The More Things Change…

Our systems of care have never actually been designed to meet the needs of persons with substance use disorders. I am not disparaging those early pioneers or those that came after who have worked very hard to implement even small elements of what an effective care system should include. All the way back to the “28-day treatment model” and even prior to that point. Short term, acute focused care that most often delivers less than the amount of care needed, provided through standalone programs without a systematic focus on supporting the process of people obtaining and sustaining long term recovery.

It also seems that every incremental improvement we have achieved as a field is then sold as a panacea and ultimately undermines our efforts to develop the system of care we actually need. When we have developed longer term, comprehensive programs for those who had more severe addictions and low recovery capital, our care systems have worked overtime to whittle them away to the point that they also provide short term care that subsequently becomes ineffective. Externally society then believes that treatment does not work, and people do not recover even when we know this is not what is actually happening. Our systems are failing, not the people.

We have an SUD care system built on a foundation of stigma and implicit bias against persons with substance use disorders. Facing these forces, pioneers for care and all of us who have come after have had to settle with what we can get, not what we need. The undertow against us is powerful yet at times hard to detect. I have talked to more than a few researchers and people who work in our state and federal bureaucracies who will not identify that they are in recovery because they know once they do, their views will be discounted and dismissed – within the very institutions charged with forging our path forward. Read that last sentence again and digest what that means.

Significant forces, much better resourced, focus on cutting care and offer window dressing or short-term strategies. Anything but investing in a comprehensive care system that supports long term recovery. If you disagree, investigate where all the money goes and remember that where systems invest money is where the priorities are. All these years later and we still focus on short term care, single substance focused outcomes, and short term, narrowly focused research. This demonstrates we actually don’t want to help people with addictions on some level as a society.

Maybe it come down to the reality that there is little appetite to help “those people” who did this to themselves. To this very day, one of the worst things that people can think of happening to them is being treated like a drug addict.

Those of us dedicated to this work push back against systemic discrimination and these overwhelming forces day in day, out, decade in and decade out.

One element of this I have been thinking as of late about the problem of focusing recovery advocacy efforts on peer recovery support services. One of the problems is that the “service” of peer support end up focused on transactional units, like traditional care, in essence delivered in units of individual or group units. We then lost the wider focus on recovery management.

Many recovery community organizations attempt to use peer services to underpin their community mission – they are essentially the only funds available. It soon becomes a matter of chasing units of service as the organization mission gradually narrows and moves away from strengthening recovery community. Some programs grow but change, moving away from a recovery orientation and into a more traditional conveyor belt of care. Treatment centers, government entities and medical care systems have also embraced hiring peers and using persons in recovery to fulfill roles peer services in like warm handoffs. The impact is one of balkanization, as there is not any connection or understanding of the recovery community or the importance of recovery management and connecting people to recovery community.  In hindsight, perhaps we should have pursued building care around recovery management as our foundation and insisted on new funding mechanisms instead of adapting what we needed into the framework of the traditional care system. We fell into the setup for failure.

The takeaway here is the goal of centering our care systems on recovery is getting lost. Decisions about us are made without us. Some days it looks to me we are continually rebuilding the limited care system as forces of implicit bias work to pull them apart, yet again. Bill White warned of these dangers in the – State of the New Recovery Advocacy Movement, delivered in Dallas Texas in 2013. The risks he warned about, colonization, over professionalization, commercialization and marginalization seem ever present in how care has been pursued. I would even suggest the federal STR and SOR dollars fueled these dynamics as the “big money” brought in the big players. The academics and large foundations landed, and they decided they knew best, and recovery communities get thrown a few small scraps, provided they behave. These matters became far too important to include us drug addicts once money is involved.   

The solutions are easy enough to identify – focus on long term recovery, design research around understanding how to measure long term recovery and design care around it. The money is there – the pathetic truth is that not helping people is costing us more in healthcare costs, criminal justice, lost productivity, and broken communities. We have been shouting this for as many years as I am old, the truths here are evident, but they fall on deaf ears.

There is hope, we know have people in recovery in significant places at the very top of our federal government, yet we must address all the systemic barriers downstream from them that keep us under the heel and not at the table in meaningful ways working to saving the lives of our brothers and sisters experiencing addiction across America.

At this moment, the fundamental question is if we have a sincere desire to actually build and sustain the care system we need?

The answer, as always will center around how deep implicit bias is against us.