THE CHALLENGE
How might we utilize a systems lens to shift our mindsets in how we see, assess, analyze and report the opioid epidemic?
THE APPROACH
I utilized systems archetypes and behavior over-time graphs to analyze the current state of the opioid addiction system and narrow the focus to one issue: limitations of harm reduction strategies in battling the opioid crisis. I drew causal loops and plotted graphs to showcase "shifting burdens" and "fixes that backfired" archetypes.
THE OUTCOME
Based on the analysis, I generated systems stories and insights revealing the gridlock situation. I brainstormed systemic solutions that could modify behaviors and mindsets. Additionally, I thought about tangible elements of structural and policy change, ultimately plotting a winning idea on the systems leverage map to illustrate its impact on the system.
MY ROLE
This week-long solo project was part of my systems class assignment. I used Kumu to depict the loops and InDesign to generate the graphs.
"I LOVED YOUR INSIGHTS! THEY ARE TRUE INSIGHTS! THIS WAS A WELL-DONE ANALYSIS."
- Dr. Natalie Privett, Systems designer at Design Institute for Health
01
THE CHALLENGE
The Centers for Disease Control and Prevention estimates that the total "economic burden" of prescription opioid misuse alone in the United States is $78.5 billion a year, including healthcare costs, lost productivity, addiction treatment, and criminal justice involvement.
One of the easy-to-identify measurable symptoms of the opioid epidemic is deaths due to overdose. The government, media, healthcare officials, and the general public have been trained to assess the opioid crisis through the lens of the number of deaths due to overdose. In 2018, 67,367 drug overdose deaths occurred in the United States. This led to a rise in one of the most controversial and short-term strategies to reduce overdose deaths, known as harm reduction. It focuses on individuals or groups for whom drug abstinence is not achievable. The goal is to decrease the harm associated with opioid addiction. Such strategies include widespread Naloxone distribution, needle or syringe exchange programs, supervised injection facilities, and safe disposal of unused opioids. In this system's case study, I focused on one of the widely used harm reduction strategies, the Naloxone distribution, and its short and long-term consequences.
02
THE APPROACH
Systems Archetypes describe common patterns of behavior in organizations. As diagnostic tools, they provide insight into the underlying structures from which behaviors over time and discrete events emerge. As prospective tools, they alert managers to future unintended consequences..*
I chose systems archetypes and behavior-over-time graph methods to capture the story of short-term fixes that backfire and shift the burden. These two tools help stakeholders visualize and understand the vicious cycles created by prioritizing Naloxone distribution and other harm reduction strategies while ignoring fundamental solutions necessary for sustainable long-term change.
*Braun, William. (2002). The System Archetypes The System Archetypes. System. 2002.
SHIFTING THE BURDEN / ADDICTION
This archetype has three elements.
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The problem symptom, in this case, is the deaths due to opioid overdose.
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The symptomatic solution includes harm reduction strategies, such as funding for Naloxone distribution and supervised injection sites.
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The fundamental solution is funding and political will for building rehab centers, behavioral therapy, and prevention through education.
This archetype starts with a problem symptom, deaths due to opioid overdose, urging policymakers and other stakeholders to intervene and find solutions. Unfortunately, the real solutions are very hard to implement for several reasons, such as insufficient funds, limited capacity, lack of skilled personnel, time delay, or requirement for a long-term commitment. That makes short-term symptomatic solutions desirable and tempting. It provides immediate reward as it quickly relieves the problem, ultimately developing a reinforcing loop, an addiction for short-term solutions, and diverting attention from real solutions.
Deaths due to opioids have been rising in the USA in the last ten years. The quick fix is to expand Naloxone distribution to reduce the death rate. The quick fix will bring down the deaths due to overdose momentarily, but It also takes attention away from the substance abuse prevention programs resulting in less funding and resources allocation for the prevention programs, ending in worsening the problem symptom. This graph shows that our current funding allocation trend shifts the burden from prevention to short-term fixes even though it is clear that Naloxone is not helping us bring the death rate down.
