Building a true system of care: Opioids and health care in the United States

March 19, 2018

By Benjamin F. Miller

The problem of opioid abuse in this country is one that has been some time in the making. And just as the problem did not appear overnight, neither will the solutions appear through one new program. In times like these, when people are dying at an unprecedented rate, we must thoughtfully consider solutions that are going to both address the crisis while simultaneously preparing us from preventing the next crisis.

It’s not uncommon for a systems approach to be ignored in healthcare. After all, most people assume that there is an actual system for care. However, as Moses et al described, “US health care is not a system, as it is neither coordinated by a central entity nor governed by individuals and institutions that interact in predictable ways.” We have a great deal of assumptions that go into our solutions for problems with health in health care central among them is a recognition that a system exists that will be capable of morphing in response to recommended changes.

Health care is a complex adaptive system, and “mechanical” approaches to problems can run the risk of having unintended consequences. Linear thinking inevitably leads us to programs and one-off solutions rather than more meaningful systems reforms. This is why we must be cautious in looking at some of the ideas coming forward around opioids.

For example, reducing opioid supply without reducing demand has major repercussions. Yet, we must simultaneously address those who need treatment while proactively working to prevent others from one day needing treatment. This means that we must have a system of care that can identify need, provide treatment, coordinate care across those providing treatment, measure outcomes, and follow up. While undoubtedly there are more pieces to be included, the point is that we typically only hit on one of these elements, which means the impact is often mitigated.

Further, integrating mental health and substance use services remains a critical but often elusive goal. Consider that in this country we still only screen for depression in primary care practices around 4%. Despite depression being one of the most diagnosed mental health conditions, we still are hesitant to screen. And if we do? Well, one study reported that 2/3 of primary care physicians could not get access to mental health or substance use services for their patients. Because of these, and many more facts, we should not be surprised that only 4 in 9 get mental health care, and 1 in 10 get substance use care.

We have a profound need as a country to integrate and bring forward an agenda that pulls together all the pieces. Solutions to problems this complex are not going to be as simple as increasing education and penalizing those who spread the drugs, whether legally or illegally. Let’s take advantage of this moment where we are having a dialogue around opioids and bring together the evidence with a thoughtful systems approach to the issue.


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