Published: 11/8/2022 11:40 AM
By Jennifer Brown
As the opioid epidemic has continued to rage on, many strides have been made in the effort to preserve life and facilitate recovery. Part of that effort has been expanded access to FDA-approved medications to treat opioid use disorder, such as buprenorphine, methadone, and naltrexone, commonly referred to as MAT: Medication-Assisted Treatment. According to SAMHSA, MAT is “the use of medications, in combination with counseling and behavioral therapies to provide a ‘whole-patient’ approach to the treatment of substance use disorders. MAT has proved to be clinically effective and to significantly reduce the need for inpatient detoxification services.” (SAMHSA, 2022)
In spite of its effectiveness, Dr. Nora Volkow, Director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health, estimates that “only 11 percent of people with opioid use disorder receive one of the three safe and effective medications that could help them quit and stay in recovery.” (Volkow, 2022)
This is particularly impactful for justice-involved individuals. “People who have been incarcerated are approximately 100 times more likely to die by overdose in the first two weeks after their release than the general public. Despite high rates of opioid use disorder among justice-involved individuals, evidence-based medications exist and can be successfully implemented within jails and prisons.” (National Council for Mental Wellbeing, 2022) Detox during incarceration lowers the tolerance for the drug, and sudden use upon release can prove deadly.
While the number of correctional facilities nationwide offering MAT has continued to increase, not all programs have been robust or inclusive. Some facilities provide only some of the approved medications, provide them only for folks who are a certain number of months from release, and/or determine eligibility based on the type and severity of crime. While better than nothing, all are problematic, and in some cases unconstitutional. (ACLU, 2021)
If it’s clear that the use of MAT in jails and prisons could prevent much suffering, reduce recidivism and increase recovery, why is MAT not more widely utilized?
Danger of Stigma
In our last two decades of stigma reduction work, the Anti-Stigma Project consistently heard that stigma hurts, punishes, and diminishes people. Many folks have told us that dealing with the stigma is often harder than dealing with the condition itself, reducing help-seeking behaviors and credibility, damaging opportunities and relationships, and diminishing the provision, choice, and quality of services.
While we know that stigma impacts help-seeking behavior, sometimes the help is simply not available, as with many who become incarcerated. Whether they were already utilizing MAT or wanting to start, in many facilities they may have no choice but to be forced into sudden withdrawal–something that is often agonizing and sometimes fatal. According to a 2021 report issued by the ACLU, “Leaving OUD untreated for days, months, or even years leaves the person at a much higher risk of overdose, death, and brutal withdrawal symptoms while still incarcerated … [and] much more likely to seek out illicit opiates if their OUD is not treated with MAT. An effective MAT program is not only about maximizing the chance of survival upon reentry, but also survival while incarcerated.” (ACLU, 2021)
Role of Misinformation
In our recent work interviewing peers in Maryland about their experiences with stigma and OUD, and in particular the use of MAT, they’ve shared experiences of widespread stigma from many directions. One common source is misinformation about the protocol itself–folks who mistakenly believe that MAT simply substitutes one drug for another. Those beliefs are not just exhibited by family or friends who are not part of the behavioral health community. Interviews with 47 addiction-treatment professionals summarized in the journal Social Science & Medicine suggest that physicians who provide MAT may be subjected to stigma themselves, not only from nonphysician counselors in abstinence-based programs, but also from other physicians with outdated knowledge or different attitudes around MAT. (D’Arrigo, 2019)
Competing Recovery Pathways
Stigmatizing attitudes and behaviors also came from peers and providers with a history of SUD whose recovery journeys were firmly rooted in abstinence, and whose personal experiences shaped the lens through which they see recovery and how it “should” apply to those they support.
Edwin A. Salsitz, M.D., an addiction medicine specialist at the Addiction Institute of Mount Sinai in New York, says that he sees it from both counselors and members of abstinence-based recovery groups. “They say you’re not in recovery, which is hurtful to people who are doing well on medication treatment. Many of these patients like to be part of a group, and they don’t want to lie and not [reveal that] they take medications.” (D’Arrigo, 2019) Adds APA President Bruce Schwartz, M.D.,“The staff who work in those programs have usually attained abstinence without the use of medication treatment, so there’s an antipathy against it. Their attitude is that ‘This is the way I did it, so this is the way it should work for everybody.’ ” (D’Arrigo, 2019)
The Role of Experience
Stigmatizing beliefs come from multiple sources, but in our work, perhaps none are more difficult to counter than the ones based on personal experiences. If someone routinely interacts with people with behavioral health challenges when they are in crisis situations, such as in emergency rooms or during encounters involving law enforcement, does their view of folks with behavioral health challenges also include people thriving and doing well?
