Addressing the Socioeconomic Complexities of Addiction—Lessons from the Kensington Neighborhood in Philadelphia

From the Monthly Blog of Dr. Lora Volkow, Dir., National Institute on Drug Abuse
Originally Posted October 29, 2019 here.

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This September, Dr. Volkow was invited by Thomas Farley, the Health Commissioner of Philadelphia, to see firsthand how that city is responding to the opioid crisis. With other members of NIDA leadership, she toured Prevention Point, a private non-profit organization providing harm reduction services to Philadelphia and the surrounding area. The group also visited the health unit of the city’s Prisons Department, where they recently started a program that provides medications to prisoners with opioid addiction, and they met with outreach workers from Temple University who operate a mobile treatment unit that provides medications and behavioral health services for opioid addiction, as well as basic wound care.

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Philadelphia’s rate of overdose deaths skyrocketed this past decade, tripling the city’s number of homicide deaths and greatly exceeding the peak number of deaths from AIDS in 1994. With one fifth the population of Manhattan, Philadelphia still has almost as many overdose deaths. It was humbling not only to see the challenges facing a city with a longstanding opioid problem but also to see the engagement and dedication of people on the ground attempting to help, as well as the struggles of those battling their own drug addiction amidst extremely hard socioeconomic challenges.

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Prevention Point’s Wound Care Clinic offers free, specialized wound care for all people

Whenever Dr. Volkow asks people on the front lines of America’s drug crisis what more NIDA can do to support and help their work, they remind her how essential it is to address the basic needs of individuals with addiction, such as stable and safe housing, food, basic medical care, and an opportunity for employment.  In the addiction field, NIDA has recognized the importance of addressing these basic needs as part of recovery support. Yet, it is crucial to realize that these needs have to be met even before a person is in stable recovery in order to facilitate them getting to recovery at all.  People cannot recover from addiction if they are homeless, isolated, and struggling to find food and safety.

Located in Kensington, one of Philadelphia’s hardest-hit neighborhoods, Prevention Point, which began three decades ago in response to the AIDS crisis, offers medications for opioid use disorder (buprenorphine and naltrexone), distributes Narcan (Naloxone) kits for reversal of opioid overdoses, and provides sterile syringes to reduce the risk of infections. It also offers testing for HIV and HCV and treatment referral when needed, wound care (people who inject drugs frequently develop infections), and linkage to behavioral health treatment.

Additionally, the center provides temporary housing and meals, as well as case management and a wide array of other non-medical services to people experiencing homelessness and struggling with addiction, such as legal services and mail services for clients who would otherwise be unable to file and receive needed paperwork. Under the impressive leadership of Executive Director Jose Benitez and Associate Executive Director Silvana Mazzella, Prevention Point provides these services with a very limited budget (facilitated by both public and private funding), in an old church.

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By visibly providing support and care for individuals with addiction, Prevention Point is embraced by some in the community but resisted by others. Some view treatment as competition for the drug market; others fear how it may affect the neighborhood’s potential for renovation and gentrification. With addiction services historically segregated from the rest of healthcare, the “not in my backyard” (“NIMB”) problem has long been a major factor in impeding access to treatment.

NIDA’s visit to Philadelphia drove home why America needs to address the stigma that still surrounds opioid addiction and its treatment. It also drove home why addressing the crisis will require a comprehensive approach—including treatment with medications along with harm-reduction (like needle exchange), as well as case management and an array of non-medical services that can attend to people’s basic needs, including helping them build meaningful social relationships.

It is crucial that drug treatment specialists do more research to find ways of effectively delivering such services and support to all communities, both urban and rural, that need them. It will require more collaborative engagement between researchers and community-level providers, volunteers, and people suffering from substance use disorders—the HEALing Communities Study, which is getting underway in four hard-hit states, is a start.

