Earlier today Jason Schwartz posted about the active ingredients and basic framework of a multi-year clinical and recovery support model.  The information he shared included elements from Robert DuPont, MD and William White, MA. 

Jason included a statement Dr. DuPont made about the short length of even our longest treatments (such as outpatient methadone or suboxone maintenance, or residential therapeutic community) compared to the length of addiction illness. 

Later in his post Jason also included the idea that the success rates associated with physician health programs, lawyer assistance programs, and programs for professional aviators, etc. simply don’t pertain to the real world or to people without as much recovery capital. 

During my interview with Dr. Dupont, we covered those topics.  I wanted to add a little more.

One point Dr. DuPont made in the interview was that our services are also short compared to the length of recovery.  In that vein, Dr. DuPont noted his approach to a five-year standard (as he pointed out is used with cancer outcomes), was to aim for full recovery five years after the last clinical touch.  Dr. DuPont stated he was interested in how a physician was doing five years after their standard five-year monitoring.

Secondly, I asked Dr. DuPont to comment on the Hawaii HOPE probation program, and the South Dakota 24/7 Sobriety Project – as examples of implementing these principles and practices with people who are involved in the criminal justice system, are not physicians, and do not generally have advanced degrees and lucrative careers.  Dr. DuPont commented on those innovative programs as starting with the same multi-year framework, the use of recovery-oriented methods, and obtaining positive results far beyond what one might normally expect.

I also covered the topic of collegiate recovery programs as aiming at a demographic that could be considered by some as hard to address.  In doing so I included the typical phrase of the “recovery-hostile” undergraduate campus environment as far from ideal to initiate and sustain recovery.  He applauded the innovation and expansion of these types of supports and programs.

Overall, we discussed these different populations all considered hard to help, and noticed shared features of these very effective programs:

• A multi-year framework
• The natural environment (not a clinical environment) as the main center of focus
• Inclusion of family or other close support persons as central, not peripheral
• Person-centered goals (both diminishment of problems and advancing personal aims) as paramount
• Incentives to help initiate, support, and sustain change over time

The interview with Dr. DuPont was one part of the agenda for that year’s Recovery Alliance Summit – a multi-year effort focused on building awareness, collaboration, advocacy and action for the sake of the person served.  To help bring this about, the Summit effort aims for its participants to begin to take a multi-year perspective across systems. 

For example, do the local or regional recovery courts, collegiate recovery programs, and professional monitoring programs know each other exist? Do the staff of such programs know about the other programs in terms of eligibility requirements, practices, and specific benefits to the individual? 

• Do we expect that the person we serve will discover all on their own that very specific support and advocacy can continue through the years of their recovery journey?
• Do we just assume the one we are serving will get along well enough after we are done helping them in our own silo?    

Helping a young adult understand and investigate¹ collegiate recovery programs is one example to study, while helping an undergraduate or graduate student² understand and investigate the advocacy of a relevant professional monitoring program is another.

References

¹ Crowe, K., Hennen, B. & Coon, B.  March 31, 2017.  A Seamless Transition: Linking College-Bound Emerging Adults with Collegiate Recovery Programs.  Recovery Campus Newsletter.  

² Coon, B.  (2015).  Recovering Students Need Support As They Transition.  Addiction Professional.  13(1): 22-26.

This was originally published in a 2019 National Association of Social Workers’ Alcohol, Tobacco and other Drug specialty section newsletter.

The most striking thing about substance abuse treatment is the mismatch between the duration of treatment and the duration of the illness.

—Robert DuPont, MD ¹DuPont R. (March, 2018) Interview with Brian Coon. Interview presented at the NC Recovery Alliance Summit, Durham, NC.

The opioid crisis has shined a spotlight on the U.S. addiction treatment system. Much of the coverage has focused on profiteering, the failure of states to reform their systems, the failure of programs to adopt evidence-based practices, and exploitation of patients. Many of these criticisms are well-deserved and have the potential to create opportunities to discuss how the addiction treatment system should be designed. Social workers need to involve themselves in this discussion to assure that the needs of vulnerable patients are considered and our values and priorities are represented.

