E1: The Psychology of Addiction & Stigma

It’s no secret that America has a major challenge on its hands when it comes to the opioid epidemic. Since its earliest stages in the 1990s, tied to an uptick in prescriptions of powerful pain management medications, opioids-- which include prescription pain relievers, heroin, and fentanyl-- have been complicating the livelihoods of doctors-- and the lives of everyday people-- on a daily basis.

The opioid epidemic has had a massive presence in the state of Ohio since its earliest stages, ranking Ohio as the state with the fourth-highest rate of opioid-related deaths. At the epidemic’s highest point thus far, Ohio witnessed the highly preventable deaths of over 4,200 people in just 2017 alone. That same year, the nation as a whole experienced 47,000 opioid-related deaths.

The most recent available data shows that Ohio’s numbers have been improving, with opioid overdose deaths dropping from 4,293 in 2017 to 3,237 in 2018-- but that was years ago. And things have, of course, only grown more complicated in the midst of the global pandemic of Covid-19.

Ohio, including Metrohealth’s home of Cuyahoga county, has been ravaged by this epidemic. It’s rare to encounter a single person in our community that doesn’t know someone personally affected by the influence of opioids and opioid addiction. It’s easy to view this epidemic almost like a monster, or a shadowy figure from a nightmare-- where did it come from? And how can we get away?

But it’s important that we recognize the role that the medical community has played in creating this epidemic. While of course entirely unintended, the influence of the pharmaceutical industry and the prescribing habits of doctors-- whether we call it a heavy-handed approach to pain management, or a one-size-fits-all solution for pain-- have created a new normal for hundreds of thousands of patients experiencing chronic pain: no pain at all, no matter the cost. At the same time, these powerful and addictive drugs are now far more accessible to the everyday American, and in turn, far more likely to be abused.

So… yes, there’s a bit of a challenge on our hands. But what can we do to be better? How can we begin untangling this mess? How can we help those in our communities who are experiencing addiction to opioids(,) and prevent further loss of life?

These are questions we attempt to answer every day in the office of Opioid Safety at Metrohealth, where we provide education, tools and resources to MetroHealth providers and staff in all opioid related matters. Our mission is to promote opioid safety throughout the MetroHealth system and in the greater community through education, advocacy and treatment. We advocate for non-opioid pain management modalities, safe

opioid prescribing, addressing the stigma of substance use disorders, and providing access to addiction treatment. We also have a commitment to offering community-based education and training to community organizations, government agencies, educational systems, and corporations, among other groups.

OnePath is here to help providers and prescribers feel equipped to take on this epidemic in their everyday practice, making a difference in their communities and the lives of their patients. Thanks for being here.

This is OnePath with Metrohealth, your toolkit for helping to combat the opioid epidemic as a member of the medical community with empathy, mindfulness, and a big-picture perspective. I’m Libbey Pelaia, community educator within Metrohealth’s department of Opioid Safety. Thanks for joining us.

So the opioid epidemic is a major issue. Maybe even an overwhelming one. So we wanted to start out this series with a conversation with someone whose job it is to calmly explain the ins and outs of addiction-- Dr. Bob Smith. We love Dr. Bob.

BOB: My name is Dr. Bob Smith. I'm a clinical psychologist, I'm also an addiction specialist. My role with MetroHealth is, I'm the director of the medical staff assistance program.

Dr. Smith employs a deeply humanistic and empathy-based approach in his practice. Understanding the motivations of his patients is hugely important to him.

But it’s also important to understand how these patients were led to develop these dependencies in the first place.

The key for everyone to understand is that opiates were never intended to be used long term as a way of managing pain. It's meant to help a person through that initial phase of acute pain. This whole concept of pain management, I think, is something that the entire country is trying to come to grips with, because we've not talked about pain management in the past, what we've talked about is eliminating pain.

If you go back and look historically, physicians and pharmaceutical companies gave the wrong message to all of our patients. For a period of time, we were using this little chart that people would rate their level of pain, and the perception was that we wanted no pain, that was the goal, that we were going to eliminate and give the person a pain-free life.

So with that as the goal, every patient thought, "Give me a pill, take away my pain." Opiates are the solution. If I'm still experiencing pain, then I need more medication to take away that pain. So, we ended up creating our own dilemma by misinforming our patients, giving them the wrong expectation, and so now we're paying for that.

How did we get here? Of course we want our patients to be as comfortable as possible, but how did things get to this point?

There's been a movement over the last probably 10, 15 years to enhance patient experience. I think if we go all the way back, the thought was, that if we wanted to create patient satisfaction, if we could give the patient a pain free experience, they would be more satisfied.

Again, I think what we need to do is to step back, because we're getting a lot of patients who are expressing dissatisfaction now, they are frustrated, they're annoyed. They're feeling that we're not working in their best interest because they're still having pain. Again, until we help them understand that in their best interest, and that's what we need to really emphasize. It is in their best interest to not make them pain-free, because to do that, we would have to rely upon opiates. But rather what we want to do is we want to help them have a manageable level of pain and function and an extremely high level to resume their life and their activities with work and with family and with friends without being impaired by an opiate.

