Overdose Deaths and Cross-sector Collaboration

Tim, a family friend, was found unresponsive by his wife after overdosing on opioids and alcohol. Tim spent 8 days in the intensive care units of 2 hospitals. Had he died—and he nearly did—he would have joined the tide of “deaths of despair” that has swept the United States. ¹ Tim’s case fit the type: he was out of work; he had long used alcohol excessively; and 3 physicians had prescribed opioids for back, knee, and shoulder pain in the previous year. Tim survived the overdose but was discharged without a clinical plan and with no clear place to turn for help.

Eight years ago, US Surgeon General Vivek Murthy wrote, “[T]he opioid epidemic cannot be solved by government alone. It will require the engagement and leadership of all segments of society, particularly clinicians.” ² Today, Murthy’s call for all-hands-on-deck seems even more urgent, as more people in the United States have died by overdose during the previous 4 years than during any other 4-year time span. ³ In Tim’s case, hands reached out from several sectors: health care systems, family and friends, his local church, and particularly his clinicians. All sought to help in their own ways. Collaboration across these sectors, however, appeared insubstantial and ineffective.

In a recent study of people who have experienced opioid dependency and representatives of institutions responding to the opioid epidemic in 1 region of southern Appalachia, we observed that those on the front lines often find effective collaboration easier to imagine than to achieve. ⁴ Collaboration is hindered by the age-old problems of different institutions having different priorities and institutions struggling to survive as much as to address the needs for which the institutions exist. We found sincere people in diverse sectors working skillfully to curb the opioid epidemic—in criminal justice systems, social service agencies, 12-step programs, religious communities, and, of course, health care. But such efforts rarely were coordinated.

Why? For one, programs are scrambling for resources, often in competition with one another. It is hard enough to sustain efforts that, apart from some medication-assisted treatment programs, by their nature do not generate much income even if they bring long-term benefits. Twelve-step programs, recovery ministries, and criminal justice rehabilitation are not financially self-sustaining. They require long-term investments. Yet, these programs also often compete with one another for the investments that are available. Nonprofit organizations apply for the same grants, 12-step programs compete for local support and leadership, and religious communities worry about losing members to other congregations. The upshot is that while many may aspire to communicate more and coordinate better with other organizations, they find few tangible incentives to do so. Clinicians caring for patients like Tim have incentives to discharge patients, not to communicate well with their loved ones.

Collaboration also is hindered by stigma, beginning with the familiar stigma toward people who experience opioid dependency. Even within communities ostensibly committed to their recovery, some people think that those whose lives are wrecked by opioid dependency get what they deserve. Even those motivated by compassion find facilitating recovery difficult. Tim is not easy to be around. He has a hard time sustaining a conversation that does not return to his various ailments and his resentment toward the clinicians and “the system” that have made his life miserable. No wonder so many clinicians have succumbed to writing the next script for pain medication, if for no other reason than to secure temporary respite from difficult conversations with patients like Tim. Or, as Tim recently lamented, clinicians may hastily cut patients off, pointing to updated prescribing guidelines when they do so. Recovery programs and churches can do the same while appealing to the importance of boundaries. Severing relationships can be easier than the work of accompanying someone who is suffering.

But another and more complicated stigma hinders collaboration to address the opioid epidemic: namely, a reciprocal distrust that emerges from disagreement about the extent to which opioid dependency is a medical versus a spiritual problem. Some see opioid dependency as fundamentally a medical problem, one best addressed as a form of disease. This vision justifies both medication-assisted treatment and harm reduction efforts (eg, needle exchange programs). Others see opioid dependency as fundamentally a spiritual problem and, therefore, not adequately accounted for in a disease model. This vision undergirds 12-step programs and other recovery ministries, many of them faith-based, that focus less on harm reduction and more on getting to the heart of the problem (as they see it).

Tension between these 2 visions of opioid dependency is expressed in competing language (eg, use disorder vs addiction, harm reduction vs healing). One carefully avoids morally laden terms; the other is comfortable with words such as brokenness and sin and God (or “higher power”). One is most at home in secular institutions, the other in faith-based organizations. One worries about blaming the victims, while the other worries about treating people merely as victims. Both affirm that those dealing with opioid dependency deserve compassion, but they advance different ideas about the shape of that compassion. And, frequently, these rival visions are grounded in rival worldviews—religious and otherwise.

What can be done in light of this foundational disagreement about the nature of opioid dependency? The people we interviewed suggested that the disagreement can be overcome, at least enough for fruitful collaboration. First, the divide is less sharp than it might seem. Those who address opioid dependency through a disease model often express appreciation for the limits of that model and the need for holistic efforts, including, for some, seeking healing through spiritually grounded programs. Likewise, those who address opioid dependency as a spiritual problem often recognize the physiological character of dependency; many acknowledge the helpfulness of medical resources on the road to recovery.

While disagreements remained, the people we interviewed found common ground in their shared struggle against the opioid epidemic. We might say that skepticism about one another’s strategies pales next to a shared commitment to helping those who are struggling with substance use issues. Contending against one another’s explanatory models for opioid dependency seems less important than contending together for a person’s flourishing. We found that organizations involved in this work find ways to maintain the integrity of their own approach while treating other approaches as complementary rather than antagonistic.

In the struggle to curb substance use issues, there seems to be room enough for differing approaches. For the sake of the millions of people like Tim, whose lives have been turned upside down by the opioid epidemic, we hope that the future sees a growing response to Surgeon General Murthy’s call—an all-hands-on-deck culture of collaboration among diverse sectors, each offering its best resources with integrity and the humility to recognize and appreciate those who come at the issue in a different way.