Thursday, November 3, 2016

When treating addiction, the words we use matter

In a JAMA editorial last month, Director of National Drug Control Policy Michael Botticelli and former DHHS Assistant Secretary for Health Howard Koh wrote that it was time to change the language health professionals and researchers use to refer to patients who suffer from addictions. This isn't simply an exercise in political correctness. Stigmatizing terms that "describe [patients] solely through the lens of their addiction or their implied personal failings" have been shown to negatively influence mental health clinicians' attitudes: someone described as a "substance abuser" was considered less treatable and more likely to be blamed for his or her condition than a "person with a substance use disorder." Similarly, they recommended describing someone with a history of having abused substances as "in recovery" rather than "clean." Botticelli knows his subject perhaps better than any previous U.S. "drug czar" (another term he prefers to not use), being in recovery himself from alcoholism.

I've written before about the failure of our criminal approach to drug misuse and the problems that misuse of legal pain medications have created for patients who suffer from chronic pain. Abetted by pharmaceutical companies whose sales representatives convinced many doctors that opioids were safe and non-addictive, the medical profession handed out powerful drugs like OxyContin as freely as Halloween candy, with devastating consequences.

Those consequences were more devastating in some communities than others. For almost every imaginable medical condition, members of racial and ethnic minorities receive less care and have poorer health outcomes, and addiction is not an exception. An article titled "Deconstructing Addiction" in NYU Physician began by describing two men in their 20s who sought treatment for heroin addictions and severe mood swings. One was diagnosed with bipolar disorder and prescribed antipsychotic medications and supervised methadone treatment. The other received an antidepressant and buprenorphine. Why were their medical plans so different? The first man was "a Latino living in a poor section of Brooklyn," while the second was a "middle-class white man from suburban Queens." Helena Hansen, an NYU psychiatrist and medical anthropologist, has worked to unravel the complex web of social and political forces that created these care disparities:

Methadone, she learned, was initially presented to the public as a tool for lowering crime in black and Latino communities. Accordingly, methadone clinics were mostly located in those areas. ... By the start of the new millenium, media reports warned of an epidemic of OxyContin addiction sweeping suburban and rural America. Buprenorphine maintenance, Dr. Hansen found, was aimed expressly at this new, overwhelmingly white cohort of substance abusers. ... When buprenorphine came on the market, ads portrayed the typical user as a white, middle-class dad who'd become addicted to painkillers after a back injury and wanted to return to coaching the son's baseball team. Even now, many buprenorphine providers accept only private insurance or out-of-pocket payments - unlike methadone clinics, which rely mostly on Medicaid reimbursements.

Although this two-tiered approach to treatment was not intended to create inequality, Hansen emphasized, it rapidly became incorporated into the structure of medicine and perpetuated stereotypes about white versus nonwhite patients with substance use disorders:

For addicted people in private care, most of whom are white, therapy is designed to minimize stigma and get the patient back to work or college; buprenorphine is used as a means toward these ends. Addicted people in public care - which covers most poor and nonwhite patients - are administered methadone under stringent supervision, steered into perceiving themselves as permanently disabled, and prescribed psychotropic medications that may further compromise their health.

On a related note, I've given some serious thought recently to going through the certification process to prescribe buprenorphine. Few family physicians currently possess a Drug Abuse Treatment Act (DATA) waiver to do so, not because the process is particularly onerous (eight hours of mandated education, half live and half online), but because most feel poorly trained and equipped to manage the psychosocial needs of these patients. I can't get a psychiatrist to see my few patients with mental illness that I consider beyond my capabilities unless they can pay cash; my heart sinks when I ponder how to arrange necessary care and social services for patients with substance use disorders. Working for a health system connected to a tertiary medical center, living in a city where the doctor to population ratio is one of the highest in the country, I rarely view myself as the health care option of last resort for anyone. But the need for accessible addiction treatment is great, and it isn't being met.