Several unique qualities of the opioid crisis (its lethality, its frequent iatrogenic origins, and the availability of pharmacological treatments) have raised important questions about treatment-as-usual representing a one-size-fits-all approach. It could be argued that the responses to these questions have been debates about which one-size-fits-all approach—inpatient, agonist, partial agonist, antagonist, harm reduction—should prevail. Social work’s emphasis on families, communities, social functioning and overall well-being provides a unique perspective. Where others are interested in reducing social costs, reducing medical costs, reducing symptoms, reducing crime and reducing disease transmission, we’re interested in all of those outcomes and maximizing the wellness of individuals, families and communities.

If we focus on maximizing individual wellness, a few models stand out. Professional monitoring programs for impaired pilots, lawyers and health professionals have very good outcomes and focus not just on the amelioration of symptoms, but also outcomes like returning to work. The most well-researched of these programs are physician health programs (PHPs). A large and long study of 904 physicians in 16 states reported the following 5-year outcomes ²DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. (2009), Setting the standard for recovery: Physicians’ Health Programs. J Subst Abuse Treat. 36(2):159-71. Doi: 10.1016/j.jsat.2008.01.04.:

• 78% of participants had no positive test for either alcohol or drugs;
• Of those who experienced a relapse, only 22% had a second relapse;
• Participants averaged 83 drug tests over a mean period of 54 months;
• 72% of participants were retained in the monitoring program;
• 72% of participants were still employed as physicians;
• Outcomes did not differ by primary substance (alcohol, cocaine, opioids) or whether they injected drugs.

It’s important to note that this study reported on 5 year outcomes, monitored alcohol and other drug use, and reported on an important quality of life measure (return to employment). This represents a rare level of rigor.

What does this program consist of? The study proposed the following elements as the essential ingredients of the model:

1. Contingency management
2. Frequent drug testing
3. Active linkage to abstinence-oriented mutual aid groups
4. Active management of relapse with intensified treatment and monitoring
5. Continuing care that lasts 5 years
6. Focus on lifelong recovery

Most readers will wonder whether these program outcomes are relevant to the general population. Objections typically fall into three categories.

The most common objections tend to focus on the doctors as a cohort with unusually high levels of recovery capital (the quantity and quality of internal and external resources that one can bring to bear to initiate and sustain recovery from addiction) ³Laudet AB, White WL. (2008). Recovery capital as prospective predictor of sustained recovery, life satisfaction, and stress among former poly-substance users. Subst Use Misuse. 43:27–54.. To be sure, there may be ways in which health professionals are unique in terms of recovery capital. However, they also face a unique set of barriers when initiating recovery. Another PHP study ⁴DuPont RL, McLellan AT, Carr G, Gendel M, Skipper GE. (2009), How are addicted physicians treated? A national survey of Physician Health Programs. J Subst Abuse Treat. 37(1):1-7. found high rates of opioid addiction (35%), high rates of combined alcohol and drug problems (31%) and high rates of psychiatric problems (48%), and 74% were not self-referred. Further, health professionals have easy access to drugs and often develop tolerance levels that eclipse those of street addicts.

Two pieces of folk wisdom may also be relevant. First, it’s often said that doctors make the worst patients. Second, a common joke in treatment and recovery circles is, “I’ve never met anyone too simple-minded for recovery, but I’ve met plenty of people who were too smart.”

So, doctors may have unique advantages, but they also have unique barriers. If there is a difference, is there reason to believe it’s stark enough that it wouldn’t work for other addicts?

A second group of objections center around the cost of this model. While the costs of this model will not be insignificant, it could be implemented in a manner that keeps it affordable in the context of health care spending. At current public funding rates in Michigan, the following services could be provided over 5 years for under $45,000: 120 days of residential treatment, 364 drug screens, 100 outpatient group sessions, 100 outpatient individual sessions, and 5 years of recovery support and monitoring from a Recovery Support Specialist.

