Beyond Binary: Rethinking Opioid Crisis Solutions
In shifting the opioid crisis conversation toward solutions, one recurrent obstacle is our binary way of thinking. Healthcare policy, like media coverage, favors “either/or” categorization of all problems and solutions. We love stories with clear heroes and villains. (If you doubt this, follow the coverage of Purdue Pharma, Insys, or other drugmakers these days.) It makes sense that our media is sometimes forced to simplify stories in this way. After all, when things get more complex, viewers tune out. What has been disheartening to me is waking up to the reality that our policy discourse falls into the same trap. This binary approach in actively unhelpful in shaping the discussion of addiction, recovery, and wellness.
The recent history of opioid prescribing is marked by vacillations. As I detail in The United States of Opioids, in the late 1800s, the standard of care for doctors prescribing opioids extended to preventing addicted patients to avoid withdrawal. By the 1920s, the Federal Bureau of Narcotics was arresting doctors by the hundreds for this practice. As the memory of this crackdown faded, the “pain as the vital sign” movement gained steam in the early 2000s. I found myself defending doctors who were being prosecuted by state medical boards for undertreating pain. The pain doctors I advise these days are so afraid of DEA and medical board response that they would rather turn away patients in pain than prescribe more than minuscule doses of opioids.
These swings from one polarity to the other – and back again – have been brutal for patients and providers alike. People in chronic pain are living in misery. In the worst cases, untreated pain is driving an increase in suicides. Rather than contributing to solving the opioid crisis, the binary approach has added another dimension to the crisis. Not only are overdose and substance use disorder rates rising but now doctors cannot treat pain effectively and people in pain cannot get the medications they need. The same dynamic predominates discussions of cannabis and psychedelics. They are the bogeyman to some, and a silver bullet to others. Part of the solution to the crisis is finding a middle ground where doctors can treat pain without fear and people who need medications can actually get them.
Biomedical and Socioemotional Models of Addiction
Of late, I have been struck by the extent to which binary thinking is obstructing the pursuit of more effective addiction treatment. Is addiction a biomedical condition? Or is it primarily socioemotional? For policymakers these days, the conversation is strictly biomedical: addiction, in this view, is no different than heart disease or diabetes, a chronic condition to be managed through ongoing medication. In some corners of the addiction treatment field, the conversation is strictly socioemotional: the path out of addiction is counseling, psychosocial support from a peer community, and a spiritual path.
The bifurcation gets in the way. Several months ago, I was meeting with a senior policymaker in a key government agency dealing with opioid addiction, listening to why medication-assisted treatment (MAT), i.e. Suboxone, is the only solution to the crisis that is actually backed up by the data (number of overdoses). When I asked about funding for counseling and social model recovery, the answer was “social model (e.g. 12-step) is nice, but where’s the data to prove that it works?” A few weeks later, I was at a conference explaining the implications of new laws prohibiting addiction treatment providers from turning away patients on Suboxone. The room was full of dedicated providers, many veterans of the recovery journey. The frustration over new anti-MAT discrimination laws was palpable. “Why,” one person asked me, “are insurance companies and government shoving an opioid substitute down our throats?”
As a lawyer navigating through clinical, regulatory, and reimbursement challenges in addiction treatment, the answer should be obvious: addiction simultaneously has biomedical and socioemotional features. Our genes and neurobiology put us at risk for substance use disorders, as do socioemotional factors like family history, and childhood trauma. Why do we have to choose? it seems the answer is that, in an environment of scarce funding, the two models of care are forced into a nonsensical competition. I frequently meet people who share stories of their children who would not be alive but for MAT. I have many friends who swear they are only alive because they went through the hard work of recovery because they found both a community and a spiritual path. We need to find a model of care that makes room for and provides access to both approaches.
Wellness and Eliminating Shame
In thinking through solutions to the opioid crisis, a recurrent issue that comes up is the way that shame and stigma keep people needing help—in prevention before, and intervention after addiction or mental health challenges arise—from reaching out. In looking for ways to normalize the challenges that lead to substance use and mental health issues, one critical item is to reframe wellness away from the binary model. In going around the country talking about addiction, I constantly get asked, “Are you in recovery?” People are quick to label themselves as being well. Addiction and mental health are problems that we talk about through other people in our lives like family, friends, neighbors, and co-workers. The underlying assumption is binary; “I am fine,” we reflexively answer when asked. My daughter is addicted. Listen to conversations and the recurring message is the same: I don’t have a problem. My friend has an anxiety disorder.
Part of the solution to the problem forces us to get rid of this binary way of thinking. We are all broken, just in different ways. Acknowledging our brokenness is what creates the space to make it safe for us to talk to each other. As I travel the country talking about The United States of Opioids, I have begun to make a point of sharing my connection to recovery and addiction. I talk about my daily work—social connection, prayer, exercise—to address my own mental health issues. I have found that being vulnerable about my own brokenness is an important way to change the conversation. Addictive behavior and mental health challenges occur on a continuum. We need to stop treating them as binary states of being addicted or not, of being mentally ill or well. By acknowledging that we are all dealing with these challenges in various forms, with different degrees of severity at different times for different people, with different coping mechanisms, we reduce and hopefully eliminate the shame for everyone. We can begin to move toward rethinking wellness as encompassing dimensions beyond smoking and weight. We must begin including our needs for human connection, spiritual meaning, and financial security. In the process, we expand the conversation and increase the chances of people who need resources are able to get them in a timely and effective way.
My goal in The United States of Opioids was two-fold: first, to think through the numerous points of system failure beyond bad behavior by drug companies. Second, to call attention to the deep social crisis beneath the surface. The first step in rethinking the crisis with more complexity is to pay attention to the countless ways that binary modes of thinking predominate and confine the conversation. I hope you will join me in moving beyond a binary mindset.
Harry Nelson is the founder of Nelson Hardiman, the largest healthcare/life sciences law firm in Los Angeles, and author of The United States of Opioids: A Prescription for Liberating a Nation in Pain (2019)