Part of McLean Hospital’s “Deconstructing Stigma” initiative — this installation at Logan Airport pictures real people telling their stories about suffering from mental illness. (Photo Courtesy Deconstructing Stigma)
Part of McLean Hospital’s “Deconstructing Stigma” initiative — this installation at Logan Airport pictures real people telling their stories about suffering from mental illness. (Photo Courtesy Deconstructing Stigma)
" “Even with the reduction of prescriptions, basically trying to put the toothpaste back into the tube doesn’t work,” said Dr. Roger Weiss, chief of McLean Hospital’s Division of Alcohol and Drug Abuse. “Reversing the epidemic by trying to go back to the beginning and undo it doesn’t work.” "
Attorney General Jeff Sessions appeared in Portland last Friday to announce “Operation Synthetic Opioid Surge” (S.O.S.), a massive federal push to round up traffickers of the synthetic opioid fentanyl and throw them in prison. The Department of Justice (DOJ) will launch the national “enforcement surge” in ten districts in eight states, including Maine, where, on average, one person dies of an overdose every day.

“We at the Department of Justice are going to dismantle these deadly fentanyl distribution networks. Simply put, we will be tireless until we reduce the number of overdose deaths in this country,” said Sessions in a statement. “We are going to focus on some of the worst counties for opioid overdose deaths in the United States, working all cases until we have disrupted the supply of these deadly drugs.”

But with nearly 300,000 people already held in state and federal prisons for drug offenses, up from 25,000 in 1980 according to the DOJ, study after study has shown that using the criminal justice system to treat a public health crisis is not only ineffective, but it’s making the crisis much worse. A recent Pew Charitable Trusts analysis of data from federal and state law enforcement, corrections, and health agencies found “no statistically significant relationship between state drug imprisonment rates” and the number of self-reported drug users, overdose deaths and drug arrests. In other words, the drug crisis is worsening despite a record number of people locked up for drug crimes. A groundbreaking 2013 study published in the British Medical Journal also found that drug prices have “generally decreased” while drug purity has increased since 1990 despite an unprecedented effort to crack down on the global drug trade.

But as millions of Americans suffer from some form of substance disorder — which includes all types of chemical dependency and addiction — only 10 percent of them receive treatment for their illnesses, according to a 2016 report by the Substance Abuse and Mental Health Services Administration.

Clouded in a myopic drug war haze, politicians have failed to appropriately deal with the crisis. Congress has not funded a federal drug treatment initiative passed in 2015 while Gov. LePage is willing to go to jail before he expands Medicaid, which could be used to treat thousands of Mainers suffering with substance use disorder.

Sen. Angus King observed that the National Institutes of Health spends about $35 billion a year on research into physical ailments — like HIV, Alzheimer’s and diabetes — while the National Institute of Mental Health has a budget of just $1.5 billion, a ratio of 35 to 1.

But rooted in all of the politics of drugs in the US is a societal stigma that treats substance use disorder and mental illness as moral failings rather than the diseases that they are. On the same day as Attorney General Sessions was doubling down on the 1990s-era drug war policies in Portland, Senator Angus King moderated a panel of health experts at the Camden Opera House to discuss ways of breaking that stigma.

Recognizing It As a Brain Disease

“I think of addiction like a disease of brain circuits. Circuits that may be similar to the ones running the light switches in this room,” said Dr. Trip Gardner, a psychiatrist at Penobscot Community Health Care. “That disease affects our memory circuits, our motivation circuits, our reward circuits, our emotion circuits. And those circuits produce not only biological symptoms, but psychological symptoms and social symptoms because the brain is the organ that we can connect with the world.”

Gardner said that the brain’s high-level controls are supposed to tell us when something is harmful, even if it’s pleasurable and rewarding. But for certain people who are genetically predisposed to substance use disorder or have experienced some kind of childhood trauma in their lives, it becomes very difficult for the brain to “apply the brake” toward using a substance it begins to see as necessary to survive. And that’s when the lower brain takes control.

“That disconnection eventually disconnects people from their careers, their personality, their values, who they are, their families, the people they love and still love when they’re using,” said Gardner. “And eventually they get deeper into themselves and eventually they die. That’s pretty much the story of most chronic diseases, in a way.”

Gardner said that public health policy should create ways to accept people with substance use disorders back into the community, as social exclusion has been shown to produce the highest amount of physiological stress, increasing the likelihood of a relapse. Throwing people in jail is the most obvious form of social exclusion, but it also includes housing and employment discrimination.

Peter Horch, owner of Horch Roofing in Warren, said he first learned about the importance of providing opportunities to people in recovery after he began hiring prison inmates from the Bolduc Correctional Facility in Warren. Since then he has hired several employees in recovery and he doesn’t drug test in the hiring process or even randomly after they’re hired.

“We’ve had great success — with a few hiccups but more success,” said Horch. “We’ve had great experiences with people who are in recovery and they turn out to just be excellent, excellent workers.”

Horch said one employee recently admitted to struggling with alcoholism after missing six days of work in a row, so he offered to pay half his salary for six months so the man could get help.

“I love these people and the reason why I’m so passionate about this is because they’re good guys, they’re hard workers and productive citizens,” he said. “It’s really frustrating to hear about employers who are not willing to give people a chance when we can have such an impact on people’s lives.”

