Insights on Substance Use Disorder Treatment and Stigma Reduction: Q&A With Sarah Wakeman, MD

There are pervasive challenges of stigma and inequity in substance use disorder (SUD) treatment in the U.S. Sarah E. Wakeman, MD, a leading expert in addiction medicine specialist at Massachusetts General Hospital, is dedicated to solving these issues by transforming care through integration, education, and policy advocacy. She is also the senior medical director for Substance Use Disorder at Mass General Brigham, medical director for the Mass General Substance Use Disorder Initiative, and program director of the Mass General Addiction Medicine fellowship.

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In this Q&A, Dr. Wakeman discusses the evolving understanding of SUD, the imperative need to reduce stigma to enhance treatment outcomes and health equity, and the integration of addiction care into general medical settings, improving patient engagement and recovery. She also highlights the vital role of recovery coaches, Bridge Clinics, and mobile Bridge Clinics services in partnership with the Community Care Vans in providing accessible and effective care directly to those in need with SUD.

Q: Can you explain the term substance use disorder and how it may differ from previous notions of substance use or addiction?

Dr. Wakeman: Substance use disorder (SUD) is the term we use for when a person has lost control of their alcohol or drug use and continues to use substances despite negative consequences to their health or life. Substance use disorders are treatable, good prognosis health conditions, and we have a range of effective medication and behavioral therapies. The diagnosis is based on meeting at least two of eleven criteria in the past year, and the craving assesses for loss of control of use, compulsive use, cravings, and use despite consequences.

SUD can be mild, moderate, or severe, depending on how many criteria a person meets. Addiction is generally synonymous with moderate to severe SUD. Substance use is a broad term that refers to the full spectrum of alcohol or drug use. Most people who use alcohol or drugs never develop a SUD. Importantly, with a shift to the term SUD, we have moved away from the old terms of "substance abuse" and "substance dependence." There were several reasons for this change, but importantly, the term abuse increases stigma, and the term dependence is confusing and frequently misunderstood.

Q: Can you discuss the goals and impacts of educational efforts to reduce SUD stigma and improve care?

Dr. Wakeman: Our goal is to improve the lives and health of our patients with SUD, to reduce mortality, and to eliminate racial, ethnic, and linguistic inequities in health outcomes. One of the main reasons we see such poor outcomes in SUD is because of decades-long stigma and outdated approaches that treat SUD differently than any other health condition. Improving knowledge and understanding about SUD and reducing stigma are key elements of improving care and, ultimately, health outcomes.

Q: How do you approach integrating addiction care into medical settings? What have been the significant challenges and successes?

Dr. Wakeman: There is a body of evidence showing patients do better when addiction treatment is readily available wherever they show up. Touchpoints with the medical system are reachable moments where we can engage with patients around their SUD and start treatment without delay. To do this, we must integrate addiction treatment across general medical settings like the hospital, emergency department, and primary care. We have seen great success from this work, including higher rates of engagement in treatment, reductions in addiction severity, and improvements in recovery.

One big challenge is helping clinicians who may not have learned about addiction in their training to feel ready to provide addiction treatment and see this as something they can all do. We also need to build a workforce of trained specialists, which we have been working to do in our fellowship programs. Like cardiology, we hope to get a future state where all generalists feel comfortable identifying and managing mild to moderate illness, and we have enough specialists to care for more severe and complex presentations.

Q: What are recovery coaches, and how do they impact patient outcomes?

Dr. Wakeman: Recovery coaches are essential, non-clinical team members who identify as in recovery from SUD. They are an incredibly valuable member of our care team who support patients on their self-defined recovery path. Working with a recovery coach is associated with reduced hospitalization and emergency department visits, improved engagement in outpatient services, and an increased abstinence rate.

Q: Can you discuss the development and outcomes of the Community Care Vans and Bridge Clinics?

Dr. Wakeman: Over a year ago, our Bridge Clinic teams began offering addiction services during some sessions on the community care vans. This collaboration has allowed our Bridge Clinic Teams to bring their care directly to the community and engage with people who may have never come to our physical spaces. This work has been a process of partnering with and listening to community leaders and members about gaps in care and consistently showing up to offer engagement and treatment.

Q: How have hospital-wide SUD initiatives affected physician attitudes and clinical practices toward SUD treatment at Mass General and beyond?

Dr. Wakeman: Early on, we studied the impact of our hospital-based SUD services at Mass General. We found that doctors who had patients who had been treated by our addiction consult or Bridge Clinic Team or worked with a recovery coach were themselves more likely to provide addiction treatment, felt more prepared to treat addiction, and found greater satisfaction in caring for patients with SUD. Most clinicians go into medicine to help people. If they don't feel like they have the tools to care for people with SUD, it can lead to feeling powerless or, worse, permeate into an approach of othering patients and shifting the responsibility onto them rather than us as healthcare systems and providers.

Building out hospital-based SUD services has a transformative effect on the care of our patients, most importantly, but also on healthcare teams, allowing them to feel empowered and supported to take the best possible care of our patients. We should use every touchpoint with patients as an opportunity to engage, meet their needs, and start treatment. Having services in place to support patients and teams in offering low-threshold, welcoming, and person-centered care allows us to make that the norm, not the exception.

Q: Can you share some insights from your work on policy advocacy and similar efforts?

Dr. Wakeman: A lot of the harm our patients with SUD experience comes from bad policy. Our historic approach as a society has been to punish or criminalize people with SUD, especially Black, Latine, and Native communities. Policy has been one way that this stigmatizing approach is enacted and enshrined. On a personal note, working on advocacy and policy has been profoundly rewarding for me and a way I counter the moral distress of watching the many ways systems have failed our patients. We can use our voices as physicians and healthcare leaders to provide education and push for meaningful change to move us toward a future where no one is punished for their health condition and where regulations are aligned with making treatment as easy as possible to access. And where we can create systems that are designed to support, heal, and invest in communities to address the reasons for problematic substance use in the first place, especially minoritized communities that the War on Drugs has disproportionately harmed.

Learn more about the Mass General Substance Use Disorder Initiative

Learn more about the Department of Psychiatry