In the context of American healthcare spending, this does not seem to be an unsustainable burden and, in fact, is likely to be a very wise investment in pure financial terms. According to The Healthcare Bluebook, it’s similar in cost as inserting a stent–just the procedure, excluding continuing care, medications, etc. 1,000,000 stents are implanted in the US every year.

The third set of objections focus on use of coercion. Doctors often participate in these programs under threat of having their medical license suspended or revoked. Many argue that coercion is a critical element in the success of the model and that transferring the model to other patients without the element of coercion would not get us similar outcomes because coercion is such an important ingredient. This is a compelling argument. Being a doctor is more than just a high paying job—it’s a personal identity as well as professional, and it provides a powerful source of meaning and purpose. The risk of losing their license is a very big stick, and the opportunity to return to practice is a very big carrot.

However, addiction professionals routinely encounter patients who are at risk of losing their children or their freedom. How can we be so sure that threats to their professional lives provide a unique source of motivation that cannot be created for other populations? Do we really believe that the an identity like mother or father is less powerful?

This raises two questions. First, how do we build similar systems to initiate and support recovery around these other patients? Second, how can we voluntarily engage patients into these systems of care?

Fortunately, William White has developed a model of care in response to these questions. His model of Recovery Management is recovery-oriented (rather than pathology-oriented) and is based on the assumption that addiction is a chronic illness that requires management over the lifespan. Recovery Management focuses on the following elements ⁵White, W. (2005). Recovery management: What if we really believed that addiction was a chronic disorder GLATTC Bulletin, September, 1-8. Chicago, IL: Great Lakes Addiction Technology Transfer Center.:

1. Models of engagement that focus on lowering thresholds, outreach and pre-treatment support services, viewing motivation as an outcome of the service relationship rather than a precondition for service initiation.
2. Models of assessment that are focused on the whole life of the recovering person, recovery capital, and continue over the span of the service relationship.
3. Service models that recognize recovery initiation and recovery maintenance are different processes requiring different forms of support, including sustained monitoring, stage appropriate recovery education and coaching, assertive linkage to local communities of recovery, and, when needed, early reintervention.
4. A shift in the locus of care from within the walls of the agency to the natural environment of the client. 
5. Viewing the client as the expert on their lives, goals, and, eventually, the long-term management of their recovery rather than seeing them as the biggest barrier to their own recovery.
6. A shift toward service relationships as partners and allies and away from relationships that are time-limited and hierarchical.
7. Models of evaluation that focus on measuring the long-term effects of multiple service interventions rather than the short-term effects of single interventions.

An important benefit of this model is that it side-steps arguments over one-size-fits-all approaches by setting our focus on providing long-term recovery management.

Many states and systems of care are attempting to deploy this model, however the implementation is often incomplete, inconsistent, too focused on individual interventions, and lack comprehension of the larger vision of the model.

Social workers are the ideal addiction professionals to execute this model. Our belief in social justice requires us to challenge the disparities in care between these culturally empowered professionals and the rest of the population. Our person-in-environment perspective and strength-based approach make us the right professionals to perform assessments and deliver services within the Recovery Management model. What group of professionals is as capable of organizing communities to support recovery and reduce stigma?

As the country struggles with the consequences of the opioid crisis and temptation builds to lower the bar by narrowing our focus to the amelioration of those consequences, social workers possess the skills, values, and conceptual frameworks to construct systems of care that deliver recovery and social justice.

References

Guest blog by Kevin Minnick, MS LMHC LCAC

Many times over the last bunch of years, I’ve run into someone who is making a recovery attempt and has a “diagnosis” of a mental health issue. Knowing full well that something like that would complicate treatment, I’ll inquire: “So tell me, what were you diagnosed with? And when was that?” To which the response goes something like this: “Well I was diagnosed with Bipolar when I was 15.” And the person is 30 years old now. Wait, what? 

