Preventing Overdose Deaths: How to Reduce Social Stigma and Barriers to Care

CLINICAL CONVERSATIONS

August 31 is Overdose Awareness Day. A recent study shows that about 1 in 3 Americans have lost someone they knew to a drug overdose.1 To help address this issue, Psychiatric Times sat down withJoseph R. Volpicelli, MD, PhD, the executive director of the Institute of Addiction Medicine, to discuss the opioid crisis, best practices for substance use disorder treatment, and more.

Psychiatric Times: In your opinion, what should clinicians be doing to help prevent overdose deaths?

Joseph R. Volpicelli, MD, PhD: With over 100,000 deaths due to drug overdose this past year, it is important that all clinicians, regardless of specialty, join in the fight to prevent overdose deaths. This includes asking patients about drug and alcohol use as part of each clinical visit. If an issue is present, clear and nonjudgmental advice should be offered so the patient can address the issue. Clinicians should be aware of treatment options, and if they are uncomfortable treating the problem directly, then appropriate referral and follow-up are necessary. Even patients who do not present with a drug issue should be educated that with the advent of synthetic opioids like fentanyl in the drug supply, any illicit drug could have a fatal dose of an opioid with simply 1 accidental use.

PT: The theme for this year’s Overdose Awareness Day is “Together we can.” Do you think substance use disorder treatment is best managed by a team? How do you employ this in your own practice?

Volpicelli: Yes absolutely, a team is essential to treat substance use disorder. Medications such as methadone and buprenorphine are very effective in reducing craving and illicit opioid use, and the medication naltrexone, or VIVITROL, is effective in reducing relapse to opioid use in someone who has detoxified from opioids. However, while effective, these medications only work when taken. Our program’s team of physicians, nurse practitioners, and counselors/coaches address psychosocial issues that lead to drug use and interfere with sustained treatment. We believe that treatment is more than recovery from drug use; it is discovering new options for individuals to find connections and meaning in life.

In addition to the treatment team, we must work together with the community to raise awareness and reduce the stigma associated with addiction. This includes improving access to care and removing barriers to quality, effective treatment.

PT: How best can clinicians combine medication and psychosocial treatment when treating patients struggling with addiction, specifically opioid use disorder?

Volpicelli: The use of medications and psychosocial support work synergistically to help patients struggling with addiction. Often, patients with opioid addiction have exhausted their finances trying to support their drug habit and fractured or ignored social connections with people because they are preoccupied with getting high. The emotional pain of financial and social isolation is temporarily removed by redosing, but this only serves to perpetuate a vicious cycle of addiction. While medications can be beneficial in reducing withdrawal symptoms and the desire to use drugs, they do not repair broken relationships with family members or give one a sense of purpose. By combining medications and psychosocial support early in treatment, we can improve treatment engagement and medication adherence. Working collaboratively with patients, the clinician can address barriers to care and help motivate patients who are ambivalent about addressing their addiction. Later in treatment, we focus on repairing broken social connections and helping patients find purpose.

A part of every clinical visit in our program is to assess a patient’s interest and engagement in enjoyable activities, and how well they get along with friends and family, and enjoy and function in their job.

PT: What practice tips would you offer to clinicians who have less experience in managing patients with opioid use disorder?

Volpicelli: The most important practice tip I would offer to less experienced clinicians is to remember that people with addictions are your friends, neighbors, and family members. Addressing their issues with the same compassion and understanding as patients with other medical conditions will help you accurately assess and offer treatment. Often, people with opioid use disorder feel stigmatized by the medical community and are reluctant to share information and accept care. Establishing a good therapeutic relationship is the most important first step.

PT: Can you speak a little to the challenges of addressing opioid addiction and use in patients with comorbid psychiatric disorders?

Volpicelli: Comorbid psychiatric disorders are very common in those with opioid addiction. Individuals with comorbid anxiety and depression will often report that drug use helps them cope and feel better. The idea of stopping opioid use then is fraught with the fear that these symptoms will get worse. To help alleviate these fears and the symptoms, it is critical to recognize and offer alternatives to drug use. Treatment can include the use of medications that specifically address comorbid psychiatric conditions and behavioral counseling.

PT: How can clinicians best screen for potential opioid use/abuse in new patients?

Volpicelli: Including questions about drug and alcohol abuse should be included in every clinical encounter. When presented without judgment, one will typically get accurate responses. Drug screening from urine or blood samples can confirm the patient’s narrative report. In addition, one can review their medication history. Virtually every state offers a Prescription Drug Monitoring Program to see if there is some anomaly in the patient’s prescription pattern (ie, increasing doses of opioids, several health care professionals writing for opioids). The physical exam can offer clues such as small pupils or tract marks on the limbs. One can also employ questionnaires that screen for drug opioid addiction, such as the Screener and Opioid Assessment for Patients with Pain (SOAPP), Current Opioid Misuse Measure (COMM), or Drug Abuse Screening Test (DAST).

PT: Do you think the opioid crisis is getting better or worse? Why?

Volpicelli: The number of fatal overdose deaths decreased last year for the first time in several decades. Increased public awareness of the opioid crisis and reductions in limitations for health care professionals are causes for optimism that the crisis has peaked. However, the addition of adulterants to the opioid supply, such as xylazine and stimulants, has made it more challenging to manage patients. Protocols to detoxify patients from opioids or start buprenorphine are more difficult as the additives to the opioid supply do not have any established effective medical treatments. As treatment becomes more accessible and is addressed more aggressively by the medical community, we should make progress in improving the opioid crisis.

PT: What would you say are today’s most pressing issues concerning substance use disorder?