“Deconstructing the Stigma”

Other panelists at the forum discussed the need to change the way we talk about people with addictions and mental illness. Health professionals and the recovery community have begun encouraging the use of “people first” language. For instance, instead of using stigmatizing terms like “addict” they’re called “people with substance use disorder.” Rather than calling someone “mentally ill” or “emotionally disturbed,” advocates use terms like “a person diagnosed with a mental health condition.”

Adriana Bobinchock, senior director of the Deconstructing Stigma Campaign at McLean Hospital in Massachusetts, argued that using outdated terms to describe people with substance use disorder or mental illness not only propagates the societal stigma these people endure, but it also causes a self-stigma, which can be a barrier for someone seeking help. One in five Americans will experience mental illness in their lifetime, according to the National Institute of Mental Health, and 75 percent say they experience social stigma as a result of their disease.

“The stigma that surrounds conditions like mental illness contributes to the fear and isolation that people feel too often,” said Bobinchock. “Back in the 1950s, cancer was an illness that no one wanted to talk about. There was a stigma of shame around it and it was a secret that families kept to themselves. Now imagine that isolation and sadness that came without the support of friends and family and the larger community? Thankfully cancer is no longer seen in that light, but unfortunately mental health is.”

That’s why McLean Hospital and a coalition of mental health advocacy groups launched “Deconstructing Stigma,”an ambitious public awareness campaign aimed at changing public attitudes toward mental and behavioral health. The campaign culminated in the installation in Terminals B and C at Logan Airport of 34 eight-foot-tall photos of real people talking about their struggles with mental illness and substance abuse as well as their treatment and recovery. There’s Meghan, a 27-year-old nanny who has suffered anxiety and panic attacks from a young age and has since been diagnosed with borderline personality disorder, for which she is receiving therapy. Other photos include Nathaniel, a 30-year-old who suffers from obsessive compulsive disorder and is the administrative director of research at McLean Hospital’s OCD Institute, and Mary, a 16-year-old high school student who used to cut herself to manage her anxiety. The campaign also features rapper Darryl Matthews McDaniels of the group Run-DMC, who recounts his struggles with anxiety, depression and alcoholism.

Bobinchock said she would also like to expand the program into small communities and is willing to work with groups in the midcoast to launch a similar de-stigmatizing campaign.

Confronting Stigma in the Medical Community

Speakers also spoke of confronting stigma toward mental illness and substance use disorder within the medical community. Christine Tebaldi, a psychiatric nurse practitioner and director of clinical business development at McLean Hospital, pointed to a statement by the American Psychiatric Nurses Association, which stresses that “whole health begins with mental health.”

“We’ve been trying to infuse behavioral health talent, behavioral health services within primary care, within emergency departments as well as in inpatient medical units,” she said. “There’s actually been a lot of work done that has proven that mental illness and physical illness interact with one another, affect one another.”

Dr. Roger Weiss, chief of McLean’s Division of Alcohol and Drug Abuse, acknowledged the role that physicians played in the addiction epidemic by overprescribing opioids to treat pain, but he also pointed out that continued efforts to curb the prescribing of such drugs is not going to be effective, as so many are now hooked on street drugs.

“Even with the reduction of prescriptions, basically trying to put the toothpaste back into the tube doesn’t work,” said Weiss. “Reversing the epidemic by trying to go back to the beginning and undo it doesn’t work.”

In 2011, Weiss, along with researchers from Harvard Medical School, published a study that found that people with opioid use disorder who took buprenorphine/naloxone, known by its brand name Suboxone, were seven times more likely to have positive outcomes than people who were not on medication-assisted treatment. Forty-nine percent of the people taking buprenorphine were successful in their recovery compared to 7 percent for people who didn’t take the drug. However, Weiss said that only 20 percent of the patients who receive treatment for opioid disorder actually receive the medication. He said few physcians prescribe the buprenorphine because of a federal law that requires physicians to take a special 8-hour course to prescribe it even though they don’t need a similar course to prescribe more serious drugs like opioids and chemotherapy. Weiss said that he once asked a colleague in France about what doctors do when a patient comes in with opioid withdrawal symptoms.

“He looked at me like, ‘What a weird question,’” said Weiss. “He said, ‘Why would someone come to emergency room in opioid withdrawal? They would just go to their doctor and get buprenorphine.’ It’s just a very different model because all doctors there can use it. There’s no barrier to doing it and they know how to use it the way they know how to use penicillin.”

Weiss said medical schools are also not teaching students enough about addiction, but that young students are very focused on it because they see it as a social justice issue.

Meanwhile, as political leaders in Augusta and Washington, D.C., reignite the failed drug war, public opinion has begun to turn against late-20th-century policies. A 2017 survey by the American Civil Liberties Union Campaign for Smart Justice found that 61 percent of Americans believe that people who suffer from drug addiction and commit serious crimes belong in rehabilitation programs, not prison. Two in three Americans surveyed said they would be more likely to vote for candidates for elected office who support reducing the prison population and using the savings to reinvest in drug treatment and mental health programs. But nothing will change unless people get organized and make it happen.

“I think all of us, we have to expect that our health care providers, the laws, the agencies, the regulations, the rules that control these systems and providers, we have to expect that they’re going to take care of this like a real disease,” said Dr. Gardner. “We have to demand it and we can’t wait.”