It goes without saying that any diagnosis carries stigma with it, whether it’s heart disease, diabetes, or any other situation that humanity will encounter. But a mental health and/or substance use disorder diagnosis is particularly difficult to shake because a diagnosis can become a label for the rest of someone’s life. So what’s someone to do when it comes to recovery? 

Let’s deal with a couple scenarios that tend to repeat themselves over and over.  

Remember my first person who was diagnosed in their teens and have carried the diagnosis with them since then? If you find yourself in this situation, then first and foremost, it might be a great idea to have an updated evaluation completed.  The problem with having a diagnosis so early in life is this: as you grow, things will change. Mental and emotional issues are sometimes transient for young teens growing into adulthood. While you may present with a set of features that certainly look like diagnosis A when you’re 15, by the time you’re 21 everything looks different. And very often, whatever was there before isn’t there anymore. What’s this mean? 

What it means is this: when you’re a teen, hormones cause more problems than a submarine with screen doors. Hormones wreak havoc on your body, your mind, and your emotions. Once you start to mature, everything seems to calm down. So a diagnosis of any type in your teens should be reevaluated once you reach adulthood (usually around 25) to see if, in fact, you really have a behavioral health issue. Better safe than sorry, my grandma used to say. 

The second is where a diagnosis took place, say, several years ago and there doesn’t seem to be any improvement. “So,” says I, “who gave you the diagnosis? And what was their recommendation for treatment?” And then I hear: “I went to my family physician who prescribed me X and that was it. I’ve been on it ever since.”  While the person felt better for a little bit, eventually a return to using substances became the pathway by which we ended up crossing paths. What happened? 

Well, research indicates that medicine alone is not really all that effective. Talking about the situation with a trained professional that can teach you some self-management techniques shows the best promise for longer term recovery when it comes to behavioral health issues. And a follow up with a trained doctor specializing in behavioral health (mostly referred to as “the shrink”) will also be able to determine if you need more, less, or any meds at all. Things change and so should your treatment plan. 

Overall, in SMART Recovery, we have tools that can be applied to many different situations. I’ve seen people with mental health issues use SMART tools to get out of situations they find difficult; we don’t have to be captives to a “label” or “diagnosis” and just think that this is as good as it gets. If you’re struggling with something beyond your recovery, get SMART and get some help from people who can guide you toward living better. 

PLEASE NOTE BEFORE YOU COMMENT:

SMART Recovery welcomes comments on our blog posts—we enjoy hearing from you! In the interest of maintaining a respectful and safe community atmosphere, we ask that you adhere to the following guidelines when making or responding to others’ comments, regardless of your point of view. Thank you.

• Be kind in tone and intent.
• Be respectful in how you respond to opinions that are different than your own.
• Be brief and limit your comment to a maximum of 500 words.
• Be careful not to mention specific drug names.
• Be succinct in your descriptions, graphic details are not necessary.
• Be focused on the content of the blog post itself.

If you are interested in addiction recovery support, we encourage you to visit the SMART Recovery website.

IMPORTANT NOTE:

If you or someone you love is in great distress and considering self-harm, please call 911 for immediate help, or reach out to The National Suicide Prevention Hotline @800-273-8255, https://suicidepreventionlifeline.org/

We look forward to you joining the conversation!

*SMART Recovery reserves the right to not publish comments we consider outside our guidelines.*

I recently came across a couple of items responding to reactions to research findings that were considered objectionable.

First, Noah Smith responds to calls to suppress findings that parental incarceration is correlated with the following benefits to their children, “reducing their likelihood of incarceration by 4.9 percentage points and improving their adult neighborhood quality.”

Smith has argued against mass incarceration and shares other’s concerns about how these findings may be used but pushes back against any suggestion that findings like these ought to be suppressed.

So what should scientists do? Should they become a caste of pure truth-seekers, removing themselves utterly from the world of politics and public affairs in order to pursue the facts in as objective a way as possible? Certainly not. Scientists are humans like everybody else, and they have a right — and perhaps even a duty — to try to make the world a better place through politics.

