Heroin addiction treatment and opioid misuse

Michael Fendrich is associate dean for research and a professor in the UConn School of Social Work, whose research focuses on policies, services, interventions, and risk factors related to substance misuse and mental health. He recently published a paper about heroin addiction treatment and how it relates to previous opioid misuse history.

Fendrich joined the UConn faculty in 2014, and was previously the director of the Center of Applied Behavioral Health Research at the University of Wisconsin-Milwaukee from 2005 to 2013. He discussed his latest study with UConn Today.

Q. How did you first get interested in the topic of heroin addiction and how it relates to previous opioid history?

A. The increased awareness of the opioid epidemic started five or six years ago, and states were implementing – at the encouragement of the federal government – prescription drug monitoring programs. I was in Milwaukee at the time and was collaborating with a school of pharmacy. I became aware that Wisconsin was one of the last states to implement a prescription drug monitoring program.

I thought this might be a really good opportunity to interview pharmacists and get a sense of what they know about substance abuse and how they view the prescription drug monitoring program. They often come at things with a medical perspective, and – I don't want to say this in a pejorative way – they don't always have a clear understanding of some of the behavioral factors. It's not their world.

It made me interested in figuring out how they would view the opioid crisis, and how they would view the potential issues around people misusing prescription medications, and what their overall knowledge level was about addiction and substance abuse.

In focus groups, we heard things like 'sometimes I feel like I am more of a policeman than a pharmacist.' Some pharmacists felt like law enforcement, some felt like health care providers, and some pharmacists felt like they are somewhere in the middle.

Q. What were some of your main findings in your most recent paper on this topic?

A. The big finding was that people [who were undergoing heroin addiction treatment] who had prior opioid history were generally more substance-involved, and they were involved earlier in those substances. They were also more persistent in their opioid use. And they were more likely to suffer some elevated symptoms of depression. So basically, the folks who were heroin dependent with that prior history had more problems than others and they didn't do as well.

The issue is, does it makes a difference? Yes, it probably does. Those people who progressed in the typical story line that has been described, with opioids and heroin, probably have a more difficult outcome, and – in terms of the potential difficulty of getting us out of this crisis – it points to how problematic this is. It is not just one opioid problem out there, it's what people's history contributes to making this a more intractable problem. There are other mental health issues that need to be addressed, especially depression – it's not just the substance abuse, which everyone is focused on. These mental health issues may mean you need to tailor how you are treating folks. We need other types of intervention that address the conditions people have, especially those that have opioid use before their heroin abuse.

Q. How did this opioid problem get so severe in our society?

A. The story people tell is well-known – an increased availability in prescribed opioid-related medications. That is part of the story. We have other issues going on in society, like lack of opportunity in terms of economic mobility and jobs. There are lots of stressors going on in society and I think those macro-forces have to be considered part of the picture. Everyone says we have a great economy now, but there are a lot of folks who are underemployed, not earning sufficient wages, or don't have rewarding job opportunities. They haven't had access to training, and this crosscuts all ethnic groups and all regions: it's rural, it's urban.

It's not, in my opinion, one particular thing that got us into this, and I will also note, there is not going to be one particular thing that's going to get us out of it. We are going to have to have policies that create job training opportunities, and have access to health care, and access to resources for everybody. We are also going to have to have more restrictive policies toward opioid drugs and opioid drug availability, but by the same token, some of these opioid drugs have been quite beneficial in terms of facilitating pain relief for debilitating conditions. It just needs to be regulated in a way that doesn't enhance potential for abuse.

Q. So is there hope?

A. Yes, I think so. It is so much on the public radar screen right now. Congress just allocated resources to expand access to treatment. The states, and here in Connecticut the DMHAS (Department of Mental Health and Addiction Services), have been the beneficiary of millions of dollars of funding from the federal government to address the problem. We do have treatment interventions in the form of medication. We have medication to address overdose, like naloxone. It seems like awareness is at a level where it needs to be if we are going to address the problem. The downside is that it seems like in Connecticut and elsewhere, the number of overdose deaths is really very high, and our rates are above the national average in Connecticut in almost every county.

Q. What are you working on now?

A. We are finishing work on a totally different topic – emergency mobile crisis services for children with acute mental health needs. There is a statewide system for kids with this need, and it diverts them from hospital emergency departments. We have a grant to evaluate these services, and whether in fact there is a successful diversion of these kids from the ER. I am really excited about that study.