Researchers Should ‘Sound Alarms’ for Vulnerable Populations.
It took the media more than a decade to catch up to Michael Stein.
“The disease burden for the opioid-dependent drug user is substantial, related to overdose, transmission of infectious diseases, and frequent hospitalization. The burden to society in terms of crime, law enforcement costs, family disruption, and lost productivity is also notable,” he wrote in a study published in 2005—long before the opioid crisis in the US began making headlines.
Stein, a physician and health services researcher, starts work July 1 as chairman of the Department of Health Law, Policy & Management. While he is modest about his early work on addiction, he was among the first physicians to prescribe and study the use of buprenorphine, which blocks the effects of opiates on the brain, for patients with heroin and other opioid dependence.
And, in his secondary role as an award-winning author, he channeled his experience into a bestselling book, The Addict: One Patient, One Doctor, One Year, which chronicled his dealings with a young female patient who was addicted to the painkiller Vicodin.
“One role of the scientist is to sound alarms,” Stein says. “My book came out of both my research and my clinical sense that this opioid epidemic was different: prescription pill-related, suburban, and reaching women equally to men. I certainly knew it wasn’t something that was going away—it had all the makings of something that would only get worse.”
Stein, who comes to SPH from Brown University, where he has been a professor of medicine, health services, policy & practice, says he was drawn to SPH for a number of reasons, including its focus on helping vulnerable populations. His research has focused on substance use disorders, HIV/AIDS, mental health disorders and the determinants of risk-taking.
Stein has published more than 275 scientific journal articles and has been recognized by the National Institutes of Health as being among the top 1 percent of federally funded clinical investigators over the past two decades, related to his interests in substance use disorders and behavioral health medicine.
A New Jersey native who graduated from Harvard College, Stein helped to support himself through medical school at Columbia University by working as a staff writer for the journal Nature. He ventured into fiction writing after earning his MD: In addition to The Addict, he has written seven other books, six of them novels. His books have been national Booksense/Indie Reader’s Choice selections and were twice nominated for the Pulitzer Prize. His first book of non-fiction, The Lonely Patient: How We Experience Illness, won the 2007 Christopher Award.
He spoke to SPH about his research, his writing, and his new position:
Q: Your research has focused on behavioral health medicine. What drew you to that field?
A: Like “public” health, “behavioral” health has come to mean different things to different people. For me, as a primary care doctor, behavioral health encompasses both physical and mental health, because the two are never separated for long. Behavioral health includes not only anxiety, but also inactivity and its cardiac risk; not only depression, but also its usual companion, pain.
To study behavioral health, as a researcher, is to offer a fuller, more flexible, more coherent, and more comprehensive account of what we human beings are—what we mean when we say we’re healthy, and therefore, what we want from our health care providers. Because my research wanders across fields, behavioral medicine has been a good cover for me.
Q: What research in behavioral medicine are you pursuing now?
A: Over the past five years, I’ve gotten interested in the possibilities, and limits, of using technologies to reach greater numbers of people looking for help with particular health issues. With NIH support, I’ve begun to develop phone apps. There are now thousands of medical phone apps, but few derive from behavioral health models, and even fewer are rigorously tested. So, I’m trying to create apps that address specialized populations—women at risk for substance use relapse, opioid users who have remained drug-free and are planning to get off treatment—and testing these bits of software.
I’ve also been involved in projects related to sleep—in people who drink alcohol or use opiates, in older people with diabetes, and in young people who smoke marijuana. With marijuana’s growing availability, we need a better understanding of its effects and side effects. Our societal opinions about marijuana use are in transition, and the science is confusing, so I’ve become quite interested in how young adults understand marijuana’s pleasures and discontents. I’ve turned my research and public alarm-sounding in this direction, as well.
Q: You were doing research on opioid addiction long before it became a mainstream crisis. Why are we seeing a spike in this problem now, do you think?
A: At this point, the persistence of the problem is beyond a “spike.” It has many precipitants, but I believe the two dominant ones were over-prescribing by clinicians, and the broad mental health effects that “The Great Recession” had across the country.
Q: You’ve been looking at non-pharmacological ways to increase tolerance to pain. Can you talk a bit about that work?
A: Chronic pain is the body’s great betrayal. It is the body turning on you. Pain undermines security and confidence. It is depressing and ruinous. As clinicians, we have limited, imprecise ways of making pain go away–not very different from 100 years ago. We are often not successful at helping our patients with pills, or at helping them enough to allow something like normal life to return.
For years, I’ve been working with a group of psychologists, trying to find ways to talk or think about pain that bring some relief—or better yet, some normality—to the lives of people with pain and depression. As clinicians turn away from opioid prescribing over the next years, finding new ways to help people in pain will only grow.
Q: You recently wrote an op-ed in the Washington Post headlined: “When medical care is delivered in 15-minute doses, there’s not much time for caring.” Is the time-pressure situation for physicians getting worse?
A: The time pressures on primary care doctors working in offices have become dispiriting in our corporatized health care systems. The best doctors resist these arbitrary appointment limits. Of course, there’s a trade-off: longer appointments often make for a longer day. While the length of the standard visit has remained constant, the average medical patient in 2016 is older, with multifaceted problems and more treatment options, than a patient 30 years ago.
I often wonder what the permission to take five extra minutes with a patient would do for young doctors. How about a randomized trial, testing 15-minute visits versus longer visits on patient outcomes, including satisfaction? All of this may be moot if and when house calls make a comeback.
Q: You’ve had a successful career as a novelist. How did that start, and what do you hope to accomplish with your books?
A: I began my writing life as a journalist in college and started more creative writing during medical school. Writing novels is talking to yourself and hoping that other people want to listen. My primary mission is to make characters who are plausible and readable, although I try to set myself a new challenge with each book, in structure or voice.
I’ve generally kept my medical and writing lives separate, though I’ve drawn on my clinical experiences for my nonfiction books. Thankfully, doctoring is not the job of the writer. As Chinua Achebe explained in Anthills of the Savannah: “Writers don’t give prescriptions. They give headaches.”
Q: What drew you to the School of Public Health?
A: So many things. I liked the idea of a public health school that was outward-looking, activist and interventionist—truly public. Second, the work at SPH and its sister institution, Boston Medical Center, has deep connections with vulnerable populations that have interested me for my entire career. Anyone who grew up during the HIV epidemic, as I did, understood immediately the importance of the impact of social determinants on health—and SPH has made this idea part of its intellectual DNA.
Third, I’m excited by the chance to work with the members of the new HLPM department, a uniquely heterogeneous and talented group of faculty whom I’m certain will teach me plenty of new things every day.
Fourth, Sandro Galea. Who wouldn’t want an office near his?