Stepping back for a moment, we just wanted to lay out a reminder of the basics-- different pain levels in patients and appropriate ways to treat them, in an ideal case.

BOB: So some individuals will present needing a procedure that is acute pain, and it can be managed oftentimes without any pain management or I should say pain medications, no opiates, just simply with any inflammatory and other medications to help the person get through their initial discomfort.

Then there are individuals whose acute pain is pretty significant, and they're going to require an opiate to help them manage that initial pain, but that's short term, it's closely monitored, and then they're weaned off of that pain medication very quickly.

Then there's a last group, a group that has what we call chronic pain and that pain needs to be managed, and opiates will be part of the management in the beginning, but for the vast majority of patients, that again will be ended and they will come up with new strategies to manage that pain going forward.

In this breakdown, the patient is weaned off of opioids. This is where a challenge comes into play-- effective and closely-monitored transition off of opioids and into new strategies for pain management isn’t always a reality for every patient. And that is, quite often, how providers end up with patients that are dependent upon opioids.

Dr. Smith says that there’s something incredibly important for providers to keep in mind when interacting with these patients.

the key is you need to be aware of your own biases and prejudices. So many people have their own life experience, either with the use of alcohol and drugs or with family members where friends who abuse alcohol and drugs, and those experiences color our responses to others. If we don't know what our biases are, they're going to come through and they may end up becoming barriers to our connecting with the individual who's seeking help.

It’s the provider’s job to create a feeling of security and safety between themselves and the patient. After all, they’re humans, too.

Our patients are fully aware of all the stigma related to alcohol and drug addiction. They've heard all of the phrases, they've heard all of the names that people call people who are addicted to alcohol and drugs. They know that people tend to view them as weak, mentally ill or morally deficient. So, you're either weak, sick or a bad person. So for them to share that they use the substance on a regular basis and that it's causing problems in their life, they have to feel really, really safe, because otherwise they're sure that you're going to judge them, and they don't ...

I mean, who wants to be labeled bad? Who wants to be labeled weak? "I don't want to be mentally ill, I don't want to be sick, I don't want to be bad, I don't want anyone to put those labels on me." So what do I do? I minimize, I deny, I rationalize, I project blame onto others, I try to explain all of my problems in some other way so that we don't look at my use of opiates or other drugs or alcohol, because I don't want anyone to think I'm an addict. Oh my golly, those are terrible people.

Dr. Smith’s approach is all about inviting patients to share, not pressuring them to do so, or shaming them into doing so.

I need to be able to form a connection. In forming that connection, it needs to be nonjudgmental and welcoming. If we can listen in a sympathetic way, a compassionate way and make a connection, then we're going to be able to work with them rather than trying to somehow treat them, do something to them, we want to do it with them.

However, Dr. Smith says that it’s important to remember that creating this dynamic is something of an art.

This takes some time. You can't do this in five minutes. It's going to take a little more time than that, and you have to be patient and you have to listen. But what it does is it allows the individual to get comfortable with you.

And comfort in a patient is the best-case scenario for everyone, including the provider. Comfort in the patient means that access to valuable diagnostic information is much more likely to be granted by that patient.

So if someone gives you an amount or an account that you don't think is true, don't challenge it, let it set. The minute that you'd begin to challenge them, what they hear is you're saying that I'm lying to you. The other thing is, don't get too caught up in how much and how often, you have to understand that people who abuse opiates and other drugs and alcohol have been asked over and over again, "How much have you been using? How much did you spend?" All of those are judgmental questions that comes from family and friends and others who are telling them very clearly you're a bad person, you're using too much, you're spending too much, you're doing the wrong thing and I am upset with you.

So, those questions are highly loaded emotionally. We want to approach those in a very gentle way, a very empathetic way. So I tend to not be too drawn into that, I might say something to someone like, "So, tell me a little bit, what substances do you use? Do you use alcohol? You do? Oh, okay. So, about how often do you drink? Okay. When you drink, how much can you drink?" Which is an interesting question, rather than how much do you drink, how much can you drink, or the same thing with opiates, "When you use opiates, how much can you use?" I tend to move away from those questions to pretty quickly looking at, "So, what's it like for you when you use? As it resulted in anyone commenting about your use? Is anyone concerned about your use?" I want to look for areas within their life where they are uncomfortable because of their use.

Dr. Smith also shared a quick and simple strategy for talking about sensitive information in a way that minimizes shame and stress.

