At the invitation of the Social Work Staff Development Committee of the HSS Department of Social Work Programs, Dr. Avery spoke before an audience of HSS social workers and invited clinical professionals. The presentation was designed to help social workers and other clinicians better understand and respond to the opioid epidemic for the benefit of patients and their families.
The original presentation has been supplemented with content provided by Dr. Vinnidhy H. Dave of the HSS Department of Anesthesiology, Critical Care & Pain Management.
A patient is prescribed opioids by another provider (e.g., a prior MD or outside MD). The patient’s current MD does not want to continue to prescribe medication, but patient sees this as the only acceptable/effective treatment.
Treating opioid use is different than that for any other substance. It’s hard to treat addiction, however, outcomes are good with more than 24 million in recovery. There is a lot of stigma and bias associated with treating people with substance use disorders (SUDs), which results from common perceptions that people with such disorders have a “moral failing.” Working in hospitals, we are less likely to see those in recovery, however, it is important to see that people can get better and to hold onto a positive image of recovery. It is also important to carefully consider how we describe the person and to avoid using shaming words, e.g., “clean” and “dirty.” (Read more about this at SubstanceUseStigma.com.)
Similar to countertransference or the automatic and unconscious ways that we judge a person, it is important that we not allow the abovementioned stigmas or prejudices affect or direct the professional service we provide to patients. Opioid use is neither “good” nor “bad.”
Implicit bias is a term that refers to the relatively unconscious and automatic human features of prejudiced judgment and social behavior.
While psychologists in the field of “implicit social cognition” study “implicit attitudes” toward consumer products, self-esteem, food, alcohol, political values and more, the most striking and well-known research has focused on implicit attitudes toward members of socially stigmatized groups, such as individuals with SUDs, African-Americans, women and members of the LGBTQ community.
The perception of opioids as being “bad” or “good” – by lawmakers, medical professionals and society more generally – has fluctuated significantly over the past century.
Since the 1960s, methadone maintenance has been demonstrated to have very good outcomes, however there is a lot of stigma attached to this practice, and it is underutilized by the hospital system.
Adolescents are using more opioids through “pill parties” and can get them online or by stealing them from family and friends. According to a data brief released in December 2017 by the National Center for Health Statistics, there was a fourfold increase in opioid deaths among 15- to 24-year-olds between 1999 and 2016.
Drugs involved in US overdose deaths include common prescription opioids such as oxycodone and hydrocodone, as well as fentanyl and heroin. Drugs kill more people in the US than do cars or guns. The Centers for Disease Control (CDC) estimated that an average of 175 American died from drug overdoses in the United States each day during 2016. This affected more males than females, but spanned the demographic and socioeconomic spectrum.
There is also a hidden epidemic emerging in conjunction with the combination of benzodiazepines and opioids. Benzodiazepines such as alprazolam (Xanax), clonazepam (Klonopin) and diazepam (Valium) increase the high when combined with an opioid. Patients also put themselves at risk by combining opioids with nonbenzodiazepine sleep aids such as zolpidem (Ambien).
When using opioids, the dopamine levels in the brain spike and the brain is rewired and motivated to increase use. Not everyone who uses opioids will develop a SUD, however some may have a genetic predisposition, and it is more complicated when pain, isolation and trauma is involved. Opioids may help in the right circumstances, such as for acute pain (e.g., after surgery), cancer-related pain, as an end-of-life treatment or when other treatment modalities have proven inadequate, but they are not useful or appropriate for treating non-cancer-related, long-term chronic pain.
It is important to set up expectations from the beginning of treatment (e.g., no early refills) and to provide a pain contract. A goal should be set for how long opioids will be used and, if they are not helping after a prescribed period, other alternatives should be used to treat pain.
For any substance use disorder there are many non-medication forms of treatment, e.g., AA (Alcoholics Anonymous), SMART, Mutual Help for Addiction Recovery, DBT (dialectical behavior therapy), mindfulness techniques and cognitive behavioral therapy, and motivational interviewing. The use of motivational interviewing is a big change in treating addiction. It is mostly driven by the patient by meeting each patient where he or she is rather than at a predefined start point. First, begin by assessing what the patient likes about the drugs: Ask questions in a nonjudgmental way to assess the patient’s readiness and move forward when there is an opening for change (with the goal being to have a “change talk”). Ask for permission to suggest treatment options and give advice. Then the patient will feel part of the conversation, and the spirit is to connect with people and find out what they want.
* Bentzley BS et al. 2015; Kreek MJ et al.,1996; 2000, 2001; 2003; 2010; Weiss et al., 2015.
Patients taking this opiate-blocking medication, cannot be on any other opioids. They must also be detoxed. This is a good option for highly motivated people.
