Name: Meaghan Mugleston
From: Spokane, Washington
Addressing the Individual, and Societal Challenges of the Addiction Crisis
Addiction Awareness Scholarship Campaign
The roots of the addiction crisis gripping our nation are a complex web of systems-level forces, fraudulent claims by pharmaceutical companies, irresponsible prescribing practices by clinicians, and the psychological and physical trauma that so many of our citizens experience over the course of their life. The systems-level elements of the late 1990’s, including the Joint Commission’s directive to include pain as the “fifth vital sign”, whereby institutions were graded on their ability to reduce patient’s pain scores, and the false reassurances from pharmaceutical companies that opioids carried low risk for the development of addiction, led to an overabundance of prescription narcotics, and culminating in the conditions necessary for the opioid epidemic to emerge. The precarious position so many in our society face due to instability in employment, housing, and healthcare access, in addition to histories of personal trauma, such as physical, psychological, and sexual abuse, created huge swaths of vulnerability as individuals sought outlets for suffering.
The explanation for why we as a nation are dealing with the addiction crisis is perhaps best understood through the stories of individuals, such as V.W., a patient at my small community health clinic in Seattle whom I first met three years ago. When I met V.W., he had been using heroin, illicit benzodiazepines, and methamphetamine on and off for the last fifteen years after having been prescribed pain pills for several years following a low-back injury while working in construction in his early twenties. At our first visit, V.W. was unhoused, and injecting heroin and sometimes methamphetamine several times a day. He decided it was time for a change when he was assaulted on a Seattle sidewalk shortly after injecting heroin and falling asleep. Over the course of several months, I came to learn that V.W. had an abusive relationship with his father, who had an alcohol use disorder, and this caused V.W. to leave home at age 16. He had a long history of untreated anxiety and PTSD from events that had occurred in his childhood, and while living unhoused. V.W.’s personal story mirrors so many of the patients I have met who struggle with substance use disorders, and highlights the root causes of the addiction crisis- a healthcare system that was irresponsible in its opioid and benzodiazepine prescribing practices, and the personal trauma that so often predisposes individuals to substance use.
As a nurse practitioner working at a Federally Qualified Health Center, I see the consequences of addiction on a daily basis. These include physical ramifications such as abscesses, endocarditis, and infectious diseases such as hepatitis and HIV. Additionally, the psychosocial toll is profound- including mood changes, paranoia, change in sleep patterns, memory impairment, loss of meaningful relationships, legal challenges, inability to maintain employment, and housing instability. The craving to use and desire to avoid withdrawal are such strong impulses that they often crowd out an individual’s ability to focus on any other aspect of their life. On a societal level, we suffer the loss of engaged members of the community who are no longer able to maintain occupations, or the civic roles crucial to a well-functioning democracy. We bear the brunt of rising healthcare costs associated with increased emergency room visits, and treatment of disease processes associated with addiction. On an ethical level, the addiction crisis has forced us to reckon with our responsibility to provide health care and housing to this vulnerable group. Perhaps most poignantly, so many families have had to deal with the grief and loss of needlessly losing a loved one to a substance use disorders. Indeed, this crisis has only deepened for both individuals and society over the last year, evidenced by the sharp rise in preventable overdose deaths in 2020.
Despite all of the challenges we face in addressing the addiction crisis in our nation, there are evidence-based solutions on both the individual and societal scales. My experience working as a nurse practitioner focused on treating patients with opioid use disorder gives me great hope that medication treatment options for this condition are a life-saving tool for individuals who are able to engage in care. The clinic where I practice ascribes to a low barrier approach to treatment, in which we attempt to get patients started on medication for opioid use disorder the same day we see them, and to be as flexible as possible when it comes to follow-up. We allow patients to walk-in for care, and do not penalize patients for missed appointments, or arriving late. This is because a large portion of the patients we treat are experiencing homelessness, or living with a high degree of life chaos, and we recognize that these psychosocial circumstances can make it difficult to comply with the traditionally rigid expectations of primary care clinics. I have also had the opportunity to increase access to treatment for opioid use disorder by practicing in locations such as a community day space for individuals living homeless, and at a case management office in Seattle. These atypical treatment settings allow patients to get access to medications in environments that may be more comfortable and convenient for them. Programs that adopt a low-barrier approach, and find innovative ways of reaching patients who may not feel comfortable in traditional clinic settings offer one important solution for treating addiction on the individual level. Furthermore, I have had the opportunity to act as a treatment “clinical champion” for my healthcare organization, encouraging more providers to receive a waiver to prescribe buprenorphine as a means of increasing access to treatment, and normalizing the management of addiction in the primary care setting. All of this work is critical to addressing the needs of individuals dealing with substance use disorder.
However, I have been engaged in this work on the individual patient level for the last three years, and although medications for opioid use disorder can be truly miraculous for those who are able to receive them, this alone is not sufficient to address the addiction crisis on a population scale. My primary motivation in seeking a doctorate degree is to reach beyond the relatively narrow sphere of influence I have on improving health for individual patients to address the systemic issues that prevent populations from leading healthy lives, particularly when it comes to addiction. Although the societal remedy for the addiction crisis cuts across myriad social determinants of health, the areas that I want to address given my professional background include preferentially advocating for those with substance use disorder when forming health policy, ensuring that health care organizations are focusing on improving care for these populations in their own systems, and training health professionals to provide compassionate care to these vulnerable persons.
In particular, I want to improve training for nurses and nurse practitioners while they are still in their nursing programs in order to reduce stigma, and improve knowledge about best practices when caring for those with substance use disorders. There is a lack of emphasis placed on caring for this vulnerable population, and as a result, many nurses lack the competence and comfort level necessary to create a safe and therapeutic environment for these individuals. This often results in people being unwilling to access health care because of previous negative experiences and prejudices.
Additionally, I would like to leverage the professional clout that comes with having earned a doctorate to act as an advisor to governing bodies such as city or county councils, and state legislatures to ensure the needs and best interests of disenfranchised groups are taken into account when policies are created. I believe nurses are well situated to translate what we see at the bedside and in clinic into a compelling argument for enacting political change that will improve social determinants of health.
Working with individuals who suffer from substance use disorders has been an inflection point in my professional life, and has caused me to consider the ways in which I can do the most good not only for individual patients I see in the clinic, but for my community and populations at scale. It has alerted me to the ways in which socioeconomic forces, and the lived trauma of individuals can coalesce into a devastating public health crisis that deeply touches all of our lives. I believe that combining my clinical work of treating opioid use disorder in individuals with new endeavors to equip health care students to care for such patients, and influence public policy such that it better protects and improve the lives of those facing addiction are salient solutions to ending the addiction crisis, and I plan to focus my efforts as a doctorally-prepared nurse practitioner on achieving these goals.