronic care. (4) Ambivalence to change is human and everyone has a part of them looking for growth. (5) Holistic treatment can heal the whole person.