We can safely take for granted that a doctor treating your back pain isn’t going to determine the course of care based on whether she thinks you’ll fully commit to getting better. She isn’t likely to start treatment with a contract stating that the only way to stay in treatment is to commit to doing everything she requires and reaching total recovery. She isn’t going to set arbitrary parameters for how fast you should recover.
It’s also safe to assume that your quest to get care for back pain won’t carry negative connotations, or stigma. You aren’t worried about being seen walking in and out of physical therapy. You don’t get sideways glances from co-workers when you tell them that you finally started addressing your bad back. You won’t be judged as a person for having back pain or giving in to its control over your daily life. If you stop going to treatment and just decide to manage things on your own, there’s a high likelihood you can go back to physical therapy again whenever you’re ready.
This is a far cry from the experience of most people seeking treatment for substance use disorder (SUD). SUD is a chronic medical disorder characterized by alterations in the functioning of the brain caused by prolonged substance exposure. It is most common in people with genetic, environmental, and developmental risk factors. The primary result is a rewiring of the brain’s reward processing, and changes to what motivates and prioritizes behavior, mood, and executive functions.
Like any chronic condition, treatment of SUD requires assessment, diagnosis and a longer-term individualized treatment plan aimed at achieving outcomes and improving quality of life. Evidence strongly supports that SUD, and specifically opioid use disorder (OUD), is best treated through a combination of coordinated treatment and therapy incorporating medication. In some cases, there may be underlying conditions that need attention, both physical and psychiatric. There’s no strict medical definition of “cured,” and every patient faces differing challenges, and differing definitions of success, related to living with the condition.
Because it affects the brain, and in some cases carries risk of death, nobody would argue that SUD is less serious than back pain, and it can be objectively quantified as one of the most serious chronic conditions Americans face.
If we know that SUD has a disproportionately high health toll on individuals, and its toll also impacts entire communities, why hasn’t health infrastructure for treatment of SUD been a top priority until recently? The answer lies with stigma.
Why stigma so pervasively impacts addiction recovery
Historically, people who use drugs have been marginalized and punished, and that marginalization extends to efforts to try to seek help and health care for it. The topic of SUD comes embedded with illegality, turning drug use into merely a bad choice or willingness to harm one’s own health in opposition of public policy. That there’s a complex web of physical, mental and social determinants at play does not become the primary consideration. Instead, the initial response is apprehension.
As a result, people fear revealing SUD to others because of its possible repercussions with work, childcare, or sense of self and personal well-being. Medical providers often avoid screening for SUD because there is a stigma about uncovering drug use, and they don’t feel they’re equipped to really do anything about it. Treatment is frequently delayed because options aren’t timely, convenient, or readily available. Many communities actively prevent treatment clinics from even opening, using discriminatory zoning practices to restrict medical use.
So before we can even get at treating SUD, we have to work through the structural violence and layers of stigma, fear, and shame barricading the front door.
The infrastructure for treating SUD has been largely separate from the rest of health care, and removed from ordinary life, which is itself a representation of the inherent stigma around SUD. What options have been available are notoriously steeped in daunting requirements like total abstinence in order to enter and continue treatment. Most treatment starts, unnecessarily, with “going to rehab.” You’re not viewed as healthy unless you completely give yourself up to addressing your drug use. You have to quit, or you’re kicked out.
Curbing dangerous use, and providing resources for safe use, are not viewed as positive health outcomes; they’re viewed as curtailing and acquiescing to hopeless defeat in an imaginary “war” requiring total eradication of the problem. And the results have been self-evident. Death tolls continue to rise. More individuals are living in poor health as a result of untreated SUD, and unsuccessful in finding treatment that works for them.
How destigmatized treatment options are beginning to change how people recover.
COVID-19, while perpetuating and exacerbating some of these problems, has forced healthcare infrastructure to come to grips with its own limitations, and rely on technology for essential needs of patients. As a result, public policy has shifted towards broad deregulation to increase access and utilize innovative tools to bring care to patients.
This has, whether intentionally or not, provided digital health and telemedicine companies with an incubator of sorts: proliferate private, convenient and personalized options for patients that avoid some of the contextual stigma that historical infrastructure is so challenged by. It has afforded some patients an opportunity to increase engagement with destigmatizing treaters, care coordination, resources, education, and socializing with people who use drugs and people in recovery. A number of treaters using telehealth as a primary modality for SUD care have been able to exhibit positive outcomes.
Due to increasing acknowledgement of the benefits of care at home from a cost and access standpoint, people who use drugs have never had more choices for accessing private treatment without fear of external judgment or repercussions. Companies are now successfully offering evidence-based medications for management of SUD and OUD at home through video conferencing in smart phone apps. Patients can chat with counselors and peer support after hours, in private, from anywhere. Engagement tools for self-guided care like cognitive behavioral therapy create more touch points without the requirement of hours at a clinic, and patients can completely avoid highly stigmatizing experiences like visiting labs and pharmacies in favor of at-home screening and shipped medications. Social media safe havens for people with SUD have become a fixture for shame-free communication.
Circumstance has cleared a new path for tackling SUD outside of the entrenched stigmatizing norms. Technology has promoted evidence-based approaches in novel, destigmatizing ways, to address a challenging chronic illness with the attention, and sensitivity, it requires. Traditional health infrastructure is beginning to take notice. Hospitals and health systems are adopting tools to promote coordination of care and education. On-demand services help to transition patients from settings regularly challenged by SUD, like the emergency department, into at-home virtual treatment programs. Prescribers are turning to tools that give patients some degree of autonomy and control over their care, while still supporting monitoring for safety.
COVID-19’s forced incubator for technology-enabled health services and treatment has shown how patients can recover, and what successful care looks like, without stigma. The question now is, how can we ensure that these new destigmatizing care options remain, and flourish?
It starts and ends with public policy and support. States, and various federal agencies, are working on new and existing regulations to account for digital health. A byproduct of easing COVID-19 restrictions could also be a return to restrictive policies that once again limit patients to stigmatizing care options. A growing number of bills are being presented that indicate some of the same apprehension, moralizing, criminalizing, and marginalizing that was endemic to pre-COVID health policies around drug use, and drug treatment. There are also growing fears of unscrupulous medical providers taking advantage of relaxed rules to commit fraud.
Applying the same outdated and unsuccessful methods of policymaking to destigmatized treatment options would be a mistake. Public policy, funding and support should follow the science, and listen to people in recovery, as well as those who use drugs. Evidence is showing that reducing barriers to medications for SUD, and human-centered at-home treatment for SUD, amongst other technology-driven treatment options, are resulting in better outcomes. Public policy must follow, giving people who use drugs a chance to seek treatment and recovery on their own terms, anywhere and at any time, without stigma.
Nicholas Mercadante, JD
Nick Mercadante is the Founder and CEO of PursueCare , a technology-enabled addiction treatment, and behavioral health services provider. PursueCare leverages ground-breaking low-bandwidth telehealth technology to provide treatment in rural and underserved communities. Their smartphone app provides direct access to comprehensive SUD and psychiatry services, while their pharmacy can ship medications directly to patient’s homes.
He previously served as President and COO of MedOptions, a national provider of behavioral health to long-term care residents. There, Nick led the development of a first-of-its-kind telehealth program to serve rural nursing facilities where traditional in-person staffing is challenging. He has worked as a practicing attorney in health risk and compliance, as well as working in healthcare technology and delivery models for DrugMax, Inc., a pharmacy and distribution company that was eventually acquired by Walgreens.