But in order to follow both the scientific ideology and their own political ideology at the same time, scientists have to manage a special sort of internal bifurcation. When seeking the facts they have to be as objective as they can, and faithfully publish what they find, but then immediately forget about that objectivity as soon as they’re doing anything other than research!

He argues that this may tie researchers up in knots, but it’s the best way to proceed.

Next, on Twitter, an addiction medicine doc and advocate responds to reactions to an unpublished paper that suggests naloxone distribution creates a moral hazard. (I posted about this a few years ago.)

He cautions against trashing the researchers on pragmatic grounds–one of them is doing work that supports progressive criminal justice agendas, that trashing from the right adversaries can actually increase her influence, and the bad optics of a bunch of men engaging in personal attacks on a woman. He also points out the frequent hypocrisy of “it’s science” arguments and, instead, asks for help picking apart the methods used in the paper.

Around the same time, I also came across this article in The New Social Worker about integrating evidence into practice. The author urges readers to consider 4 things: “what intervention/s was/were tested; who was sampled in the study; what measures were used in the study (if a quantitative study was conducted), and; what the results of the study were).”

Good advice, but that isn’t what caught my attention. After considering those 4 elements, the reader should synthesize the findings and “tell the story“ of what the studies say.

It seems to me that this is often the crux of the problem–the story we tell based on a set of findings. Despite all of the calls for us to “follow the science“, science can’t determine our priorities, values, goals, etc. We have to decide what endpoint we want to pursue and science can tell us something about how realistic it is and what pathway might be most effective at getting us there.

I’m not a scientist or researcher, but many of these arguments strike me as missing what science is capable of, particularly in the social sciences, and what we should do with science.

First, the notion that science will be free of bias strikes me as wishful thinking. Science is biased by the profession and orientation of those conducting research, by what can get funded, by what can be easily measured, by what can be accomplished in the time-frames acceptable to funders and researchers, by what can get published, by the questions that interest the researchers, etc.

Second, I tend to think that what research can tell us is fairly limited. Science, generally, cannot tell us what to do. Research can provide information that can help us decide what to do. The information it provides is often narrow and context-specific. It can’t tell us The Truth, but it sometimes can tell us a truth. Even that narrow truth is subject to review and change as new information becomes available.

Third, it’s up to us to decide our goals, priorities, what’s an acceptable outcome, what’s intolerable, how we define our context, what information is most applicable to the context we’re working within, and what story the available pieces of information tells us. For example, consider a patient who is receiving end-of-life care. Science may be able to tell us treatments that might extend her life for 6 or 12 months, but it can’t tell us whether that’s good. She and her family have to make judgments about her quality of life and priorities. Maybe her quality of life is so poor that extending her life is not desirable. Or, maybe her priority is quality time with her family, including a vacation, and the treatments to extend her life would not permit that.

Fourth, many of these arguments fail to acknowledge, value, and integrate experiential knowledge. Empirical knowledge is important, but it’s only one way of knowing and is incomplete. Borkman explained the importance of experiential knowledge this way, “As sources of truth, professional and experiential knowledge are not mutually exclusive. First, even professionals use some experiential knowledge in their practice. Newly credentialed professionals are not regarded as seasoned until they have had personal experience in the real world of work.” ¹Borkman, T. (1976). Experiential Knowledge: A New Concept for the Analysis of Self-Help Groups. Social Service Review, 50, 445 – 456.

So… when we encounter findings that trouble us, how should we respond? We can question the methods and whether these findings are likely to be replicated. We can question whether it’s applicable to the contexts we work within. We can question the real-life significance of the findings. We can ask whether the researchers asked the right questions–the questions and answers that are most relevant to the people involved and the practitioners serving them.

In many cases, the objection is less about the actual data and more about the story being told with the information. For example, imagine we found no methodological problems in the study that found the 4.9% reduction in likelihood of incarceration improvements their adult neighborhood quality for children of incarcerated parents. I’d have questions about the significance of those findings and the definition of adult neighborhood quality, but let’s imagine all those questions were satisfied.

