The 2000s marked a steady incline in overdose deaths in the United States, largely driven by prescription opioids, heroin and the emergence of illicit fentanyl. And while the Centers for Disease Control and Prevention reported a four percent decrease in the number of overdose deaths between 2017 and 2018, the total number was still four times higher than in 1999. Needless to say, the nation had become gripped by the opioid epidemic, prompting it to be declared a public health emergency.

A NEW CENTER PROVIDES HOPE

The spring of 2017 ushered in a major milestone in the fight against addiction, with the founding of Boston Medical Center’s Grayken Center for Addiction. The center, made possible by a groundbreaking $25 million gift from Eilene and John Grayken, was estab-lished as a springboard for BMC’s decades-long expertise and leadership in the treatment of substance use disorders (SUDs). Doing so galvanized BMC’s position as the de facto national leader in addiction, allowing it to double down on its efforts in prevention, treatment, recovery and research.

In the three short years since its found-ing, the center has certainly made good on its mission to bring addiction out of the shadows and make long-term recovery a reality—namely in the areas of combatting stigma, supporting young adults with substance use disorder and developing and disseminating evidence-based approaches both locally and nationally. Of course, none of which would be possible without the center’s experts in addiction medicine and the leadership of recently retired Executive Director Michael Botticelli, former Director of National Drug Control Policy in the Obama White House, and Medical Director Miriam Komaromy, MD, FACP, DFASAM, who joined the Grayken Center in 2019 following a national search.

“Grayken is made up of smart, hard-working and dedicated people who are united around a mission,” says Komaromy. “Grayken is a leader because of the people behind it. They’re the reason BMC has been and will continue to be so strong in the arena of substance use disorders.”

FIGHTING STIGMA, CREATING NATIONAL RESOURCES

As much as stigma has underscored the addiction crisis, combatting it has been a driving force in the Grayken Center’s mission. The Grayken family, having been personally affected by SUD, found it vitally important to make their gift public—a powerful message of support given their typical preference to conduct their philan-thropy anonymously. Building on this strong show of support, the center launched several initiatives to reduce the shame, guilt and fear of judgment silencing so many who struggle with SUD. For one, Botticelli’s own recovery journey played a key role in national discourse around SUD. “He’s an eloquent spokesperson for the damage that stigma causes and the ways that we can address it, including education,” says Komaromy. “And we’ve seen others adopt some of the same approaches we’ve taken here because of him.”

The approaches Komaromy describes include the Words Matter Pledge and Employer Resource Library. The former offers non-stigmatizing, person-centered and clinically appropriate word choices in an effort to transform the way people talk about SUDs and those who suffer from them. The list is continuously updated, and while a seemingly mundane change, research proves language plays a significant role in in the perception of and attitudes toward addiction. The Employer Resource Library originated from a survey conducted among BMC employees. “What we were really clear about from the start was not just focusing Grayken on patients, but also employees because the issue was affecting our BMC family as well,” explains Botticelli. The survey revealed employees desired a better understanding of SUD policies and benefits, which led to a revised benefits guide. True to BMC fashion, both found widespread use beyond hospital walls.

“We were getting inquiries from [other] employers, including some very large employers, who were saying they were hearing the same feedback from their employees,” Botticelli notes. “We developed a no-cost employer toolkit from the resources we developed for BMC. We worked with employers in Massachusetts and other states and received significant national attention.”

IDENTIFYING THE GREATEST NEED

The center also wants to be as efficient and effective as possible in addressing addiction in its earliest stage. As such, a major strategic planning process was undertaken to determine how the center could focus its resources and energy where the need was greatest.

“BMC had a preeminent position both locally and nationally because of its clinical care and innovation along with its work in research. We wanted to build on that by asking the question, ‘Where is the greatest need?’” explains Botticelli. “We brought BMC leadership and clinical faculty together with partners from the state, and we also examined what was happening on a federal level. What emerged was that young adults were being severely affected by the opioid epidemic. They were less likely to have developmentally-appropriate care and less likely to go into treatment.”

