Addressing Veteran Opioid Addiction through Social Design
TIME FRAME: 2 weeks | TEAM SIZE: 3 members | ROLE: Research + Facilitation
Our goal with this project is to develop a social design strategy that leverages communities surrounding the problem of veteran opioid abuse to create solutions that are able to mitigate or solve said problem. Due to the intimate and experiential nature of this topic, rather than utilize a traditional user-centered design approach, we aim to incorporate domain experts into the design process, thereby scaffolding their own design ideas rather than injecting our own.
BACKGROUND
About 60 percent of veterans returning from deployment in the Middle East, and 50 percent of older veterans, suffer from chronic pain. This is versus the 30 percent of Americans who suffer from chronic pain nationwide. Although the U.S. Department of Veterans Affairs (VA) is supposed to provide care for veterans and their dependents, veterans still have uneven access to healthcare.
Untreated chronic pain increases the risk of suicide, so it is important to treat the causes of chronic pain. However, the VA used to almost exclusively treat veterans’ chronic pain by prescribing opioids. Instead of helping veterans recover from war, the VA masks their pain with potent drugs, feeding addictions and contributing to a fatal overdose rate among patients that is nearly double the national average. In other words, veterans are being over-medicated as the VA struggles to keep up with their need for more complex treatment and are twice as likely to die from an accidental opioid overdose than a non-veteran.2
Since 2012, the VA has tried to curb overprescription and abuse of opioids. It has reduced the number of veterans receiving opioids by 20 percent, lowered dosages, increased screenings for depression and substance abuse problems, and created comprehensive approaches to chronic pain. Some VA centers have started to introduce programs on managing chronic pain with acupuncture, yoga, mindfulness, and physical therapy that can either reduce the need for painkillers or eliminate it entirely. But such programming is still lacking in many centers. The number of veterans with opioid-use disorders continues to grow, as evidenced by the number spiking by 55 percent from 2010 to 2015.
References:
Childress, Sarah. "Veterans Face Greater Risks Amid Opioid Crisis." PBS. Public Broadcasting Service, 03 Mar. 28. Web. 05 May 2017.
Glantz, Aaron. "VA's Opiate Overload Feeds Veterans' Addictions, Overdose Deaths."Reports. The Center for Investigative Reporting, 28 Sept. 2013. Web. 05 May 2017.
High Level Takeaways
The current system in place that the VA uses to treat veterans with chronic pain is inefficient and impractical. Access to health care and support needs to be made more accessible to veterans. However, current social landscapes and interactions prevent proper treatment and upkeep.
By facilitating needed interactions and removing points of frustration between veterans and other stakeholders, we hope to reduce and sustain low opioid addiction rates among U.S. veterans. We can achieve this by preventing veterans from getting addicted to opioids in the first place and successfully intervening if they are or happen to become addicted.
UNDERSTANDING & REFRAMING THE PROBLEM
Creating a Cultural Model
The creation of a cultural model serves two key purposes in our design process. The first is to better understand the relationships between our stakeholders at a structural level. Different stakeholders depend on each other in ways that may not be obvious at first, so uncovering this is important. Secondly, creating a cultural model helps us identify certain pain points, which pose opportunities for design intervention.
Developing a Value-Flow Model
Creating a value-flow model helped us understand the exchange of resources among our stakeholders. This step was important, as it outlined “value-driven” relationships, and allowed us to clearly visualize the constraints/obligations that different stakeholders have to one another.
In this case, the VHA is funded exclusively by the federal government, meaning that it may suffer from inadequate funding.
Developing a Block Diagram
The block diagram provided us with an overview of the problem space and all the factors that contribute to veteran opioid addiction.
Settling on a Social Approach
Veteran opioid addiction is a widespread and long-term problem; it is neither local nor time-bounded. As long as VHA physicians continue to prescribe addictive medications to veterans, there is a potential for these patients to become addicted and the problem will never, truly be resolved. For these reasons, we believe a micro approach to opioid addiction is inappropriate.
Political approaches are typically adopted to either reinforce or change the intended audience’s perspective; however, nearly everyone—regardless of political party affiliation—would agree that veteran opioid addiction is a serious issue that should be addressed. Raising awareness or inspiring social action is also unlikely to have any notable effect on the explicit problem.
This rationale led us to adopt a social approach toward the problem of veteran opioid addiction. A social approach facilitates addressing the problem directly and provides for the eventual transfer of the design outcome to community owners.
Identifying Key Stakeholders
Once our research led us to a socially-driven approach, it was necessary to target a few specific stakeholder groups to address any social interaction issues between them. Although our main focus is on the veterans, we also identified potential groups who can have significant impact on veteran opioid use.