What bothers me is the support for a story that parental incarceration benefits their kids. If the information is solid, this information can, and should, provoke questions, including:

• If it’s clear that these kids experience improvements in these domains, how important are they?
• What are the other important domains that influence the present and future quality of life for these kids and their families? How are these affected by parental incarceration?
• Are these improvements evenly distributed?
  • For example, do children of violent parents experience significant improvements while other kids experience adverse effects in these areas?
• What are the mechanisms of the improvements these kids experience?
  • For example, is it a function of kids moving in with a stable family member?
• If the wrong story is being told, what’s a better story? Something like, “system fails to support kids until a parent is incarcerated”? (I have no idea if that’s accurate, but it’s just an example of a narrative constructed around a finding.)

Most importantly, it should provoke questions about how we might have facilitated these improvements without the incarceration of a parent. (Maybe before the incarceration and even preventing the incarceration.)

Again, I don’t know anything about the motives, methods, and rigor of this research, but some of these arguments turn into battles about who gets to produce and own knowledge. This seems especially strange in the social sciences where we are dealing with so much complexity that isolating causal factors often seems hopeless.

Instead, we might be better off using these moments to explore the story being told and the values involved. If we wish to reduce incarceration and improve the lives of at-risk kids, can we use this information and discussion as an opportunity to ask better questions, to commit to pursuing more helpful information, to clarify our values, to better live our values, to improve the lives of these kids and their parents?

These disputes come up all of the time in all sorts of areas. Unfortunately these disputes too often resemble power struggles seeking professional and ideological domination and invalidation of “adversaries”rather than the expansion of knowledge and interventions. I’ve participated in these dynamics and I regret it. Today, I try to engage troubling findings in good faith to see what I can learn and add to the discussion.

This week I ran across a wonderful STAT News article by Dr David Eddie and Dr John Kelly “People recover from addiction. They also go on to do good things,” it was published a few days ago.  One of the motivators for me writing  this blog article is to draw attention to it in hopes that people read it. If you do nothing else, stop here and read the linked article above. It is an exceptionally well written piece that every policymaker in the nation should consider. I clipped out this section, with intact embedded hyperlinks to draw attention to what they are saying below:

“Around 75% of people seeking recovery from a substance use problem achieve their goal, though it may take them some time to achieve full remission. The average number of attempts before success is five, though the median number is just two, meaning that a small number of outliers — usually individuals with the greatest addiction severity and other concomitant mental health issues — who need five-plus attempts, inflate the numbers, making them look worse than they are. Along with several colleagues, we recently completed a landmark study which, for the first time, comprehensively surveyed Americans who said they had resolved an alcohol or other drug problem.”

This is incredible work, and research continues to confirm what people in recovery (who are the experts on recovery) have known for a very long time. We get better, and when we do, we are assets to society. When we recover, we  also save an incredible amount of resources as we are no longer costing society resources in a myriad of ways. I figured this out about a year or so into recovery, around the time I first started working in the SUD field.

I was so excited even in those days about what research was showing us. I would share the developing body of literature with anyone who crossed my path. Around 2001, we learned that treatment resulted in a 7:1 ratio of benefits to costs. I can only imagine what it would find if we factored in recovery support services in. They didn’t exist then. At the time, I figured that all we would need to do is let the world know, policies would change and we could build a robust care system. We would not just keep people alive. In recovery we thrive. We would drastically reduce the number of persons trapped in the criminal justice system and the consequences of addiction in our hospitals and human services programs.

Of course, that is not what happened. Research did not drive the conversation in the direction of expanding access to services that even averaged the minimum threshold of effectiveness or addressed drop out in any systematic way. Services remained fragmented, lengths of stay generally did not budge and may even have decreased over the years. We failed to develop and address care that followed the person until we hit the right individualized combination to meet their needs. The stats clipped above from the article are remarkable – 75% of people seeking recovery eventually achieve their goal. Can we imagine what this would look like if we systematically engaged people earlier and stuck with them until they got better with comprehensive services?  It would change our society. The question is will we ever do it?