FIXES THAT BACKFIRE
In this “Fixes that Backfire” scenario, a problem symptom, deaths due to overdose, drives public attention and pressurizes politicians to take action. A solution is quickly implemented that relieves the symptom (loop B1). In our case, the band-aid solution is the expansion of Naloxone distribution and opening supervised injection facilities. Such harm reduction solutions temporarily reduce damages due to the opioid crisis; however, the symptom returns are often worse than before. Naloxone distribution reduces deaths due to overdose, but it does not solve the fundamental addiction issue.
By increasing Naloxone distribution, we increase the demand for naloxone resulting in increased prices. Eventually, it becomes hard for rural counties and underserved urban neighborhoods (hard-hit areas) to buy Naloxone, reducing access to the life-saving drug. Pharmaceuticals find a new niche to profit from complex health issues and short-term band-aid solutions implemented by the government. This leads to an increased number of people living with opioid addiction and an ultimately increased number of overdose deaths.
In less than five years, health workers have seen the price of Narcan skyrocketing. In some cases, it has increased 261% from the initial prices. It’s a fundamental supply and demand problem. By May 2017, all 50 states and the District of Columbia had passed legislation designed to improve layperson Naloxone access. However, significant shortfalls in access continue to persist due to inadequate distribution and prohibitive costs. As the government increased the distribution and demand, pharmaceutical companies jumped at the opportunity to make a profit and increased the price. This graph shows that the rise in deaths due to overdose leads to higher demand for Narcan, causing the prices to rise. Inaccessibility of Narcan reduces the effectiveness of the Naloxone expansion program.
03
THE OUTCOME
Based on the analysis, I generated systems stories and insights revealing the gridlock situation. I brainstormed systemic solutions that could modify behaviors and mindsets. Additionally, I thought about tangible elements of structural and policy change, ultimately plotting a winning idea on the systems leverage map to illustrate its impact on the system.
INSIGHTS
01.
Is death due to overdose a proper method to report the opioid crisis?
The government, media, healthcare officials, and the general public have been trained to assess the opioid crisis through the lens of the number of deaths due to overdose. We give extra attention to the overdose death data, but very little attention to the number of people addicted to opioids or its economic burden. By focusing on just the death rate, we shift the system’s purpose from reducing addiction to reducing deaths, leading to a series of short-term fixes that deteriorate the situation.
02.
Naloxone promotes revolving door syndrome for many addicts.
Most people know that Naloxone saves lives, but very few know that about 1 in 20 patients treated for a non-fatal opioid overdose died within one year of their visit. We rarely ask and give attention to people who survive the event. There have not been many research studies that answer these questions, but reports suggest that Naloxone enhances a revolving door syndrome for many addicts.
INTERVENTION IDEA
Change the way the news regarding opioid overdose is reported.
The idea here is to incentivize local and national level journalists to make a minor change in how they report death's due to opioid overdose. We all are accustomed to seeing news headlines or reports showcasing the number of people who died due to opioid overdose, but we rarely see the numbers on opioid addiction. We know how many people die from an overdose, but we don't know how many are battling the addiction. What if we make a minor change in the format for how headlines are written, or in how news is reported on television. What if we make it mandatory to report overdose deaths in the following format. Instead of reporting "XXXXX number of people died due to opioid overdose," report it as "Out of XXXX number people suffering from opioid addiction, XXXXX died due to overdose."
As illustrated in the system leverage map below, this small change will bring awareness regarding the magnitude of the addiction problem and shift our mindsets in seeing, assessing, and analyzing an issue. This small effort will help us see the bigger picture and the root cause, and it will put pressure on the officials to take action to save lives and prevent people from getting hooked to opioids in the first place by primordial prevention. It will also help change the public's perception and opinion on the ethical question: are tax dollars being used to appropriately solve the issue, or not? It will bring more accountability, awareness, and enthusiasm to solve the issue.
The system leverage map