Opioid-treated U.S. veterans
Opioid-addicted U.S veterans
Veterans’ families
VHA policy makers
VHA physicians
Counties (jail, criminal courthouse)
Taxpayers
Developing Scenarios
We crafted the following 27 scenarios to consider the implications of our proposed solution on different types of stakeholders and how elements of the solution might change depending on the individuals involved and the interactions among them.
Physical limitations. After suffering severe burns to his hands and arms, Sam was honorably discharged and has been receiving treatment for chronic pain. Part of this treatment involves chronicling his daily experiences in an application issued by the VA. Sam uses the voice input option to record his thoughts when prompted, and the data is subsequently sent to a VA server for analysis. The system is designed to notify VA physicians of mood changes that may be indicative of developing psych conditions.
Paralysis. Luke is a veteran who is paralyzed from the waist down. He also experiences chronic pain in his back due to his injuries. Because of his disability, he cannot partake in alternative forms of therapy such as yoga. However, his wearable still keeps track of his vitals and activities (it’s been adapted to motions he uses while in his wheelchair) and disseminates them to a system. The wearable also encourages and reminds him to perform tasks that he might overlook or neglect as he adapts to being unable to use his legs.
Sensory issues. Following an 18-month deployment to Iraq, Carl was diagnosed with severe PTSD and Sensory Processing Disorder. Carl’s doctor has him use the VA’s new mobile application that collects self-report (e.g. surveys, journal), smartphone-collected (e.g. location), and wearable sensors’ data (e.g. heart rate, movement) to monitor his well-being. However, due to Carl’s oversensitivity to tactile stimuli, his doctor decides to omit the wearable component and have him use features of the application that don’t rely on data from the wearable device.
Psychiatric conditions. Kate returned from Iraq five months ago and was given a clean bill of health. As she works to readjust to civilian life, Kate’s doctor has her use a wearable device to monitor her sleep patterns. After several months, the collected data reveal that Kate’s sleep and energy levels have been decreasing while nightmares are increasingly more frequent. These trends prompt a doctor’s visit and subsequent diagnosis of depression and PTSD.
Reluctance. Initially, Bill was very resistant to taking opioids, but started doing so after his doctor outlined a plan that involved the gradual cessation of opioid treatment. Motivated by the agreed-upon plan, Bill followed the prescribed exercises designed to address both his physical and psychological well-being (e.g. yoga, surveys, journaling, etc.). Bill’s doctor was able to monitor his progress using the data collected by the application that issued the exercises. After two years, Bill was thrilled when his doctor decided to remove opioids from his treatment plan.
Engagement. Steve is given the task of keeping track of his biometric data, as well as keeping up with his treatment regimen and checking in regularly with his physician. He meets all his deadlines and consistently checks in with all the information the VA needs to make sure he’s on track. After 30 days of consistent, consecutive check-ins he receives a badge that commemorates his progress. As he continues to improve, he collects more badges as tokens of his improvement.
Distrust. James wants to reduce his opioid treatment over time, but he doesn’t trust the systems that would record his data and send them to his physician or loved ones. He’s very private and wants to keep the information to himself, so he refuses any type of regimen involving doctors keeping up with his stats, especially in real time (he hates being “monitored” or “spied on”).
Pride. Carla suffers from chronic pain and has been prescribed opioids, but she holds a carefully constructed outward persona to those she knows. She actively tries to hide the fact that she uses opioids, even though she needs them (for now) to function. Her doctor tries to convince her that it’s okay to use them because she really needs them.
Social withdrawal. Kate’s family members are worried that her depression and PTSD are worsening. After hearing their concerns, Kate’s psychiatrist has her install a smartphone application that tracks her GPS coordinates and proximity to other smartphones. Summaries of the collected data allow Kate’s doctor to determine the extent of her social isolation and devise treatment plans that combat social withdrawal.
Social engagement. Jose has always had many close friends, but has been struggling with survivor’s guilt since returning from Afghanistan. His doctor asks him to use a VA application that periodically issues electronic surveys designed to assess psychological well-being. By viewing summaries of the data, Jose’s doctor determines that he is becoming more socially withdrawn and prescribes an SSRI to help Jose cope with his anxiety.
Overdose (supportive family). With the help of supportive family members, Dan has battled opioid and heroin addiction since suffering severe injuries in Afghanistan. One evening, his wearable device reports a dangerous decrease in Dan’s heart rate. In addition to contacting emergency services, the application notifies Dan’s brother, Robert, who is less than two miles away. Robert arrives before paramedics and in time to administer naloxone to reverse the overdose and save Dan’s life.
Overdose (unsupportive family). Coping with chronic pain and PTSD has led Matt to spiral into opioid addiction. His friends and family members have grown increasingly frustrated by his apparent apathy and inability to kick the addiction. One evening, Matt’s wearable device reports a dangerous decrease in heart rate. In addition to contacting emergency services, the application notifies Matt’s health team of the overdose, so someone with knowledge of Matt’s situation can be present when he arrives at the ER.
