News & Updates — Grantee Spotlight

FORE grantee Jonathan Avery, M.D., associate professor of psychiatry and director of the Substance Use and Stigma of Addiction Program at Weill Cornell Medicine in New York City, is collaborating with colleagues at the Massachusetts Institute of Technology Media Lab and the Dalio Center for Health Justice at New York–Presbyterian to develop a virtual role-playing tool to assess physicians’ attitudes toward patients with opioid use disorder (OUD) and help them build empathy toward them. We asked Dr. Avery about what fuels clinicians’ stigma toward OUD patients and how this new training approach might help.

You edited a book that looks at how the stigma toward addiction affects family relationships, jobs, and people’s experiences in the legal and health care systems. What do we know about how stigma develops among physicians?
Avery: My research has shown that health care provider attitudes are worse toward those with substance use disorders than toward any other medical or psychiatric conditions. And strikingly, providers’ attitudes may even get worse over time.

There are a lot of reasons for this. One is that we view this health condition as different from others and often reject the disease model of addiction. We see people struggling with addiction as bad people doing bad things as opposed to people who are unwell and at the service of a hijacked reward system. There’s also a bias that can develop in the course of our medical training, because we don’t interact with people in recovery. We often see people in emergency settings or in medical practices who are in the middle of substance use disorder crisis, and never seem them when they are recovered in the future. And so our only experiences with them are negative. And in fact, among substance use disorders, providers have worse attitudes toward those who use opioids compared to other substances.

Why is that?
Avery: Doctors played a role in the creation of the opioid epidemic, and now we’re really tasked with tackling it. Yet many of us might not want to — in part because we don’t have the knowledge or skills, but also due to stigma. And then I think the deaths from opioid overdoses make us nervous. People view treatment for OUD as more intense and scarier than treating someone who’s drinking or using nicotine. And so I think that that also creates the need to distance oneself psychologically.

How did you learn to empathize with people with addiction?
Avery: My dad was a hospice physician and his experience was that there are certain folks who never get a chance to tell their stories. And he focused on dignity therapy, which helps people write their narratives when they’re facing the end of their life. And then my experience in medical school and residency was that people with substance use disorders may also feel misunderstood, and often don’t have a chance to tell their stories. I started doing dignity therapy with patients with substance use disorders, which really fueled my understanding of the addiction process and my desire to be an addiction professional. And at the same time, literally everyone in my life told me not to be an addiction professional. That just made me want to double down.

Why do you think so many people tried to steer you away from addiction medicine?
Avery: I think a lot of people feel like it’s not in the realm of medicine, that we should be doing surgery or, you know, pediatrics — things that seem like areas where you can make a change. And the reality is that we can do more in addiction to change people’s lives than in most other parts of medicine.

How do you hope your intervention will help other clinicians develop empathy for people with opioid use disorder?
Avery: One thing I always teach my residents is that one of my goals as an addiction provider is to be the friendliest face the patient has ever seen. They’re so used to finger-wagging, negative approaches. I always say, ‘If I can do it as a bald, middle-aged man, certainly you can do it with your hair and young face.’ And then a few years ago I met Dr. Rosalind Picard of MIT’s Media Lab at a meeting where she was talking about her ability to teach empathy using technology that looks at people’s faces and gives them feedback on the degree that they’re empathic. That’s how this partnership began.

How will your tool work?
Avery: It will be an online tool that records users as they interact with videos of OUD patients in different clinical scenarios and settings, such as in the emergency room or in a primary care clinic. The user will get feedback in real time about how effectively they’re expressing empathy through their facial expressions. Then at the end, they’ll get video clips showing their facial expressions and explaining how they did. We’re hoping the tool creates awareness that empathy is something that we can communicate and that we may lack in situations that feel stressful, like interactions with challenging patients. We in medicine are often really boring teachers. We’re hoping to make this not another rote training, but something that you can interact with and play with.

Where are you now in developing this tool?
Avery: We’ve recorded a number of clinicians’ interactions with folks with opioid use disorder. The next step is showing these clips to people with lived experience with opioid use disorder. They will rate what they like and don’t like about the clinicians’ expressions. And then Dr. Picard and her colleagues at MIT will use that information to create a tool that’s able to analyze the faces of the clinicians and provide feedback. Her research has found that certain facial expressions can communicate empathy, disgust, anger, or a range of other feelings. She’s used this technology to teach empathy in other settings, including other health care settings. But this is the first time it has been used to build empathy for patients with substance use disorders.

And how are you partnering with the Dalio Center for Health Justice?
Avery: We’re very lucky to partner with the director, Dr. Julia Iyasere, who is helping make sure our patients represent a diverse group of individuals, and that our technology doesn’t fall prey to racial bias. She is also helping us develop training modules about how other biases including those based on gender and race can play a role in perpetuating stigma toward folks with opioid use disorder.

Where do you expect to see the tool used?
Avery: We’re going to test it with Cornell medical students to see how it works. But ultimately, our goal is to make it available to all health care professionals, not just medical students and physicians, but also nurses and other staff who interact with folks with opioid use disorder. In most health care professionals’ training, the stigma of addiction is not addressed, or it’s like a throwaway comment at the beginning of a lecture. There’s a real deficit, which makes no sense because about 10 percent of hospital admissions are related to substance use. We can’t keep pretending that this isn’t something we see every day.