According to Dr. Salsitz, “Such attitudes may take hold in medical training, where MAT is often passed over on rounds and medical students are not exposed to success stories involving patients who use MAT, said Salsitz. “For many medical students, a large part of their education takes place in large urban hospitals, where the methadone patients are admitted if they’re not doing well. If that’s all you see, that’s what you expect.” (D’Arrigo, 2019)
Multiple studies of law enforcement and medical professionals show varying degrees of negativity toward the use of MAT, which researchers propose is linked to their constant exposure to people who are not doing well.
Stigma in Policies and Practices
Stigma can manifest itself not just as beliefs and interactions, but also in policies and environments that can either reduce or exacerbate stigma. One of the frustrations voiced by providers as well as peers involves the way in which medications are dispensed in MAT programs without enough privacy or confidentiality. Logistics become even more complicated in correctional settings, which are subject to heightened security measures for storing medications, and the potential for MAT medications to be secretly and unsafely shared with others in the facility.
When Maine’s Department of Corrections implemented the use of MAT in their facilities, they purposely dispensed MAT using the same process as for other medications. According to Deputy Commissioner Ryan Thornell, “A medline is a medline, if we don’t want to stigmatize people for prioritizing their treatment, why would we single them out by having them in a separate medline?” (Black, 2021)
A Multi-Pronged Approach
Maine prepared for their rollout of MAT through extensive training to 500 staff members, including both global information about the science of addiction as well as the specifics of MAT. Importantly, they also spent significant amounts of time in discussion with multiple stakeholders, including their residents, in order to uncover their true concerns and attitudes toward the rollout. According to Deputy Commissioner Ryan Thornell, “What we recognized through the conversations with residents, staff and other states was that we needed to address attitudes, fears and reservations.” (Black, 2021) It didn’t happen overnight, but MAT is now available in Maine in local jails as well as state and federal prisons. (ACLU, 2021)
According to Commissioner Randall A. Liberty, “We’ve seen an increase in staff opening up about their struggles, seeking the staff-oriented peer support network, expressing their feelings about situations more in the last couple years. Creating a culture of wellness doesn’t start and stop with our residents, this cuts across the entire system.” Liberty himself opened up about his own behavioral health struggles to both staff and residents. (Black, 2021)
Our two decades of work with the Anti-Stigma Project has echoed the importance of that kind of frank discussion. Education is important but has limitations: learning about MAT’s effectiveness doesn’t ensure that the underlying beliefs about MAT, or the people who utilize it or provide it, will shift. We have found that kind of change requires both a cerebral and visceral approach, and a clear understanding that education is always reciprocal. Yes, people learn about others, but they also learn about themselves.
Maryland Steps Forward
Here in Maryland, we have much to be proud of, including being the first state to mandate the provision of MAT to individuals being held in local detention centers. 2019’s House Bill 116 requires that, by January 2023, local correctional facilities must make all three FDA-approved medications for opioid use disorder (MOUD) options available to any individual in need, and this must take place within 24 hours of their incarceration.
Will stigma reduction in those settings help to ensure continued progress? Current research is asking thoughtful questions, and we look forward to being part of the continued work in Maryland to create a more responsive, effective and respectful behavioral health system and the systems directly connected to it.
References
ACLU. (2021, June 30). Report: Over-jailed and un-treated. American Civil Liberties Union. Retrieved October 17, 2022, from https://www.aclu.org/report/report-over-jailed-and-un-treated
Black, A. (2021, August 17). Maine’s Department of Corrections on what it takes to implement Mat Services. Corrections1. Retrieved October 17, 2022, from https://www.corrections1.com/correctional-healthcare/articles/maines-department-of-corrections-on-what-it-takes-to-implement-mat-services-bCjcwIwWuyB8JplW/
D’Arrigo, T. (2019). Stigma, misunderstanding among the barriers to mat treatment. Psychiatric News, 54(19). https://doi.org/10.1176/appi.pn.2019.10a2
Medication-assisted treatment (MAT). SAMHSA. (n.d.). Retrieved October 17, 2022, from https://www.samhsa.gov/medication-assisted-treatment
Medication-Assisted Treatment (MAT) for Opioid Use Disorder in Jails and Prisons: A Planning and Implementation Toolkit. (2022, February 4). National Council for Mental Wellbeing. Retrieved October 19, 2022, from https://www.thenationalcouncil.org/resources/medication-assisted-treatment-mat-for-opioid-use-disorder-in-jails-and-prisons-a-planning-and-implementation-toolkit/
Volkow, N. D. (2022). Making addiction treatment more realistic and pragmatic: The perfect should not be the enemy of the good. Health Affairs Forefront. https://doi.org/10.1377/forefront.20211221.691862