Baker is president of the Massachusetts Society of Addiction Medicine and an assistant professor of medicine.
Over many years, I have resuscitated countless numbers of patients dying from a drug overdose while working as an emergency physician. I knew I had to stop everything else I was doing and treat the overdose patient immediately because they could die within minutes. We had to clear a resuscitation room and start ventilation on arrival, get an IV into their scarred veins, and quickly inject naloxone (Narcan). They usually started breathing again and woke up confused and angry, suddenly in acute withdrawal, writhing in pain, vomiting, and moaning in agony. Most ripped out their IVs and looked for an exit. If they had to fight their way out, they did. Nobody said, “Thank you.”
For years, I was angry and didn’t try to stop them from heading back to the street. Eventually, I was able to put my emotions aside and focus on the rest of the patients I had to see. I never thought about why overdose patients acted that way. Even as faculty at Johns Hopkins and Harvard, I knew nothing about the treatment of addiction because I was never trained — not for a single hour — that substance use disorder (SUD) is a treatable disease.
I didn’t learn that until after my youngest child, Macky, died from an opioid overdose.
Understanding Should Be First
I eventually came to understand that addiction is a disease, not a choice or moral failing. Before I learned that, I thought that punishment was the solution, and I believed the myths that people with addiction needed to “hit rock bottom” or only deserved “tough love.”
Late in Macky’s journey, I realized that he responded to understanding, compassion, and love, but it was difficult for me to maintain that self-control in the face of his SUD and the behaviors that accompany continued use. He ultimately found recovery with emotional support from our family, professional counseling, and the right medication. He was rebuilding his life — he was in school and working. But then he needed surgery after a car accident. Macky was injected with fentanyl before the operation and 26 days later, he was dead from an overdose.
Stigma Remains the Biggest Challenge in Healthcare
Just days before Macky died, he told me that stigma was the biggest barrier he faced when trying to recover. He felt the sting of rejection and scorn from the community and from healthcare providers who believed that his addiction was his own fault and refused to help him. He knew that many physicians feel that “addiction is a crime that deserves punishment, not a disease that needs treatment.”
I now ask myself, can we change that attitude? Can we imagine the patient in front of us as one of our own family members and offer empathy and acceptance, and honor our duty to treat? If the clinical situation is challenging or unfamiliar, shouldn’t we reach out to an expert for support? These were questions Macky asked, too.
It is now a fallacy to believe, “I’m doing my part to end addiction. I don’t prescribe opioids!” We are in the era of illicit fentanyl and that is what is killing our family members, not prescription medications. Overprescribing is a dark part of our past, but the problem now is fentanyl — cheap, easily available, and a ubiquitous adulterant in street drugs. We know how to treat pain responsibly and we need to know that even when legitimate prescribing of opioids decreases, overdose deaths increase because people in pain often turn to the street for relief, where they unknowingly find counterfeit pills filled with fentanyl.
We must also recognize that the vast majority of people with SUD in the U.S. can’t find effective treatment. But it is our responsibility to put aside judgment and offer appropriate treatment to the best of our ability.
What Can You Do to Help Treat Substance Use Disorder?
First, be prepared. Most people who die from an overdose have seen a healthcare provider in the year before their death. How grateful would you feel if someone in your family needed help for SUD and a clinician offered to help them recover instead of turning them away?
With empathy and understanding, ask your patient if anyone in their family has an issue with substance use.Learn how you can treat SUD by becoming a prescriber of SUD medications and hear from a physician on how she addressed her own fear of treating opioid use disorder.Learn about treatment options in your region and access resources on evidence-based care to treat SUD.Identify addiction specialists you can partner with to guide you through the initial steps of treatment, follow-up care, and when specialist referral is necessary (e.g., via organizations like the Massachusetts Consultation Service for Treatment of Addiction and Pain, the American Society of Addiction Medicine, and the Substance Abuse and Mental Health Services Administration).Recognize that “referral to treatment” is not enough when that referral is merely providing a telephone number or name of a service; a “warm hand-off” is needed, and those relationships need to be cultivated.
Prescription pills didn’t kill my son — street drugs did. Our patients and families will not be protected from death by drug poisoning if all we do is turn our patients away when they have severe or unremitting pain. This will often lead them to find an alternative from a friend, online, at school, or from the street. They just won’t know that what they have found is fentanyl.
Most people with substance use disorder cannot access effective treatment, but we can change that. We know what works and we have the responsibility to help however we can.
It’s time for all of us in healthcare to step forward, let go of our animosity toward people with addiction, and face our own fears about how to treat SUD. Most people can be treated right from the doctor’s office, with medications that are safe and effective. The only “treatment bed” the patient may need is the safe, loving one in their own bedroom.
James Baker, MD, MPH, is president of the Massachusetts Society of Addiction Medicine, physician expert for the Massachusetts Consultation Service for the Treatment of Addiction and Pain, associate medical director of Merrimack Valley Hospice, and assistant professor of medicine at Tufts University School of Medicine.
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