Want to Fix the Opioid Crisis? First, Think Structurally

I am often asked to come up with creative ways to address various health care problems. When I was asked by a client a few years ago to come up with some ideas to address the opioid crisis, I dove in to the latest academic literature, news reports, and books (if you haven’t read it yet, and are interested in the bigger picture of opioids, check out Dreamland by Sam Quinones). Thousands of pages later, I came to what seemed an obvious conclusion: opioid misuse and abuse is not a singular crisis, but the effect of a huge set of policy decisions that have occurred over years.

In a recent commentary in the American Journal of Public Health, author Nabarun Dasgupta of the University of North Carolina, Chapel Hill, and colleagues are blunt – “The structural and social determinants of health framework is widely understood to be critical in responding to public health challenges. Until we adopt this framework, we will continue to fail in our efforts to turn the tide of the opioid crisis.”

Using a structural framework to analyze causes of the opioid crisis generates “an alternate hypothesis…that an environment that increasingly promotes obesity coupled with widespread opioid use may be the underlying drivers of increasing White middle-class mortality,” the authors point out. “Complex interconnections between obesity, disability, chronic pain, depression, and substance use have not been adequately explored.” Also, suicides “may be undercounted among overdose deaths,” they say. “Under both frameworks, social distress is a likely upstream explanatory factor.”

In order to “turn the tide” on the opioid crisis, the authors urge a focus on patient suffering, tied to things like social disadvantage, isolation, and pain. However, one of the challenges is that the U.S. health care system is “unprepared to meet the demands elucidated by a structural factors analysis.”

Again, seems obvious, but still bears repeating: the health care delivery system is not built to deal with structural problems.

Addressing these types of factors requires “meaningful clinical attention that is difficult to deliver in high-throughput primary care.” Indeed, the current “institutional, legal, and insurance architecture have robbed clinicians of time and incentives to continue care for these patients,” the authors say.

Incorporating social determinants of health (SDH) into care plans also highlights the need to “integrate clinical care with efforts to improve patients’ structural environment,” the commentary says. While the commentary authors recommend, “Training health care providers in ‘structural competency’” as promising, as the system scales up “partnerships that begin to address upstream structural factors such as economic opportunity, social cohesion, racial disadvantage, and life satisfaction,” I’m not as inclined to think health provider training alone will suffice. When I was first taught the basic premises of SDH and structural thinking as a young graduate student, the discipline was already decades old.

Knowing the importance of SDH is not enough. Until the evidence base is deeper, it is difficult to get payers to reimburse such as activities. (See next week’s blog for a great example though!)

Thinking structurally is not so difficult to learn, but acting structurally is extremely difficult. Still, the opioid crisis – like so many health care conundrums – can’t be solved without it. Let’s get to it.