Grappling with the opioid problem

New partnerships, reduced stigma are key to solving opioid crisis, experts say

Mollie Rappe   

With opioid drug overdoses causing more than 100 deaths across America each day, the scale of the nation’s opioid crisis has now reached that of the HIV-AIDS epidemic at its peak.

That’s according to Michael Botticelli, former director of the White House Office of National Drug Control Policy, who served as keynote speaker at an Oct. 23 panel discussion on science-based solutions to the opioid crisis. The event, held at Brown University, was convened by Brown and the American Academy of Arts and Sciences.

Given the scale of the public health crisis and the need for innovative solutions, Botticelli, who now directs the Grayken Center for Addiction at Boston Medical Center, emphasized the importance of including members of the affected community in policymaking. 

“At the height of the HIV-AIDS epidemic, there was an expression that those affected often used as they talked about the inclusion of people who were affected as part of the solutions to the problem,” Botticelli said. “That was: ‘Nothing about us without us.’ I think it’s a clarion call for our work here today about how we involve affected communities, affected people, active drug users, into the highest level of policymaking.”

Botticelli moderated the panel, which included Rebecca Boss, director of the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, and Brown University researchers Traci Green, Brandon Marshall and Dr. Josiah Rich. 

Keynote speaker and panel moderator Michael Botticelli, former director of the White House Office of National Drug Control Policy and executive director of the Grayken Center for Addiction at Boston Medical Center, emphasized the importance of including members of the affected community in policymaking in complex public health and social issues such as the opioid crisis.

The need for partnerships — not just with affected individuals, but among researchers, health care providers, elected officials and others — emerged as a common theme in panel discussion. 

Rich highlighted Rhode Island Gov. Gina Raimondo’s Overdose Prevention and Intervention Task Force, on which he serves as an adviser, as an illustration of the type of partnership among policymakers, researchers and community members that can be successful.

“This is a very complex problem,” said Rich, a professor of medicine and epidemiology at Brown. “To address this, you don’t just need scientists developing new medications. You don’t just need clinicians making better treatments… We need that and more. We need all hands on deck.”

Green, an adjunct associate professor of emergency medicine and epidemiology at Brown, noted that partnerships with public safety officers and first responders have been critical — not only because they've helped increase the use of naloxone, a medication that rapidly reverses the effects of overdose, but also for getting more voices to the table. 

Boss, who co-chairs the Rhode Island task force, said that building partnerships within affected communities can save lives, treat addiction and change perceptions about people with opioid use disorders. 

She said a new treatment center in Newport found success largely because it forged relationships with local businesses, law enforcement and community members before it opened.

“Any partner in this discussion is the right partner…” Boss said. “Look at the movement of Mothers Against Drunk Driving and the influence that had. We have mothers who are getting angry, and angry mothers can move mountains.”

Confronting stigma

Botticelli noted that for an epidemic to proliferate, conditions must be ripe. He said that a strong stigma against people with substance use disorders, combined with the treatment of addiction as a law enforcement problem rather than a health care challenge, were two major factors that led to the opioid crisis. 

Marshall, an associate professor of epidemiology at Brown’s School of Public Health, said that he continues to see stigma as one of the most significant barriers to new solutions.

"[There is an] ongoing stigma and stereotyping of people who use drugs as not wanting to change — not wanting help," Marshall said. "Those false stereotypes prevent implementation of a lot of research and a lot of interventions that we know work.”

Boss added that medication for addiction treatment, which has been proven to save lives, is also often stigmatized as less than 'true' recovery. 

Rich added that stigma against medication for addiction treatment can even extend to medical practitioners, some of whom have resisted taking the training required by the Drug Abuse Treatment Act (DATA) in order to prescribe medications for the treatment of opioid use disorders. 

Only 4 percent of doctors have the DATA waiver, Botticelli said, and less than half of those with the waiver regularly prescribe medications for opioid use disorders. He praised the Warren Alpert Medical School’s award-winning curriculum, which trains students to diagnose and treat addiction. 

For individuals confronting addition, Marshall said, positive interactions that cast the stigma aside — in contexts such as sterile syringe exchanges, for example — could not only reduce immediate health risks but could also start a longer-term path to treatment and recovery.

U.S. Sen. Sheldon Whitehouse of Rhode Island introduced Botticelli’s keynote and spoke of his experience working in Congress toward the eventual passage of the Comprehensive Addiction and Recovery Act of 2016. He said he has seen progress toward reduced stigma. 

“The manner in which [the act] passed... confirmed that a lot of the stigma that had been the dark shadow on this medical issue has abated,” Whitehouse said. “We did not have colleagues saying, ‘This is a moral failing and these people need to be locked up and gotten off the streets’… People understood this was a medical issue [and] it does require treatment, and for that to work, we need research.”

Brown’s Office of the Vice President for Research partnered with the American Academy of Arts and Sciences to convene the event. University President Christina Paxson offered opening remarks and noted the critical role that researchers at Brown and elsewhere play in creating science-based solutions. 

Green and Rich, for example, are principal investigators for a new $11.8 M Center of Biomedical Research Excellence (COBRE) on Opioids and Overdose. Marshall has conducted research on the effectiveness of fentanyl test strips to reduce overdoses and peer recovery support interventions. 

All four panelists, led by Green, conducted research that found medications for addiction treatment in prisons significantly reduced overdose deaths among those who had been recently released.

Paxson credited those efforts and others for a 4 percent reduction in opioid-related deaths in Rhode Island in 2017 compared to 2016. 

“Research into opioid abuse is an urgent national priority,” Paxson said. “Against this very bleak national picture, Rhode Island has offered reasons for hope.”