Sometime in early November, we were sitting around a table in Adams Coolidge Room talking about the Long Island Bridge closure and its effects on the homeless population in Massachusetts, specifically in regards to the current opioid epidemic. Two years ago, the Long Island Bridge closed, displacing hundreds of homeless persons relying on the shelters and detox centers on the island. Some of those beds have yet to be relocated.
In 2015, 1,574 people died from an overdose in the state of Massachusetts. In April of this year alone, there were 174 deaths. Upwards of 4 people die due to an overdose in the state every day. The Department of Public Health reports that in 2016, benzodiazepines were present in approximately half of opioid-related overdose deaths, and cocaine was present in almost a third. Meanwhile, the rate for heroin has been decreasing, while fentanyl has been increasing.
Source: MA Department of Public Health
And still, finding a place to locate treatment beds has been incredibly difficult. Everybody has been affected by the opioid epidemic, and everybody wants to fix it. Just not in their backyard.
It’s not just about stigma, however; centers for recovery require trained professionals, but with low salaries, it’s no wonder that burnout rates are so high. Moreover, these services are not always economically viable. 32 beds can generally create enough returns to be sustainable, but 32 beds require a significant amount of space and staff.
The reimbursement rates for detox services are also incredibly low when compared to general hospitalizations, including psychiatric services. This makes it very difficult to sustain a recovery program. Currently, a huge gap in substance use treatment is in step-down programs like clinical stabilization and transition support services (CSS and TSS); this is not to say that we have enough detox beds, but the availability of step-down programs is abysmal. Most hospitals, if they have detox at all, do not have CSS or TSS programs because these step-downs are costly and more difficult to sustain -- though they are the most essential.
To clarify, the detox beds we are referring to are for acute detox; this generally lasts 3 to 5 days and can be done at a detox center or at a detox bed in a hospital. Clinical Stabilization Services (CSS) are often two weeks long, while Transitional Support Services (TSS) last from two to four weeks. CSS and TSS are the step-down programs that can be used as step-downs or for persons who do not require detox and may be recovered but at the risk of relapsing. While the capacity in the state in 2015 for acute detox could serve up to 3,500 individuals a month, CSS programs available could only serve 600, and TSS programs could serve around 330. The continuum of care does not stop here, however, given that recovery from a Substance Use Disorder (SUD) is a long-term commitment, and relapses do occur. Thus, this long-term approach must include residential treatments, halfway houses, and outpatient community services that provide more holistic approaches to a disease that is as clinical as it is social.
So this is where our conversations led us: there’s a lot of stigma. There’s a lot of need. And there’s not a lot of money, at least not in a scarce-resource model where health care must be rationed. The problem isn’t simply that there aren’t enough beds in step-down programs for people recovering from SUDs; rather, the people recovering from SUDs who may need these programs the most are falling through the cracks because the low reimbursement rates for many of the CSS and TSS programs disincentivize insurers and administrators from accepting medically complex patients. Given the inherently complex nature of SUDs, endocarditis or psychiatric conditions are often common. Thus the disqualification from more long-term treatment on the basis of “medical complexity” restricts those with severe health conditions to the most minimal level of care.
In the larger scale, the problem lies in the history of substance use treatment throughout our nation’s history. SUDs have been, unfortunately, divorced from the disease model, and those who treat disease do not always know how to treat SUDs. In medical school, the curriculum does not require medical students to learn about addiction. Only psychiatry residents have to learn about addiction for a period of a month. Meanwhile, those who deal with SUDs are not only psychiatrists. Because of the high rates of comorbidity related to addiction, most physicians will have to encounter and treat someone with a substance use disorder, and more often than not, this treatment will be a common routine of clinical care. Then why is addiction not essential in the framework of medical education?
The problem is that the current system is not working for many people. While methadone, buprenorphine, and suboxone are all viable alternatives, or complements, to hospitalization and detox, many communities have stigmatized these long-term treatments, just as other communities have stigmatized detox centers.
The problem is that we are in the middle of an epidemic, and those who do receive treatment are more likely to relapse if they are unable to access CSS or TSS treatment. Post-detox overdose rates are as high as they are because detox decreases tolerance, and when patients are sent back into the same environment in which they were using drugs, they are left without the necessary support structures that chronic diseases require. The most medically complex patients are the most likely to fall through the cracks, simply because their vulnerabilities create a liability. And when a patient relapses, he/she is more likely to be thrown out of the recovery program. How is that, that the model of recovery for an SUD has been so radically divorced from the models that we use to treat other chronic diseases like hypertension, diabetes, or heart disease? If a patient has a heart attack, he is not thrown out of the hospital. He is immediately rushed back to receive more care, and the physician is forced to reconsider the treatment plan and make adjustments. Meanwhile, when a patient in an addiction program relapses and uses opioids, he is often kicked out. What makes addiction so much more complex?
We have been part of a group of Harvard undergraduates and medical students who have recently tried to navigate these dilemmas, and it is fair to say that after countless meetings with public health officials and physicians at Harvard-affiliated hospitals, we are left with more questions than before. However, we have also learned that, unlike most advocacy work, physicians, health officials, and local activists alike have the will to act. The opioid epidemic is a personal epidemic. And that gives us the ability to push.
So what are we thinking? If Harvard-affiliated hospitals could revolutionize addiction treatment, this advancement would not only save countless lives, but it would also pave a path for much needed research on addiction recovery methods. We have spoken to several physicians at Mass General Hospital and Brigham and Women’s Hospital who care deeply about this issue. We have spoken to the Department of Public Health. Everyone wants to do something, and the moral push that our undergraduate and medical school coalition can provide is essential in bringing together many of the pieces to this puzzle. So maybe we create a bridge clinic with step-down rehabilitation services. Maybe we expand a wing in each hospital and provide CSS and TSS services. Maybe we push for something more revolutionary: a Center for Addiction Research and Treatment that can serve as both a treatment center (with detox and its step-downs) and a teaching school where we can fill in the gap that has been left out in the medical school curriculum. Already, we have seen the importance of starting this conversation, of opening the lines of communication between those passionate about this issue. Now, we must push for more -- from the state, from hospitals, and from the medical schools -- for the revolutionary treatments we need to stem the opioid epidemic, and from ourselves, to actively work to decrease the toxic stigma surrounding SUDs.
Daniela Muhleisen ’19
Laura Kanji ' 19