Colleagues who have been around longer than I recount to me similar experiences in the 1980s and work they did to educate the public about the benefits of helping people who have substance use issues. The impact of these efforts and the favorable research available at that time was not enough to sway the public or policymakers. We didn’t fund care or  increase access, or move things towards more comprehensive services. It just didn’t happen. Fragmented, short term care for some, but not all people who need it has been the gear we have been stuck in since before the age of Disco.

There is an immense reservoir of implicit bias across society about addiction and recovery. History shows us that we do not want to help people even if saves money and lives. We expend our resources on punishment and unending devastation. Afterall, “those people” did it to themselves. We do not want to help “those people” even if it makes sense for every other reason. People in recovery play a roll too. A person wiser than I observed a lot of us recovering people pull punches and don’t speak out nearly as much as we should given the extent of the devastation and death across our community. The most fortunate of us smile and sit at the table as tokens even as nothing changes, and we bury our family and friends. In a subconscious way, perhaps we buy into the moral model believing we don’t deserve better care. Perhaps we believe we did it to ourselves and so we don’t deserve better.

I applaud Dr Kelly and his team of researchers who have made such huge contributions to what we know. They are doing invaluable work. We are in their debt. I hope society pays attention. The truth remains:

We typically get better, and when we get better, everything else improves too.

The fundamental question is whether society is ready to focus on redesigning care around long term wellness for all of our diverse communities because it makes every bit of sense to do so. I hope this time that science wins over bias. The world would be fundamentally better place in such a sea change.   

Jason Schwartz guest-edits Recovery Plus Journal. Stimulating and relevant articles on: what’s essential for recovery to happen, recovery-oriented harm reduction, problems with ‘sticking with the evidence’, moral injury, and some surprises with language and stigma. Good weekend reading!

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This piece originally appeared on April 27, 2021 in a Health Affairs Blog. It is reposted here with permission and is available in Spanish.

The COVID-19 pandemic has highlighted the large racial health disparities in the United States. Black Americans have experienced worse outcomes during the pandemic, continue to die at a greater rate than White Americans, and also suffer disproportionately from a wide range of other acute and chronic illnesses. These disparities are particularly stark in the field of substance use and substance use disorders, where entrenched punitive approaches have exacerbated stigma and made it hard to implement appropriate medical care. Abundant data show that Black people and other communities of color have been disproportionately harmed by decades of addressing drug use as a crime rather than as a matter of public health.

We have known for decades that addiction is a medical condition—a treatable brain disorder—not a character flaw or a form of social deviance. Yet, despite the overwhelming evidence supporting that position, drug addiction continues to be criminalized. The US must take a public health approach to drug addiction now, in the interest of both population well-being and health equity.

Inequitable Enforcement

Although statistics vary by drug type, overall, White and Black people do not significantly differ in their use of drugs, yet the legal consequences they face are often very different. Even though they use cannabis at similar rates, for instance, Black people were nearly four times more likely to be arrested for cannabis possession than White people in 2018. Of the 277,000 people imprisoned nationwide for a drug offense in 2013, more than half (56 percent) were African American or Latino even though together those groups accounted for about a quarter of the US population.

During the early years of the opioid crisis in this century, arrests for heroin greatly exceeded those for diverted prescription opioids, even though the latter—which were predominantly used by White people—were more widely misused. It is well known that during the crack cocaine epidemic in the 1980s, much harsher penalties were imposed for crack (or freebase) cocaine, which had high rates of use in urban communities of color, than for powder cocaine, even though they are two forms of the same drug. These are just a few examples of the kinds of racial discrimination that have long been associated with drug laws and their policing.

Ineffective Punishment

Drug use continues to be penalized, despite the fact that punishment does not ameliorate substance use disorders or related problems. One analysis by the Pew Charitable Trusts found no statistically significant relationship between state drug imprisonment rates and three indicators of state drug problems: self-reported drug use, drug overdose deaths, and drug arrests.  