Decreasing pain. Lindsay has been consistently providing responses to each application-issued, electronic pain survey. After several weeks of reporting that she is in less pain than before, the VA hospital contacts Lindsay about making an appointment with her doctor to discuss revisions to her opioid regimen.
Physical activity. Bob goes to his VA physician for treatment. His physician gives him a Fitbit that monitors his physical activity daily and over time. Bob’s physician also has access to this information, and can keep track of Bob’s physical activity which correlates with his physical and possibly even psychological well-being.
Alcohol intake. Alissa’s VA physician gives her a chart to fill in detailing how much alcohol and medication she ingests per day (how many drinks, any OTC medications, non-prescription medications). Alissa completes the chart each day so she and her physician can keep track of her healthy (or unhealthy) habits. When Alissa has many drinks over a consecutive number of days, her doctor checks in to make sure she is okay.
Biometrics. Felix is given a wrist wearable that keeps track of his vitals and activity: heart rate, blood pressure, time spent exercising, etc. It can also test his blood sugar, cholesterol, and if there are any drugs in his body. It sends all this data back to a system that both he and his VA physician can see, as well as anyone else Felix decides to give access to.
Prior opioid abuse. Stephanie is a veteran who had previously been prescribed opioids as a result of chronic pain from a wartime injury. However, because of an incident in which Stephanie nearly overdosed on her medication, her physician and family feel a need to be more involved in how Stephanie manages her medication. Stephanie’s family and physician are able to monitor her usage cooperatively as a way to keep her safe.
Busy physician. Andrew is a veteran returning home with chronic pain. He visits his VA-assigned physician, who prescribes him opioids, but not before informing him of the potentially addictive nature of the drug. Andrew and his physician are able to work together to monitor his usage of the drug through an application that keeps Andrew’s physician involved without taking up too much of his time. As a result, Andrew is able to avoid addiction and recover from his pain.
Distracted physician. Mike recently returned from Afghanistan and has begun seeing a new doctor for help managing his chronic pain. After filling out the electronic prescription, the system alerts the doctor to a possible issue: he has entered a much higher daily opioid dosage than is typically prescribed by VA physicians for patients with similar characteristics to Mike (gender, weight, etc.). Realizing his error, the doctor corrects the dosage before printing and handing Mike his prescription.
Involved physician. Jack fills out a daily survey with quantitative data about himself: how much he weighs, his blood pressure, how much he slept, the quality of his sleep, how many minutes he spent exercising, and whether or not he took his medication. His VA physician can access this data, and if she notices anything amiss or the emergence of a negative trend, can immediately schedule an appointment to see him.
Uninvolved physician. Regina is a veteran with chronic pain due to a wartime injury who was prescribed opioids by her VA-assigned physician. Although Regina has concerns about the severity of her prescription, her physician is difficult to contact and seems uninterested in her concerns. As a result, Regina worries constantly about balancing the potential for addiction with her chronic pain.
Supportive family. Sarah has recently returned from Afghanistan and suffers from PTSD, major depressive disorder, and chronic pain from injuries sustained overseas. Although she wants to get better and stay away from opioids, her depression and trauma make it extremely difficult to follow routines and taper off of medications. She turns to support from her friends and family, as well as her VA physician who works closely with Sarah’s loved ones to make sure she stays on track.
Unsupportive family. Jason suffers from chronic pain and has been prescribed opioids as a pain-easing measure. Although his family and doctor are trying to work with him to ensure he is taking his medications responsibly, Jason feels that they don’t fully understand his situation, and instead asks a fellow veteran to help him monitor his opioid usage. The two are able to work together to keep Jason’s opioid use in check.
No familial support. Joyce is working hard to recover from an opioid addiction, but her family does not acknowledge her progress or try to help encourage her when she needs it. They also do not feel inclined to discuss any information with Joyce or Joyce’s physician, so Joyce can only rely on herself and her physician.
Supportive friends. Benedict has a number of fellow veteran friends who have all come home with chronic pain as a result of battlefield injuries. Although they are connected with VA doctors and given opioid prescriptions, they understand the drugs’ potential impact and want to keep each other safe. They agree to help each other monitor their opioid usage and recovery, establishing an impromptu support network.
Cooperative stakeholders. Brian is a veteran who developed an addiction to opioids after taking them to manage chronic pain resulting from an injury sustained during a tour in Afghanistan. Brian’s family and doctor all want to help him use his opioid prescription responsibly. Brian’s family trusts his doctor, and are generally proactive about Brian’s condition. As a result, Brian, his doctor, and his family are able to share information and work together to monitor his well-being and recovery.
Uncooperative stakeholders. Arnold is a veteran returning from a tour with an injury that requires an opioid prescription. Arnold’s family cares about him very much, but has heard a lot of bad things about the VA health services from fellow veteran families and would like to ensure their son is receiving the care he needs. With Arnold’s permission, they are able to independently monitor his care and recovery process, so as to ensure his well-being.