The New York City Health Commissioner’s standing order has been revised to include the single-step, FDA-approved intranasal naloxone HCl (Narcan) product and there are over 730 pharmacies across NYC where anyone can walk in and obtain this or another naloxone product without a prescription.
For patients with insurance, they will pay a copay (Medicaid copays are usually a $1), but may not have a choice in which formulation they receive. For patients without insurance, paying out of pocket varies based on formulation.
There has been a culture change with regard to how we treat opioid use and under what circumstances we provide options for treatment. The general approach is to slowly taper and discuss this at every medical visit. It might not be a problem today, but eventually external factors or comorbidities can have ill effects on the person. The anticipatory anxiety and fear of reduction is greater than the process. Go for the early win by reducing small doses over time and then increase the taper. Meet patients where they are – at whatever level they are prepared to accept treatment and advice. Always provide options and resources, and don’t rush it.
Jonathan Avery, MD
Director of Addiction Psychiatry, NewYork-Presbyterian Hospital
Assistant Professor of Clinical Psychiatry, Weill Cornell Medical College
Vinnidhy H. Dave, DO
Pain Management Division, Hospital for Special Surgery
Jonathan Avery, MD
Director of Addiction Psychiatry
Assistant Professor of Clinical Psychiatry
Assistant Dean of Student Affairs
Weill Cornell Medical College
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
Bachhuber MA, Saloner B, Cunningham CO, Barry CL. Medical Cannabis laws and opioid analgesic overdose mortality in the US, 1999-2010. JAMA Intern Med 2014; 174:1668-73.
Bentzley BS, Barth KS, Back SE, Book SW. Discontinuation of buprenorphine maintenance therapy: perspectives and outcomes. J Subst Abuse Treat. 2015 May;52:48-57.
Johnston LD, Miech RA, O'Malley PM, Bachman JG, Schulenberg JE. (December 16, 2015). "Use of ecstasy, heroin, synthetic marijuana, alcohol, cigarettes declined among US teens in 2015." University of Michigan News Service: Ann Arbor, MI. Retrieved from http://www.monitoringthefuture.org.
Kreek MJ. Opiates, opioids and addiction. Mol Psychiatry. 1996 Jul;1(3):232-54.
Kreek MJ. Methadone-related opioid agonist pharmacotherapy for heroin addiction. History, recent molecular and neurochemical research and future in mainstream medicine. Ann N Y Acad Sci. 2000;909:186-216.
Kreek MJ. Drug addictions. Molecular and cellular endpoints. Ann N Y Acad Sci. 2001 Jun;937:27-49.
Kreek MJ, Borg L, Ducat E, Ray B. Pharmacotherapy in the treatment of addiction: methadone. J Addict Dis. 2010 Apr;29(2):200-16.
Leibschutz JM, Saitz R, Weiss RD, Averbuch T, Schwartz S, Meltzer EC, Claggett-Borne E, Cabral H, Samet JH. Clinical factors associated with prescription drug use disorder in urban primary care patients with chronic pain. J Pain 2010;11:1047-55.
Ries RK, Fiellin DA, Miller SC, Saitz R (Eds.). The ASAM Principles of Addiction Medicine, Fifth Edition. Wolters Kluwer, Philadelphia 2014.
Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse health effects of marijuana use. N Engl J Med 2014;370:2219-27.
Weiss RD, Potter JS, Griffin ML, Provost SE, Fitzmaurice GM, McDermott KA, Srisarajivakul EN, Dodd DR, Dreifuss JA, McHugh RK, Carroll KM. Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study. Drug Alcohol Depend 2015; 1;150:112-9.
We hope that you find these resources helpful; they are provided for informational purposes only and are not intended to comprise a complete list. Links to sites are not meant as endorsements or recommendations by HSS or its faculty.
Pharmacy information: Send patients to a nearby pharmacy that is dispensing naloxone under the New York City Health Commissioner’s standing order, or write prescriptions for naloxone. The Health Commissioner’s standing order has been revised to include the single-step, FDA-approved intranasal Narcan product, and there are over 730 pharmacies across the city where anyone can walk in and obtain this or another naloxone product without a prescription. You can find a nearby participating pharmacy by using their pharmacy locator. (Expand the "Drug and Alcohol Services" menu and select "Naloxone in pharmacies.") For patients with insurance, they will pay a copay (Medicaid co-pays are usually a $1), but may not have a choice in which formulation they receive. For patients without insurance, paying out of pocket varies based on formulation.
Prepared by Mavis Seehaus, MS, LCSW
Director, Ambulatory Care Social Work Services
Department of Social Work Programs
Hospital for Special Surgery
Addiction Institute at Mount Sinai – Beth Israel (Medicaid, commercial insurance)
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Addiction Institute at Mount Sinai – West (Medicaid, commercial insurance)
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Bellevue Hospital (Medicaid, commercial insurance)
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Hazelden (Commercial insurance only)
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