If I'm going to talk about amounts or frequencies, I tend to offer very large amounts, very high amounts, because then that makes it safe. So if we're talking about opiates, I would say to someone, "So, what would you say, do you use 300, $400 a day?" And most people are going to go, "Oh, no, not that much, maybe a couple of $100 a day." "Okay." But if I had said, "Do you use 50 a day?" Well, now if they use 200 a day, that sounds like a lot, and that makes them uncomfortable

Motivational interviewing is a huge part of Dr. Smith’s process, he tells us. Through analyzing patients’ experiences and motivations through gentle, empathetic conversation, Dr. Smith helps patients forge paths towards positive change.

I'm not telling them they're an addict, I'm not telling them that they need to stop. What I'm doing is I'm exploring with them. "So you use opiates? Tell me about that. What's it like for you? About how often do you use? When do you use? Who do you use with? Does anyone have any concerns about your use? Do you have any concerns about your use? Oh, you do? Tell me about that."

Remember motivational interviewing, because we’ll come back to that later.

Of course, not every interaction with a person experiencing addiction is going to be a pleasant one. Dr. Smith said that there’s a very specific way to approach situations like this.

Most often, if people are upset, it's because they're seeking drugs and they're thinking they're not going to get them. In that situation for the provider, you have to have really clear guidelines, clear boundaries, so that as you're talking with the patient, you help them understand that this is not personal. If I'm telling you I'm not going to renew your prescription for an opiate, or I'm not going to write a prescription for your opiate, it's not because I don't like you, it's not because I'm judging you, it's not because I think you are "an addict," it's because that's not what I do, and that's not the appropriate medical care for patients with your disorder.

So let's talk about why that is, and let's talk about what are the options, and then I need just be very consistent. What I don't want to do is escalate, I don't want to raise my voice because if they raise their voice that doesn't do anything. Most often as they get more upset I tend to lower my voice and listen more and wait for the opportunity to educate and to reflect back that I hear their frustration, I hear their disappointment, I hear that they believe that they need the opiod, and then I have to help them come to an understanding of, "We need to take a look at other options and things that we can do."

Dr. Smith said that another situation that can bring out negative emotion in those experiencing addiction is discussion or mention of weaning off opioids or reducing their dosage.

When we're dealing with someone who's struggling with opiates, we want to be able to help them see the need to cut back or quit. Not because I'm telling them that they have to do that, but because they begin to see the benefit, the logic based upon their anxiety, their concerns. If we can help them know that we're going to support them, we're going to educate them, we're going to provide care that will enable them to safely stop and learn strategies to remain abstinent, I think that anxiety then starts to go away.

Dr. Smith also believes that it’s very important the patient understand that the road to recovery is a long and complex one. Detoxification is just the beginning.

it's important to recognize that if you have reached a point where your tolerance to opiates is so high that you require detoxification, that detoxification is the medical management of your withdrawal symptoms. It is not in and of itself sufficient treatment for addiction. Too often I hear of persons struggling with opiate addiction, going into detox, and then at the end of detox saying, "Well, okay, I completed treatment, I'm good now." Then of course they relapse soon after, because their misperception was that the detoxification process was the treatment, and it's the medical management of the withdrawal. The other thing is medication-assisted treatment. We've got some wonderful medications now with Suboxone to help individuals in their recovery from opiate addiction. But again, Suboxone in and of itself is not sufficient treatment.

While it’s important to frontload the more challenging aspects of recovery, Dr. Smith tries to bring attention to the imminent upsides of recovery as well-- as long as patients understand that it will take work to get there.

One of the things I try to do with persons early in recovery is to predict improvements. So I want them to know that things are going to get better, but I want them to have realistic expectations. Too often people get sober or stop using a drug and they're expecting that within a matter of days or weeks that everything's going to be better again. So I try to help them understand that that's not realistic, things will get better, but let's look for the little things, first things that are going to improve are going to be appetite, sleep, gradually your moods are going to start to stabilize, your ability to focus and be productive and then your relationships. So by predicting it in a way that's very logical and it allows them to have realistic expectations, they then can measure their progress and feel good about what they're accomplishing.

Remember when we were talking about motivational interviewing earlier? Dr. Smith’s entire approach to working with patients experiencing addiction really comes back to that: helping patients see that changing habits is really in their own best interest.

For individuals to actually achieve ongoing recovery, it requires a change in the way they think, which then results in a change in what they believe, which then finally results in a change in the way that they act. True recovery requires lots of changes, changes in environment, changes in relationship, changes in the way that you approach life and cope with stress. All of those become really important factors that's much more than simply taking the medication. The medication reduces urges, it helps people avoid relapse. That's again, an important part of the treatment, but it's only part.

Next time on OnePath with Metrohealth, we get into the details of how the technology caregivers use on a day-to-day basis can assist them in mindfully prescribing for their patients.

OnePath with Metrohealth is a production of Evergreen Podcasts, produced, written, and engineered by Hannah Rae Leach and mixed by Sean Rule-Hoffman. Special thanks to Mike Tobin, Karolyn Tibayan, Joan Papp, Joya Riffe, and the entire Department of Opioid Safety in making this show possible.