In conclusion, Dr. Volkow said, “I also strongly encourage scientists who work in other aspects of addiction research to spend time at local addiction service providers to get a firsthand understanding of the challenges faced by those on the front lines, to visit neighborhoods that have been devastated by addiction, and to speak to those afflicted. It can be a valuable reminder of how every aspect of a person’s life—from employment, to housing, to interpersonal relationships—can be either a vulnerability or an asset on the road to addiction recovery. “

Supporting Our Physicians in Addressing the Opioid Crisis

From the blog of Dr. Lora Volkow dated August 31, 2018

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A recurring theme among addiction researchers and professionals is the so-called treatment gap: under-utilization of effective treatments that could make a serious dent in the opioid crisis and overdose epidemic. Ample evidence shows that when used according to guidelines, the agonist medications methadone and buprenorphine reduce overdose deaths, prevent the spread of diseases like HIV, and enable people to take back their lives. Evidence supporting the effectiveness of extended-release naltrexone is also growing; but whereas naltrexone, an opioid antagonist, can be prescribed by any provider, there are restrictions on who can prescribe methadone and buprenorphine.

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A series of editorials in the July 5, 2018 issue of the New England Journal of Medicine made a strong case for lessening these restrictions on opioid agonists and thereby widening access to treatment with these medications. For historical reasons, methadone can only be obtained in licensed opioid treatment programs, but experimental U.S. programs delivering it through primary care docs have been quite successful, as have other countries’ experiences doing the same thing. Although buprenorphine can be prescribed by primary care physicians, they must first take 8 hours of training and obtain a DEA waiver, and are then only allowed to treat a limited number of patients. Some physicians argue that these restrictions are out of proportion to the real risks of buprenorphine and should be lessened so more people can benefit from this medication.

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Stigma contributes to reluctance to use evidence-supported treatment—both stigma against addicted individuals and stigma against agonist medications, due to the persistent myth that they just substitute a new addiction for an old. This idea reflects a poor understanding of dependence and addiction. Dependence is the body’s normal adaptive response to long-term exposure to a drug. Although people on maintenance treatment are dependent on their medication, so are patients with other chronic illnesses being managed medically, from diabetes to depression to pain to asthma. Addiction, in contrast, involves additional brain changes contributing to the loss of control that causes people to lose their most valued relationships and accomplishments. Opioid-dependent individuals do not get high on therapeutic doses of methadone or buprenorphine, but they are able to function without experiencing debilitating withdrawal symptoms and cravings while the imbalances in their brain circuits gradually normalize.

Treating patients with addiction may be uniquely complex and demanding for several reasons. Patients may have co-morbid medical conditions, including mental illness; thus they may need more time than doctors are reimbursed for by insurers. They may also have pain, and while pain management guidelines have changed to respond to the opioid crisis, those changes have not necessarily made a doctor’s job any easier, since there are currently no alternative medications to treat severe pain that are devoid of dangerous side effects.

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Because of the complexity of Opioid Use Disorder (OUD), providers may find that it is not sufficient to simply dispense a new prescription after a quick consultation. These patients often need ancillary services provided by nurses or other treatment specialists; and in the absence of these extra layers of support, treatment is less likely to be successful, reinforcing physicians’ reluctance to treat these patients at all. In short, physicians are being blamed for causing the opioid epidemic, but thus far they have not been aided in becoming part of the solution.

Medical schools are starting to respond to the opioid crisis by increasing their training in both addiction and pain. For example, as part of its training in adolescent medicine, the University of Massachusetts Medical School has begun providing pediatric residents with the 8-hour training required to obtain a buprenorphine waiver—an idea that is winning increasingly wide support. Physicians in some emergency departments are also initiating overdose survivors on buprenorphine instead of just referring them to treatment. And through its NIDA MedPortal, NIDA provides access to science-based information and resources on OUD and pain to enable physicians to better address these conditions and their interactions, including easy-to-use screening tools to help physicians identify substance misuse or those at risk.

But if physicians are going to assume a bigger role in solving the opioid crisis, healthcare systems must also support them in delivering the kind of care and attention that patients need. Physicians need the tools to treat addiction effectively as well as the added resources (and time) for patients who need more than just a quick consultation and a prescription.