Volpicelli: We have effective treatments, but they are often not accessible, and once started, it has been a challenge to keep patients engaged in treatment. Structural issues such as limited health care resources in poorly served urban and rural communities, the cost of quality care, and a medical community that does not fully embrace addiction as a medical condition compromise the use of the available effective treatments.

PT: Your research led to the discovery of naltrexone to treat alcohol addiction, an FDA-approved medicine intended to reduce alcohol craving and relapse. Can you share a little bit about your research process? Are there any specific findings you think might surprise your fellow clinicians? Are there any efficacy issues?

Volpicelli: This year marks the 30th anniversary of the US Food and Drug Administration approval of naltrexone to treat alcohol addiction (and the 40th to treat opioid addiction).Research has convincingly shown that naltrexone is a safe and effective treatment for alcohol addiction. There are over 50 placebo-controlled randomized trials and supporting meta-analysis of these trials to show that naltrexone is effective. There is no other form of alcohol addiction treatment that has such a large empirical basis for its effectiveness. However, only about 10% of those with alcohol addiction receive any treatment for alcohol use disorder, and less than 2% of those in treatment receive a prescription for naltrexone. The biggest disappointment in my research career is the underutilization of naltrexone.

Perhaps the most surprising finding among my fellow clinicians is that naltrexone is so versatile in how it can be used. Most clinicians use naltrexone in recently detoxified patients with the goal of complete abstinence. However, we know that reductions in alcohol use can have substantial health benefits, and particularly for individuals who drink alcohol occasionally, naltrexone can be administered in a targeted way to moderate one’s drinking.

Naltrexone can be prescribed as a daily pill, targeted to drinking situations, or given as a once-a-month injection. When integrated with psychosocial support, naltrexone is very effective for those with high baseline levels of alcohol craving and those with a positive family history of alcohol addiction. Alcohol addiction is likely a heterogenous disorder, and some people are not naltrexone responders but would respond to other medications. Future research is needed to best match the right medicine for the patient.

PT: How best can clinicians integrate harm reduction models into opioid use disorder treatment?

Volpicelli: While abstinence from illicit opioids is the preferred goal, for many individuals, it is unrealistic in their current situation. For various reasons, people are either unwilling or unable to abstain completely. In these cases, engaging people in treatment and reducing harm as much as possible is important. It is often stated that we need to meet people where they are at, which is very true if we engage people in treatment. I would add, though, that if people are in a bad place, we have a responsibility to not only meet them where they are at but also help them move from that bad place. So, harm reduction at its best reduces harm and encourages growth to a healthy, productive life.

PT: Are there any other substance use disorder treatments in the pipeline that you are excited about?

Volpicelli: The introduction of injectable formulations of buprenorphine and naltrexone, like VIVITROL, has been a welcome addition to opioid addiction treatment. The use of a sustained-release version of these medications reduces the risk of medication diversion and nonadherence. In addition, several exciting new medications to treat substance use disorder are in the pipeline.

For example, GLP-1 agonists such as semaglutide have interesting preclinical and early reports of effectiveness in treating alcohol addiction. Also, there is renewed interest in psychedelic-assisted therapy, such as low-dose psilocybin, to treat alcohol and opioid addiction. I have also been involved in nonmedical treatment, such as the use of neurostimulation techniques. Finally, to help address issues in access to treatment, there has been increased interest in virtual telemedicine and digital therapeutics to help provide psychosocial support.

PT: You designed a treatment modality called the BRENDA Model (B – biopsychosocial evaluation, R – report findings to patient, E – empathize, N – what are the needs of the patient, D– direct advice, A – assess patient's response to advice). How can clinicians employ this in their own practices?

Volpicelli: Researching medical treatments for addictions is often compromised by subject nonadherence and dropouts. To address this, I designed the BRENDA approach to improve treatment engagement and retention. This approach borrows from motivational enhancement techniques and is easy to learn and use effectively—even with clinicians without formal training in motivational interviewing. The first step is to conduct a full biopsychosocial evaluation to evaluate how substance use is associated with adverse consequences. The subject is then given feedback on the evaluation to help them make the connections between their substance use and its consequences. This process is conducted with an emphasis on empathy and a nonjudgmental attitude to get a sense of what issues are most relevant to the subject. Next, the collaboration between the clinicians and the subject identifies the needs and goals of the subject (ie, why the subject would want to reduce their drinking or drug use). As the subject feels the clinician has a fair understanding of what matters most to the subject, the clinician offers direct advice, such as starting a new medication, and explains how the intervention will benefit the subject. Finally, the clinician assesses the subject's response to the direct advice and the motivation to follow through. Any ambivalence or reluctance to follow through is explored, and barriers to treatment recommendations are addressed.

This approach was successfully used in research studies and is easily applied in clinical settings. Clinicians and their staff can be trained to adopt this approach to improve the therapeutic relationship and approach each patient with the empathy and care they deserve. While it may take a little extra time with the patient, improving patient engagement and adherence is worth the effort.

PT: Do you have any final thoughts to share?

Volpicelli: Addiction treatment is safe and effective. The main challenge for the medical community is to help reduce social stigma and barriers to care. We all have a responsibility to help inform the public about the advances in medical treatment for addictions and how integrating medical care with psychosocial support can bring freedom to those who suffer from addiction.

PT: Thank you!

Dr Volpicelli is the executive director of the Institute of Addiction Medicine.

Reference

1. Kennedy-Hendricks A, Ettman CK, Gollust SE, et al. Experience of personal loss due to drug overdose among US adults. JAMA Health Forum. 2024;5(5):e241262.