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February 23, 2021
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To truly address the causes giving rise to the opioid epidemic, and of addiction at large, we need to shift our focus away from looking at the different causes and effects of the epidemic, and towards patient behavior.
In shifting our outlook, we can observe substitution patterns that reveal whether a patient uses opioids truly for pain or for other reasons. Not based on the outcome statistics regarding mortality and overdoses, but through behavioral shifts that appear as a reaction to a change in the healthcare system.
We know the number of prescription opioids have decreased but the number of opioid-based overdoses have increased. The perception that patients will simply switch from one form of addiction to another is well known, and probably the biggest difference in how the medical and legal community approach the opioid epidemic.
Law enforcements view the epidemic through outcomes, such as mortality rates. But behavioral health decision models that view the epidemic through behavioral shifts create a different perception of the opioid epidemic, one that accurately reflects the patterns of behavior seen among patients.
These models look at healthcare as a system, defined by the interactions and behaviors of patients and providers.
Such models find that reducing the number of prescription opioids have little effect on overdose rates, and that the greatest impact in reducing mortality comes from greater access to opioid addiction medicine and reducing relapses among those who have already suffered from non-fatal overdoses.
This should come as no surprise. When we change the perception of the epidemic from outcomes and statistics to a series of behaviors, we shift our perception of the solution to the epidemic.
The opioid epidemic is really a series of sub-epidemics defined through unique healthcare ecosystems, each exhibiting its own unique patterns of behavior. The public health policies for one locale may be effective in that region, but counterintuitive in another region.
We must become more granular in our approach to enacting healthcare policies for addiction treatment. Analyze the individual decisions that create the broader trends we see in healthcare. And study the layers of behavioral consequences that emerge from any patient decision.
We must truly immerse into the systems method of thinking.
Ray Dalio discusses the flow of thought, and details first, second, and third order thought patterns, in which each thought pattern affects the other thoughts and is affected in return – using the flow of a river as an analogy.
The unique multi-layered thought patterns that are observed across populations of patients are called emanative and emergent properties. Emanative properties are directly observable trends seen in simple pattern dispersion patterns. Emergent properties are more subtle trends not easily observed and visualized only by superimposing different pattern variances over different time horizons.
We intuitively understand why physical therapy orders should vary with opioid prescription rates. But the exact nature of that relationship is a complex array of variables that emerges only when observing patterns trending over time horizons – in effect, manifestations of perception shifts.
These second and third order properties are silently influencing healthcare systems through unique relationships within each healthcare ecosystem. This explains why some solutions work in certain regions, and why certain trends appear inconsistently in one part of the country, but not the other.
Numerous studies have attempted to demonstrate a direct relationship between economic factors like unemployment rates and opioid overdoses. But by and large the studies have been inconsistent – because they present incomplete conclusions that do not study the full complexity of the issue, and simplify relationships to linear correlations, which are insufficient to describe complex systems.
We need systemic models of complexity to study healthcare in its entirety. Models that adjust dynamically depending on the changing patterns of behavior. Anthropologist Jared Diamond applies similar frameworks to observe trends that may not appear imminently obvious throughout history. It is no coincidence that he describes world history as layers of an onion to be peeled away, layer after layer, through which perceived cause and effect is actually impacted by a more subtle cause, which in turn has its own even more subtle cause, and so on. Eventually Diamond learns the relationships among the events in history are more important than the events themselves and developed novel interpretations of history based upon this belief.
Nassim Taleb, who coined the term, ‘black swan’, when discussing rare but calamitous events in financial markets, has studied complexity in different systems. He describes the complex relationships within any complex system as either fragile, not fragile, or antifragile to describe the systemic effects of individual stresses or single inputs upon the system.
Studying healthcare ecosystems as a complex function comprising of multiple complex patterns allows us to visualize the effects of individual patient behavior on the entire healthcare system. Fragile systems get worse in times of chaos, not fragile systems remain the same, withstanding, but not improving in times of chaos, and antifragile systems improve in times of chaos – all changing in response to something, as a relationship.
Similarly, a healthcare ecosystem is not defined by clinical guidelines or public policies. It is defined by the interaction of patients towards those guidelines and policies. This shift towards complexity, seeing patients as a composite of numerous decisions and behaviors, changes healthcare from an objective analysis of individual patient data towards a subjective study of interacting patient perceptions.
The patterns of thought, decisions, and subsequently behavior define the complexity in healthcare. Essentially evolving from individual perceptions and behaviors into a system of perceptions with its own unique tendencies. Something we should begin to appreciate as we shift our perspective of healthcare towards a complex system.
Systemic thinking in healthcare recognizes that addiction is part of a larger set of behaviors and influences that defines healthcare itself, not dependent upon any one individual or group.
Because ultimately, systems are deduced from behavior, as the interactions define the system as much as the individual patients and providers within that system. All coming together in a coherent feedback process.
And like systems, there are different feedback points, each shifting dominance in the overall system, that are all inherently oscillatory. Just like the systems of perception that define the true nature of healthcare, and the underlying uncertainty that has defined much of reactionary behavior during the opioid epidemic.
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