On the Frontlines of the Opioid Crisis: A Doctor's Experience

In an episode of Pew's "After the Fact" podcast entitled "Treating the Opioid Epidemic," Dr. Shawn Ryan, chief medical officer at BrightView, an outpatient addiction medicine practice based in Cincinnati, spoke about his work and issues surrounding treatment of opioid use disorder. This Q&A is drawn from his full interview. Dr. Ryan reflects on the challenges—and the promise—of treating patients suffering from opioid use disorder.

Q: Once you get someone past the critical phase of an overdose, how hard is it to get them into treatment?

A: Right now, we don't have a lot of answers. There is not a good linkage to treatment at this time in many emergency departments across the United States. … There are wait times throughout the entire country for any appropriate treatment for opioid use disorder.

You might be able to get into a treatment program, see a board-certified addiction specialist, a competent licensed therapist, and a social or case management support person and get the whole biopsychosocial intervention. Or you might end up camping in Utah.

We need to work very hard in the medical system to get standardized treatment so people know what they're getting when they go to get it. 

Q: When you get a patient into your office, what do you tell them about the road they have ahead?

A: When we're talking to them, we have got to give them the real story, which is: This is going to be some work, this is a fairly long journey. It's the same discussion you have with anybody with another complex chronic illness, [such as] cancer or diabetes. You can't—or shouldn't—sit them down for a minute and a half and say, "As long as you take these medications, you'll be perfectly fine," because that's not accurate.

We spend some time laying out the timeline because it's important for them to be engaged. You want to make sure that they stay vigilant because relapse is a very challenging part of this chronic, relapsing disease.  

Q: How does medication-assisted treatment work?

A: Currently, there are three FDA-approved medications: methadone, buprenorphine, and long-acting naltrexone. They are all very good medications and substantially increase the success of a patient being sober and getting to recovery. Medication-assisted treatment is the best [approach] for patients with opioid use disorder.

As physicians, we sit down with the patient, do a history, physical, and then we present them with options and talk about the risks and benefits. We also deal with friends, family, and law enforcement professionals who may not understand the medications. There's a lot of stigma around methadone, for example. I always go back to the science and look at the results of studies. Thousands and thousands and thousands of patients across many decades have done very well on medication-assisted treatment, and it is our first and foremost recommendation.

Q: It's not just a matter of giving folks these medications. Is there behavioral therapy as well?

A: That is correct. Patients come to us with all manner of disease severity. They may have just started to slip down the slope of substance use disorder and are using too many Percocet [pills] that they're buying off a friend, or they may come in distraught and homeless. By and large, almost every one of our patients has some need for psychosocial intervention and some need for further support. If you're in the area of the country where those sorts of other interventions are not available, then we should still advocate for medication use alone. It does by itself reduce mortality.

Q: Opioid use disorder brings with it a social stigma. What do patients tell you about that?

A: This is probably one of the most challenging topics, not only for our patients but also for the public. More problematically, this stigma pervades professional treatment. It's throughout the entire society and obstructs people getting into treatment because they're afraid of the stigma.

By and large, when [patients] go to primary care physicians, especially years ago when we started our program, they would be dismissed, the staff would be rude to them, and the physicians themselves would be rude to them. You can imagine if you're a patient trying to get treatment and you haven't used drugs in weeks or months and your life is starting to turn around, and you go see a medical professional who you think is supposed to be the one individual who will be accepting, and then they abuse you in that way. It's very distressing.

Q: In addition to the stigma, what are some of the other challenges these patients face?

A: I think one is that people believe an individual can just stop using opioids, that they can just bite on a rag, go into a dark room, and just bear it and get through it. We know through the scientific studies of animals, as well as our experience with humans for decades in attempts to get people to stop using opioids, that that does not work. People need to understand that this drug really has what I would describe as the most profound grip on people that I can ever imagine.

Q: Do you sense that your colleagues in the medical community are starting to change?

A: I do. I've said the same message for about four years straight, and after much repetition, I've gotten through to many professionals. …. People have opened their eyes, and they've realized that it is their relative, it is their child, and they'll say, "Please help me; I've got to fix this for my kid."

Q: If you could wave a magic wand and ask for two or three changes, what do you think would make a real dent in this problem?

A: First and foremost would be harm reduction. We need to focus on that. I'd ship millions of doses of [opioid overdose reversal drug] naloxone all over the country. Second would be to make treatment—and I mean evidence-based, certified treatment—available to people right when they want it. When you look at the statistics, 1 out of 10 people [in need of care] get treatment for a substance use disorder, but that doesn't mean you get medication-assisted treatment; that means they get some treatment.

But we know that as many as 3 out of 10 [of these] people are actively seeking treatment, so we already have 200 percent more people actively seeking it and would probably have many more if it wasn't so stigmatized. And so immediate access to evidence-based, certified treatment would be my second magic wand.

We have a medical system that basically forces most primary care physicians to see their patients in about six to eight minutes. I am here to tell you that is not enough time to deal with the complex psychosocial and management of pain issues with anything other than a prescription for opioids. We have got to reorient our medical system and the primary care networks and support those physicians who are doing yeoman's work and give them the time to talk to their patients about these complex issues.