CREATING THE CO-DESIGN SESSION
The Goal of the Session
Following our exploration of the problem space, we determined that the most valuable focus for our co-design session would be a preventative one. As interaction designers, it seemed foolish and, frankly, dangerous to pursue a curative approach; we do not and cannot know enough about the delicate balance of addiction and recovery to implement an effective strategy in that arena. Furthermore, the strong disconnect between larger organizations like the VA and individual veterans and their families means that a high-level, structural intervention was also unlikely to have a strong impact.
As such, we designed our session to bring together the relevant stakeholders to help prevent addiction from occurring.
Participants
After exploring the topic domain, we decided to narrow the scope of our co-design session to four specific stakeholder groups:
Veterans with previous experience taking opioids—one who has beaten opioid addiction, one who has been prescribed opioids, and one who consciously rejects opioids as a way to manage chronic pain
Family members of veterans with experience taking opioids—one who has lost a veteran to opioids and one with a vet currently using opioids
VHA physician
VA administrator
We believe that these four stakeholder groups represent those most capable of creating potential solutions within the selected problem space; i.e. preventing opioid addiction in veterans before it occurs.
Our expectation is that the VA will facilitate participant acquisition.
This poster is intended to serve as an internal document providing a visual overview of the session.
After careful consideration of the collaborators and stakeholders who would contribute to the co-design session, we planned and developed four activities for them to participate in:
Sharing Experiences (Directed Storytelling)
Connecting the Dots (Journey Mapping)
Situation Sketching (Storyboarding)
Discussion of Design Ideas
Selected Activities
Sharing Experiences
Veteran and non-veteran participants will be asked to prepare a personal story to share. Participants are allowed to ask questions to frame and guide the conversation. They will also listen for specific facets of the stories. This activity should help us better understand the experiences of all participants and better develop empathy for everyone involved.
Connecting the Dots
Participants will work together to consolidate a shared narrative based on the stories shared in the previous activity. They will then identify frustrations in their interactions and come up with ideas that could potentially remedy the pain points. This activity should facilitate brainstorming a wide variety of design ideas from multiple perspectives.
Situation Sketching
Attendees will participate in a storyboarding activity where they will sketch out situations where a design idea changes an interaction. These sessions will ideally elaborate on and refine the brainstormed design ideas.
Discussion
Following the storyboarding sessions, participants will share their storyboards and discuss their potential design ideas. Everyone will work together to highlight the three best ideas.
POST-SESSION
Visualizing Feedback from the Session
Following the co-design session, we will determine the three best ideas generated during the session to expand into full, concrete proposals.
We would then present these proposals to the VA. Following the presentation, we would move forward by agreeing upon a single proposal to pursue, and would begin production and development of the agreed-upon approach.
The VA would provide oversight and guidance to the team chosen to develop the solution. Maintenance of the designed service would be the responsibility of the VA following its completion, so that it might continue to exist and serve within the VA’s ecosystem for veteran rehabilitation.
Potential Directions
Although our project was first and foremost intended to result in the creation of a co-design session, rather than concrete solutions, we extensively discussed possible solutions that may arise from the session.
Solutions in this space were primarily focused on creating cooperation between VHA physicians and veteran family members to act as a preventative force against addiction for veterans newly prescribed opioids. Some ideas in this vein included mobile apps that collect location data and prompt veterans to self-report their well-being, so that family members and physicians might receive warnings if something were to go wrong. Furthermore, because of the preventative nature of our approach, our solutions included ways to engage veterans in fighting addiction, including inventive data visualizations that detailed their progress.
Veteran Information
Veterans could have a way to keep track of their moods, sleep patterns, whether or not they’ve taken their medications, and other relevant information. A wearable or app could also passively keep track of factors such as exercise and biometric data.
Goal Gamification
Veterans could set goals to reach such as exercising, decreasing medication dosages, or even self-care in general. This may manifest in a game-like feature or peripheral display where the veteran’s game results would directly correlate with their lifestyle. For example, hydration apps ask users to water plants each time they drink a glass of water. Users might also take care of a virtual pet in similar ways they would care for themselves.
Data Visualization and Notifications
Veterans would be able to see their information and data over time to keep track of their progress. This information would also be available to their physician and anyone else the veteran chooses to give permission to. In the event of a possible health crisis, the physician and any emergency contacts could also be notified and easily check in with the veteran to see if everything is alright.
FINAL THOUGHTS
We recognize that opioid dependency and addiction poses a serious problem for veterans returning home. We also understand that despite limited resources, the VA works tirelessly to keep veteran clients safe. We believe that, together, we can co-design a potential solution that will ensure that our veterans get the care they need, when they need it.