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Noah Nesin, who was a family doctor in Lincoln and Mattawamkeag for 30 years, is innovation advisor at Penobscot Community Health Care, where he recently retired as chief medical officer.
A few years ago, I had the opportunity to provide urgent care to a person who had developed an opioid use disorder. This person was a professional, had built a successful business with their spouse, lived in a beautiful home and had a family. But they and their partner had each developed a use disorder and, as a result, had lost their business and their cars and were on the verge of losing their home. Obviously these folks also feared losing their children.
The partner for whom I provided care was trying to withdraw from opioids “cold turkey,” which is an excruciating physical and emotional experience, and has a much lower chance of short- or long-term success than medical treatment for this disease. When I suggested that they consider medication for opioid use disorder, the response I heard was distressingly familiar. They lived in a small town where no treatment was available. They were ashamed of their disease. They were concerned about becoming isolated from clients, family and friends, and they had no way to arrange transportation for the care that might be available an hour or so from home.
I do not know how things turned out for this family, and I think about them often.
This National Recovery Month — and every month, to be honest – I think about the unaddressed issues that put people at risk for substance misuse, like underlying emotional trauma (for example, the loss or absence of a parent, or being the victim of or witnessing physical, sexual or emotional abuse) and unaddressed mental illness, including depression. I think about the social and medical devastation caused by the most commonly misused substance – alcohol.
I think about the very real practical barriers to all kinds of care that are common in rural areas – transportation issues, cost of care, and access to care. Specifically, we do not have enough mental health professionals in Maine to meet the needs of our communities and many communities have no local mental health care available at all. I think about generational poverty and lack of opportunity. And I think of the housing crisis in our state,as having a home becomes unaffordable for more and more Maine people.
But most of all I think about stigma. The stigma associated with the diagnosis of a use disorder, the profound shame that is engendered as a result, and how often that is the biggest barrier to effective treatment. That shame very often prevents people from seeking care, or, if they seek care, from initiating medication for addiction treatment, and staying on it long enough to truly benefit. And that stigma, in my opinion, is the reason that treatment for opioid use disorder is not available in every healthcare setting, including all primary care and mental health practices, hospitals, emergency departments and long term care facilities.
Stigma suffuses the language we use as a society, like “addict” and “junkie,” which serve to dehumanize people who suffer with these diseases, or “clean or dirty urine drug screens,” which harmfully oversimplify and apply snap judgment to the very complex course of recovery that most people face.
Stigma also leads to the dichotomy of abstinence versus harm reduction (in other words, cold turkey versus medication) that is so often the framework of discussion of treatment models. We do not apply this false choice with any other chronic disease. Instead we work to meet people where they are, try to understand their values and goals, and then work with them for continuous improvement in their condition.
With the resources that are now available to our local and state government, we have an opportunity to address some of the structural issues described here, and there are wonderful local groups in the Bangor area and around the state working on those problems. But addressing the stigma associated with addiction costs nothing. It simply requires that we stop and think about our biases and what might underlie them, that we explicitly acknowledge the humanity of every other person and recognize their potential, nor matter how much they are suffering with this devastating disease, and that we compassionately confront stigma when we see and hear it, whether it is in a headline, espoused by a policy maker or uttered by a friend. By doing that simple but hard thing, each of us can help people like my patient get treatment, stabilize their disease and return to their true selves.