Imprisonment, whether for drug or other offenses, actually leads to much higher risk of drug overdose upon release. More than half of people in prison have an untreated substance use disorder, and illicit drug and medication use typically greatly increases following a period of imprisonment. When it involves an untreated opioid use disorder, relapse to drug use can be fatal due to loss of opioid tolerance that may have occurred while the person was incarcerated.

Inequitable Access to Treatment

While the opioid crisis has triggered some efforts to move away from punishment toward addressing addiction as a matter of public health, the application of a public health strategy to drug misuse remains unevenly distributed by race/ethnicity. Compared to White people, Black and Hispanic people are more likely to be imprisoned after drug arrests than to be diverted into treatment programs.

Also, a 2018 study in Florida found that African Americans seeking addiction treatment experienced significant delays entering treatment (four to five years) compared to Whites, leading to greater progression of substance use disorders, poorer treatment outcomes, and increased rates of overdose. These delays could not be attributed to socioeconomic status alone. Studies have shown that Black youth with opioid use disorder are significantly less likely than White peers to be prescribed medication treatment (42 percent less likely in one study, 49 percent in another) and that Black patients with opioid use disorder are 77 percent less likely than White patients to receive the opioid addiction medication buprenorphine. 

A Vicious Cycle of Punishment

The damaging impacts of punishment for drug possession that disproportionately impact Black lives are wide ranging. Imprisonment leads to isolation, an exacerbating factor for drug misuse, addiction, and relapse. It also raises the risk of early death from a wide variety of causes.

Besides leading to incarceration, an arrest for possession of even a small amount of cannabis—a much more common outcome for Black youth than White youth—can leave the individual with a criminal record that severely limits their future opportunities such as higher education and employment. This excess burden of felony drug convictions and imprisonment has radiating impacts on Black children and families. Parents who are arrested can lose custody of their children, entering the latter into the child welfare system. According to another analysis by the Pew Charitable Trusts, one in nine African American children (11.4 percent) and 1 in 28 Hispanic children (3.5 percent) have an incarcerated parent, compared to one in 57 White children (1.8 percent).

This burden reinforces poverty by limiting upward mobility through impeded access to employment, housing, higher education, and eligibility to vote. It also harms the health of the incarcerated, their non-incarcerated family members, and their communities.

Moving Toward a Public Health Approach

Five years ago, the 193 member nations of the United Nations General Assembly Special Session on drugs unanimously voted to recognize the need to approach substance use disorders as public health issues rather than punishing them as criminal offenses. Research is urgently needed to establish the effectiveness and impact of public health–based alternatives to criminalization, ranging from drug courts and other diversion programs to policies decriminalizing drug possession.

In addition to policy research, proactive research is needed to address the racial disparities related to drug use and addiction. From the opioid crisis, we have learned that large research initiatives can be mounted that engage multiple stakeholders—including the justice system (courts, prisons, jails) and the health care system—to cooperate toward the common purpose of reducing a devastating health problem. From the COVID-19 crisis, we have learned that the research enterprise can adapt and rapidly mobilize to address critical threats. These lessons can be applied to reduce systemic inequities in how addiction is addressed and to advance access to high-quality addiction care for all people who need it, whatever their race or background.

With this in mind, the National Institute on Drug Abuse is redoubling its focus on vulnerabilities and progression of substance use and addiction in minority populations. We are exploring research partnerships with state and local agencies and private health systems to develop ways to eliminate systemic barriers to addiction care. We are also funding research on the effects of alternative models of regulating and decriminalizing drugs in parts of the world where such natural experiments are already occurring.

People with substance use disorders need treatment, not punishment, and drug use disorders should be approached with a demand for high-quality care and with compassion for those affected. With a will to achieve racial equity in delivering compassionate treatment and the ability to use science to guide us toward more equitable models of addressing addiction, I believe such a goal is achievable.

Nora Volkow, Addiction Should Be Treated, Not Penalized, Health Affairs Blog, April 27, 2021, https://www.healthaffairs.org/do/10.1377/hblog20210421.168499/full/ Copyright © 2021 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.