Out of the findings came several activities focusing on young adults, including the expansion of BMC’s novel CATALYST program—which treats SUDs in adolescents and young adults— to community health centers, in order to reach and deliver care tailored to the needs of a younger patient population. The Grayken Center didn’t stop there, though. It provided support and resources for parents and families of young adults with SUD to address a variety of needs, from identifying a SUD to coping with the loss of a child. Additionally, the center hosted a symposium, which brought together the top experts in the nation to develop principles of care for young adults with SUD. It is also beginning work to encourage adoption of the principles broadly across the nation.

SCALING PROGRAMS ON A NATIONAL LEVEL

Parallel to these specific accomplishments, the center has also made strides in accelerating the dissemination of its programs and care models on a national level to meet the urgency of the opioid epidemic.

“BMC is not alone in the fact that its patients have been affected by the opioid epidemic or substance use issues. But what sets BMC apart is the fact that we’ve developed very innovative, evidence-based programs that integrate addiction care into people’s overall care, no matter where they are, whether that’s primary care, emergency care, prenatal care and so on,” says Botticelli. “This is exceptional work, but it shouldn’t be. It should be standard of care in hospitals and health systems across the country and that’s what we’re trying to achieve.”

In addition, the center has helped lead the charge in urging national, state and local policymakers to reduce barriers to care. “With the help of our Government Affairs team, Grayken has been able to foster policies and laws geared toward providing better [SUD] care and treatment,” notes Botticelli. “My hope going forward is we continue to think about ways that make it easier for people to get into and stay in care.”

PIVOTING TO A GLOBAL PANDEMIC

Perhaps one of the most important aspects of the center is its ability to swiftly respond to shifts in the addiction landscape to always meet the needs of patients. This was most recently evidenced by the COVID-19 pandemic. Between clinic closures and social distancing guidelines, staff turned to alternative approaches like telehealth and online recovery services to continue to provide support for patients. “We had to do everything possible to make sure people who needed treatment were still getting it,” explains Botticelli. “Our clinical staff, in a very quick fashion, completely re-tooled their programs.”

Among the center’s quick-thinking responses was implementing substance use care and harm reduction services in the hospital’s COVID Respite Unit (CRU)—a building on BMC’s campus that was transformed into a shelter for stable COVID-positive people without a safe place to quarantine. Komaromy and several addiction colleagues anticipated a high need for SUD care in the CRU and prepared protocols accordingly, including naloxone training (an antidote to opioid overdose, also known as Narcan). “There was a tremendous need for treatment of patients with SUDs,” she recalls. “It was an opportunity to support patients in a medicalized shelter environment where we were providing housing support alongside 24-hour medical care and substance use disorder care.”

The center is also looking at ways in which it can advance policy in the wake of the pandemic. “Federal regulations that govern the way we can treat SUDs have been relaxed during COVID in order to keep treatment as accessible as possible,” says Komaromy. “Now we’re engaged in advocacy to make sure those interventions are permanent, so expanded access can continue post-COVID.”

THE FUTURE OF THE GRAYKEN CENTER

Looking ahead, Komaromy is eager to continue to evolve the center’s work. Building on her extensive and diverse background in treating addiction in many different settings, her immediate plans involve creating a “front door” to substance use treatment programs where people are triaged to the appropriate services in a timely manner, integrating behavioral health interventions across the spectrum of substance use programs and starting an addiction nursing fellowship for inpatient nurses.

Komaromy is quick to point out that Grayken would be remiss if it did not address SUDs from a number of angles and move forward in an integrated, high-quality way.

“We need an all-encompassing approach to have a big impact on substance use disorders,” concludes Komaromy. “There are a lot of questions to answer. ‘Is our workforce educated? Are you providing evidence-based care and staying up-to-date on the newest opportunities for effective treatment? Is your care accessible? Are you looking at the social barriers your patients are facing and thinking about ways to tear them down? Are the regulations in harmony with what’s needed in order to provide the best care? Are there unanswered questions we need to tackle with a research agenda?’ That’s just a snapshot of how the pieces fit together and why it’s important to focus on all of them instead of just one.”