Raising the Bar for Addiction Care: A Conversation with a Leading Addiction Medicine Specialist

Hadley Fitzgerald, Center for Health Care Strategies
Sarah Wakeman, MD, Medical Director for Substance Use Disorder, Mass General Brigham

As the opioid and polysubstance overdose crisis continues in the U.S., health systems and providers are implementing innovative models to better meet the needs — and save lives — of people with substance use disorder (SUD). Unfortunately, few people with SUD receive the care or treatment they need. This means that people with SUD often come into contact with providers in acute care settings due to medical complications related to substance use, yet are too often seen by medical staff who lack the training to deliver the best possible care for these patients.

The Better Care Playbook recently spoke with Sarah Wakeman, MD, Medical Director for Substance Use Disorder at Mass General Brigham (MGB), to learn more about how quality addiction medicine programming can be implemented in general medicine settings, including primary care, inpatient, and emergency departments (ED). The conversation highlights the ever-present barriers that result from societal stigma for people with SUD and also the promising ways that health systems, payers, and policymakers can push to address SUD just as they do other treatable medical conditions.

Q: As Medical Director for SUD at MGB, can you describe the SUD initiatives, in terms of what services are provided, how they are delivered, and by whom?

A: Our SUD initiative, which launched at Mass General Hospital in 2014, stemmed from the voices of community members who were experiencing the pain and suffering of the opioid overdose crisis long before it was making national headlines. Seventy-five percent of local residents identified substance use as the number one most important issue on our community health needs assessment. At the same time, the hospital system was becoming an accountable care organization and thinking about population health and value-based care. We used this opportunity to learn about innovations in addiction care to redesign our approach to make treatment for SUD available, accessible, and welcoming at any touch point along the health care continuum.

Too often, people with SUD are blamed for frequent re-admissions and longer stays, but patching up an acute consequence of SUD is not the same as addressing the underlying condition of SUD.

In the inpatient setting, we started an inpatient addiction consult team. If someone comes in after an overdose, they should be seeing an addiction specialist — they shouldn’t just be acutely stabilized and discharged. This is the same approach you’d want if you had a family member or loved one who had a heart attack, and then was connected to a cardiologist.

We expanded integrated primary care by creating teams of addiction champions. These teams include physicians and nurses who are able to prescribe medications for SUD, as well as mental health professionals when needed. There are also certified recovery coaches who are in long-term recovery themselves and can provide support through shared lived experience and address any structural barriers to care.

We also started a bridge clinic, which is designed to drop barriers to SUD treatment and provide immediate access and walk-in services for people in the ED, inpatient setting, or community. More recently we created an ED-based addiction care team, a perinatal clinic for people with SUD, and several SUD-focused training/fellowship programs.

Q. Can you share some of the impacts of these initiatives on patients?

A: We found that patients seen by the inpatient addiction consult team have a reduced addiction severity index after discharge both for alcohol and drug use and a decreased number of days of use. Patients with opioid use disorder seen by the addiction consult team are more likely to start medication treatment in the hospital, and they also have a reduced 30-day readmission rate. These data paint a picture of value and how these initial touch points can lead to long-term care. For example, when patients are initiated on buprenorphine by the inpatient consult team, they continue treatment for many months.

In the primary care space, we found that the integrated primary care model led to a decreased number of ED visits and a reduced number of inpatient hospital days. With our bridge clinic, we found that patients have a reduced number of ED visits. We also found that after an initial visit, 70 percent of patients will actually re-engage in the bridge clinic and come back for two or more visits. This suggests that the model is providing care that people can stay connected to.

Q: We understand — from some of your research — that there are gaps in medical education for addiction care, which can influence providers’ attitudes and preparedness in treating SUD. How do these types of initiatives influence how hospital staff view SUD treatment and people with SUD?

A: We studied hospital and primary care doctors before and after the launch of the SUD initiative, and found that physicians with a patient who received services from one of our clinical service lines had improvements in their attitudes, their sense of preparedness, and their willingness to offer treatment to patients themselves.

We found that the recipe for success is a combination of things. First, you need health system leadership to prioritize addressing SUD as a medical issue. Historically SUD has not been a major concern for academic medical centers, so having the CMO or CEO of the health system sending the message that they value SUD treatment goes a long way.

You also need the staff to feel like they have the resources and support — for both the patient and provider. For example, a primary care doctor can submit a clinical question for the addiction care team and receive a response within 24 hours. Or a patient referred by an ED doctor to the bridge clinic can walk-in and be seen within a day, which is different than the traditional model of calling for an appointment for weeks later or getting on a waitlist.

Finally, addressing stigma around substance use is critical, such as staff trainings that target stigma. In this country, substance use is criminalized and people with SUD are punished in many ways. Hiring recovery coaches to be part of the care team can be a powerful component in addressing stigma and changing the organizational culture around SUD.

Q: What are the larger implications for the field — including other providers, payers, and policymakers — based on initiatives like the ones you’ve implemented and studied?

A: Health systems and providers should treat SUD as any other health condition — like heart disease or diabetes — where we have a standardized, evidence-based approach to providing care for patients with clear quality measures. If we are not providing this care, then we are denying effective treatment to patients who need it. The same way that we drive quality care for other health conditions — including developing standards and guidelines, incentivizing quality improvements, shared risk contracting, etc. — should be applied to SUD.

SUD should be treated as any other health condition — like heart disease or diabetes — where we have a standardized, evidence-based approach to providing care for patients with clear quality measures.

We need to make medications for addiction treatment easier to access. It’s huge news that the latest Omnibus bill eliminates the X-waiver requirement (for buprenorphine), but the system for accessing methadone remains very outdated and difficult. These are life-saving medications, and for opioid use disorder have been shown not only to reduce mortality but also improve remission rates.

We also need to develop a trained workforce with funding for fellowship programs and a stronger SUD medical school curriculum for students and residents. Payers should reimburse for these services, with parity around this reimbursement, including for addiction specialists.

Q: You’ve written on the significance of language when it comes to SUD, including the importance of using the phrase “medications for addiction treatment” vs. “medication-assisted treatment.” Can you tell us why language matters when it comes to how the field discusses SUD?

A: Language is incredibly powerful, and it influences how we all think, whether we realize it or not. People might think this is about political correctness or semantics, but it's really not. Studies show that even highly trained clinicians will recommend more punishing treatment when they're given a vignette of a patient who is described with stigmatizing language.

Studies show that even highly trained clinicians will recommend more punishing treatment when they're given a vignette of a patient who is described with stigmatizing language.

People are people. They may have a health condition, but it doesn't define them. For example, the term “abuse,” which means a willful act of misconduct, is still common in the names of many federal agencies. It should be gotten rid of altogether. As well as any term that labels someone as their condition, like “alcoholic” or “addict.” We don't label other people this way with other health conditions. Another problematic term includes the notion of “clean.”

Finally, there are biases embedded in terms like “medication assisted treatment,” which can seem subtle, yet have very real and deadly consequences. The intense stigma against medication as a treatment for addiction is enshrined in our laws and regulations that make it so hard for doctors to be able to offer these life-saving medications for SUD. Even many recovery communities are still not fully accepting of medication treatment and there are a number of legal cases about how people are discriminated against because of their medication treatment, such as being denied employment, housing, and nursing home care. The idea that medication is assisting treatment really implies that medication is not in-and-of itself treatment. If people want to keep the acronym “MAT,” then just get rid of the word “assisted” and have it mean “medications for addiction treatment.” A good gut-check is to ask if it sounds weird to use this language in talking about a patient with diabetes or heart disease or cancer. It should sound like we would talk about any other health condition.