Following Up on Dying in Vein
Dr. Jenny Makenzie's documentary Dying in Vein addresses Utah's opiate epidemic in a very emotionally vulnerable way by delving into the personal lives of family members and individuals struggling with substance abuse. She also includes interviews from health care and treatment providers about problems in the health care system that contribute to the problem and barriers for treatment for those seeking help. Her play on words vein vs. vain is poignantly felt in the movie as viewers witness the suffering of loved ones who have lost a family member. The panel discussion provided a chance for viewers to ask questions about the science of addiction, current treatment opportunities, and—on a personal note—check in on the brave people who shared their stories. We are glad to continue some of that discussion here.
Sarah Jane Dunn – LCSW
College of Social Work Community Advisory Board Chair, 2018-2020
Answers to these questions were provided by:
Maddy Cardon—featured in the film and one of the panelists
Eric Garland—one of the panelists; faculty member and associate dean for research in the College of Social Work
David Denio—a faculty member in the Substance Use Disorder Treatment Training program
Could you speak to stigma within the recovery community?
- MC: I think this question was asked in the context of MAT (medication-assisted treatment) during the panel discussion. In the recovery community, there are a lot of vocal opinions about what recovery should look like and what it means to be abstinent. For example, a person using MAT may be met with disapproval. It's important to engage in the narrative that everyone’s recovery process is unique to them and that's okay. Part of the beauty of recovery is creating a new life that is supported by the many different ways of healing. Different ways work for different people. Educating people on the success and effectiveness of MAT is a good place to start.
Detox & Treatment:
In the film, we learned that insurance wasn’t covering opioid detox. Is this still the case? If so, why not?
- DD: Since opioid detox is generally not life threatening many insurances are not covering it as an inpatient service. Some insurers will cover outpatient detox medications and clinic visits. Some insurers will only cover detox a certain number of times.
Do you feel medication-assisted treatment (MAT) is medically necessary? Does the use of medication factor into the success of patients?
- DD: MAT is a tool, and just like any tool there are times where it is appropriate to use and times where it is not. In addition to prescribing the medication, there should be a thorough assessment that includes items such as: use of other substances, ability to create a good social support group, ability to reintegrate into society (working or volunteering), ability to stay out of legal trouble, etc.… A good MAT provider will take all of these things into account when making the decision to provide MAT (or not). Of note, evidence shows that those who receive MAT are more likely to be retained in treatment and more likely not to use illicit substances. This treatment is also associated with decreases in crime (especially theft).
- EG: This issue should not be about opinion; it should be about data. The data from multiple, well-controlled studies clearly demonstrate that MAT reduces relapse, overdose, and opioid-related harms.
How do we avoid a switch to MAT abuse?
- DD: That will be dependent on the MAT’s provider to accurately assess what is going on. An interdisciplinary team would be beneficial to prevent MAT abuse.
- EG: Medications like methadone and suboxone should be coupled with efficacious behavioral therapies. I found in a randomized clinical trial that Mindfulness-Oriented Recovery Enhancement (MORE) plus medication significantly improved outcomes over medication alone. MORE is also an efficacious therapy for reducing prescription opioid misuse.
What are the indicators you look for when evaluating whether a person is seeking emotional relief or physical relief? Is this something that is now done before administering opioids?
- EG: Currently, physicians often assess for psychological distress before administering opioids. However, they do not typically assess whether or not patients take opioids to alleviate negative emotions, and in truth, patients’ brains may have a hard time discriminating between emotional and physical pain. Clinically, the best option right now is to simply ask a patient if they sometimes take opioids to alleviate stress, anger, sadness, or worry. In the future, one might use psychophysiology (e.g., either measurement of heart rate variability of EEG) to determine if a patient has a deficit in the ability to regulate his or her emotions, and whether that deficit is linked with opioid misuse.
Do you feel it is appropriate to place blame on the pharmaceutical companies and physicians for the opioid crisis?
- DD: On the Pharmaceutical companies: Documents revealed in lawsuits against several pharmaceutical companies show many of these companies continued to push their products after knowing about the addictive potential. Documents from Perdu and J&J show efforts to paint “addicts” as the problem rather than take any safety measures. On Physicians: There are some physicians that have added fuel to this fire. However the influence of industry cannot be understated. Industry was able to change guidelines and have pain added as a vital sign and metric for hospital reimbursement. Physicians were taught to prescribe narcotics and that products like oxycodone did not have high addictive potential. There were/are some prescribers that were influenced by profit over their oath but my experience is that they are fewer compared to those who were taughtincorrectly.
I believe that the idea of teenagers and young adults numbing themselves to emotional pain begins because they are not taught ways to feel these emotions constructively. Is this a legitimate precursor for our panelists' experiences? Being proactive early, what would that look like?
- MC: The film highlighted an important narrative about the human desire to not feel pain. Part of the healing process for me has been learning how to be okay in my humanness, by feeling the emotions that are sometimes difficult and learning how to face something I previously may have wanted to hide from. With that being said, it's important to remember that all humans have this tendency. Addiction is complex, and current research argues a major genetic component to addiction. I do believe that learning to be with our emotional experiences in a new way is an important tool in recovery. If had known how to face emotions differently would I have still become addicted? I would say yes. I often joke about using drugs when I was happy, sad, excited, etc. it wasn't simply an emotional relief I was seeking. Wanting to numb emotional pain is a slice of the pie when it comes to addressing substance use disorder, but we have to be careful to not assign causation where it isn't there.