Mar 4, 2017

Stuck Systems Slow Reforms

Over the past five years, advocates and organization leaders throughout the country have focused on the overdose epidemic. Have we made sufficient progress? What obstacles get in way of reform?

Nebraska’s former Director of Behavioral Health, Scot Adams, says healthcare organizations are just like people with addictions, in that they are stuck in denial. People in trouble must confront and overcome denial in order to change for the better. The systems that serve the public must also confront and overcome issues of denial if they are to fundamentally improve how they operate. Adams enumerates several aspects of denial embedded in healthcare systems. He writes:
Twenty-five percent of general hospital beds are filled with persons being treated for effects of substance abuse, like overdose, but not the core issue – addiction. And that goes further to include physical health care, with the standard practice at many emergency departments to “fix what’s in front of me” and ignore the rest. Or at best, refer it somewhere else. Value-based health care is helping this – however that is more the payer’s hot ticket right now and less the provider organizations that are still working as they were trained. They are paid to fix the broken arm, but not to drill down about the cause – a drunken fall.
Adams also blasts systems for tolerating “good ole denial.” He notes that this takes several forms. One creates a culture in which addictive behaviors appear normal because they are so prevalent. Another involves clinicians who avoid unpleasant or resistant clients. A third leaves medical professionals reluctant to identify dangerous behaviors because they don’t want to wrongfully accuse someone of being an addict or mentally ill. A fourth form of denial involves “old schoolers” in the addictions field who deny the value of medication-assisted treatment (MAT). Adams writes:
Some of these professionals have never been trained in the specifics of addiction and think it’s just another mental health malady to add to the treatment plan.
Public health and addiction experts have been calling out examples of embedded systemic denial and explaining how this produces barriers to effective care. When Dr. Jennifer Mooney of the Cincinnati Health Department recently testified about overdose trends before Cincinnati City Council, she said first responders face issues of inadequate training and a system that’s “really not congealed” in trying to help addicts. She said police “run into dead-ends a lot of times.” She said even though Hamilton County is “resource rich” with treatment options, including intensive outpatient care, 28-day programs and long-term residential programs, there’s not enough capacity for all the people who need help right now.

The terms “really not congealed” and “not enough capacity” are well taken, because few local treatment programs are specifically designed for opiates. The reason for the lag in evidence-based care for opiate addiction? Dr. Mooney cited “the comfort level of prescribing clinicians.”

Here is another example. In mid-2016, Dr. Christine Wilder, director of the UC Healthcare system’s addiction practice delivered a keynote address to an audience of over 200 advocates, clinicians, and funders at the Hamilton County Recovery Service Board’s annual meeting. In her remarks, she urged her audience to start delivering more medication assisted treatment. She told the audience she heard a colleague say he “just doesn’t like buprenorphine.” “Not like?” Dr. Wilder said. “Practicing medicine should not be like Facebook.”

Systemic denial pervades every element of community systems, hindering not only what happens in clinical offices, but also the level of effort and pace of reform. Resistance to change affects healthcare organizations, treatment funders, housing providers, residential care facilities, courts, prosecutor’s offices, and jails. It produces odd combinations of wishful thinking and weak action. Leaders might advocate publicly for solutions, but delay required approvals. Resistance to change is keeping systems weak, disconnected, underpowered, and fragmented. It is producing horrific results for clients despite the best efforts and intentions of clinicians and public servants.

Terry DeMio of the Cincinnati Enquirer recently reported on the efforts of some three dozen experts working in treatment systems and the criminal justice system in Kentucky and Ohio (along with dozens of ordinary community members) to help a young woman move past prostitution and addiction – unsuccessfully – over the course of four months. The article relates how, time after time, the young woman and her expert helpers encountered systemic barriers including limits on treatment, lack of secure housing, and medication treatment delivered without psychosocial support. The situation DeMio describes is not uncommon. Municipal Court judges see people with this set of problems every day.

What is left unsaid in DeMio’s article is the slate of treatment approaches and care models that are known to be powerful enough to address situations like these, but are not being deployed in our communities. Assertive community treatment (ACT) teams, trauma-informed care approaches, and integrated care models are well-documented and evidence-based. When solutions are implemented, delay is typical. Ohio declared an overdose emergency in 2011, but took six years to adopt American Society for Addiction Medicine’s evidence-based treatment protocols.

Those who know about evidence-based protocols and practices recognize the technical failures and stuck systems. They also know that the bodies of overdose victims are literally piling up. The Dayton, Ohio, Coroner’s office has run out of space to store bodies, and must rent cadaver storage space from funeral homes.


del Valle, L. (2017). Ohio coroner’s office running out of room because of overdose deaths. Retrieved February 10, 2017, from

DeMio, T. (2017) In hell: The fight to save one addict. Retrieved February 10, 2017, from

Ohio Psychiatric Physicians Association (2017) Ohio MHAS promotes ASAM guidelines for treatment of opioid use disorder. Retrieved February 10, 2017, from

Oss, M. (2017). Addiction & Hospital Utilization – The Endless Loop? Retrieved February 10, 2017, from

Rosemeyer, J. (2017). Cincinnati saw fewer heroin overdose deaths in 2016 than the year before. Retrieved February 7, 2017, from

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