Resolving America’s opioid crisis is clearly more difficult than just saying “no” to opioid use.
A key complication is that many opioid addicts also have mental health issues, said Mark McGovern, PhD, a professor of psychiatry and behavioral sciences who joined Stanford in January. McGovern’s research focuses on patients with both psychiatric and addiction disorders. I connected with him via email.
What inspired you to focus on patients with both psychiatric and substance use disorders?
In my personal experience and clinical practice, it seemed obvious that many people who had a problem with alcohol or drugs also had a mental health issue, whether it was depression, anxiety or something else. When I entered the world of research, the epidemiological and clinical prevalence data verified my anecdotal experience. About 70 percent of patients with a diagnosis of a drug or alcohol disorder have another psychiatric disorder. And of those with a psychiatric disorder, approximately 50 percent have had a substance use problem at some point. Ironically, our mental health care system, including our education and training programs, are organized as if people have one or the other problem but not both. It turns out that if a person has both types of disorders, their life outcomes are significantly worse. This struck me as an enormous health care disparity.
How do you treat these patients?
I spent the past 20 years designing interventions that address these ‘co-occurring disorders’ within the same treatment course. We worked with systems of care — including large organizations, counties, states, tribes and nations — to reconfigure services to provide integrated care. These efforts included the use of both psychotropic and addiction medications, integrated combined therapies, and changes in attitude, philosophy, organizational structure and financing.
We need to address these behavioral health issues in both primary care and specialty settings. Common problems such as depression, anxiety, alcohol and drug use disorders are ubiquitous in primary care settings. As with any medical condition, early intervention before disease progression results in better outcomes. Further, most people with these conditions don't seek specialty care, but typically do see their doctor for other problems or routine health care visits. Unfortunately, substance use disorders typically aren’t screened for in primary care, and they are currently addressed in only the most obvious and severe cases. People at Stanford are just beginning to develop an innovative model of behavioral health integration that addresses the complex array of these conditions.
How do you use addiction medications?
Before I arrived at Stanford, I was at Dartmouth where I consulted with the states of northern New England — Vermont, New Hampshire and Maine — to combat the opioid addiction epidemic, including heroin and prescription narcotics. There are three FDA-approved medications for opioid addiction: methadone, buprenorphine and naltrexone. Unfortunately, even though they are very effective, these medicines are not widely available to people with opioid addiction. We worked most closely with physician practice groups across Vermont to prescribe buprenorphine and naltrexone and deliver high quality care. For example, we used learning collaboratives to engage physicians, improve access to buprenorphine and reduce the differences between different doctors. Overdose death rates in all New England states except Vermont have continued to rise, whereas Vermont’s has decreased since 2015. And the number of Vermonters receiving addiction medications has grown from 800 in 2013 to close to 5000 today.
I remember meeting my patient Bobby (a pseudonym) who was a general contractor with a successful business. He injured his back in 2004 and was prescribed Percocet for pain by his primary care physician. Gradually, he noticed that he needed more medication to get the same pain relief, emotional relief and stress reduction. Over time, Bobby shuffled from doctor to doctor to obtain opioid prescriptions allegedly for his family members. He transitioned to heroin by 2006. Prior to his opioid addiction, he had no history of illegal activities and no substance problem. Bobby’s wife did some online research and learned about addiction medications. They were both drawn to the possibility of buprenorphine, because he might be able to get it from a ‘regular doctor’ without going to rehab and ruining his business. Bobby was seen in our clinic and responded extremely well to the medication, and discontinued his use of other opioids. Interestingly, he said that he still had occasional pain but it was more important to be functional than pain free.
What advice do you give to trainees?
When educating medical students, psychiatric residents and fellows and clinical psychology interns at Stanford, I advise them to:
- Understand addiction as a chronic medical condition that has its basis in the brain, even though its manifestations radiate across the person’s life, relationships and world.
- Empathize with the person who is suffering with this condition, who may not be able to accept or describe it clearly, but who is nonetheless struggling to control it. It’s not their choice; it is not their ‘Plan A’ in life.
- Know that effective treatments are available, and that you can provide them.
- Have high hopes that recovery is possible for patients with addiction.
Previously: The opioid crisis: Medicine X panelists explore the complexity of managing chronic pain, Is pain in the brain? A pain psychologist discusses alternative to opioids and Repeal of ACA would worsen opioid epidemic, Stanford researcher says
Photo by Eric Norris