Substance Use Care System On a Precipice

I have been a student of the field for well over three decades. I have operated an outpatient and a residential program treatment program and in recent years ran our statewide recovery community organization here in Pennsylvania. My work has led me to be very engaged with policy matters, with care system workforce being a major area of focus.  It is my sense that substance use is our leading public health crisis beyond COVID-19 and that greater focus on substance use and long term recovery can save lives, communities and resources. Increasingly, my sense is that our SUD workforce and our entire care system is in an exceptionally precious position. In my opinion, failure to pay attention to our growing SUD workforce crisis will be disastrous.

In many respects, our care system workforce crisis is not new. The challenges we faced twenty years ago remain, and we have new ones too. An aging workforce that is underpaid, overworked, saddled with massive administrative burden working in an acute care system. An ever-increasing amount of their time is spent trying to get fewer and fewer units of services.  Compensation in inflation adjusted dollars was higher when I started my career than they are now. Care providers have a smaller pie with an ever-increasing amount of non-direct care requirements.

The people who do this work do it because they care deeply about the outcome – getting people into recovery and helping them sustaining it over the long term. My organization, PRO-A, the statewide recovery community organization for Pennsylvania did an SUD Workforce survey for our the Pennsylvania Department of Drug and Alcohol Programs a number of years ago. The overall sentiment was that people were leaving our workforce because they were able to spend less and less time doing the actual work of helping people. Without that, they had no reason to stick it out. They are the heart and soul of our SUD care system workforce and the are leaving in droves even as we make it harder to get into the workforce.

Since then, we have submitted several reports to our state, including  a 2019 report titled Thriving Communities in Recovery: Policy Report on National Trends, Best Practices, and Evaluation of How Pennsylvania Can Improve its Recovery Environment that focuses on retooling care towards a long term support model and in 2020 a report on our state SUD peer workforce challenges and opportunities.  What I have learned though my focus on our SUD care system workforce is that there are people who do this work despite the difficult challenges and overwhelming barriers that make this work very challenging.

The core of our entire SUD service system from my perspective is the recovery community and family members with lived experience. They get up every day and do the work because these are “their people.” They do it because at some point in their own histories someone was there for them when they needed. They do it to pay it forward. They do it to save lives and help others into recovery because it is a mission that they believe in. They do it despite all the challenges. They do it because few others will.

But my sense is that it is getting increasingly harder for them to do. As I noted in my PA State House Human Services Committee testimony a few weeks back on the impact of COVID-19 on our care system, staff are risking their lives and sometimes dying as a result of their jobs and COVID-19. Programs are saddled with extra expenses because of the virus and plummeting censuses. Seasoned staff who have long had their fingers stuck in the holes of our service system levees are getting very tired. Relapses are increasing, substance use and overdoses are dramatically increasing. I talk with a lot of people doing this work across the nation and truth be told I hear exhaustion in their voices. I see veteran staff leaving for other work or retiring in increasing numbers.

It has been said that every crisis presents opportunity. What we have right now are multiple crises converging and a diminishing window of opportunity. We have an addiction epidemic that has been picking up steam in recent years, an SUD care system workforce crisis that has been simmering on the back burner for decades. The black swan COVID-19 crisis has put health disparities and care system challenges in stark relief. Addiction is a central element in many of our societal challenges. Our very fragile SUD care system is beginning to fall apart, and much like a stream bank undercut by flowing water much of what is happening is not visible to those standing on the sidelines.

If there was ever a time to retool our care system and focus on workforce development, it is right now. Every indication is that we are going to need a reinvigorated care system and a strong workforce. My observation is that we never actually get to focus on workforce challenges because there is always some other more acute, pressing issue. The time is now, the opportunities abound, but every moment we delay, our workforce challenges become a bit more challenging and harder to address.

So what should we do? For one, we need to recruit and develop more people in recovery to do this work over the long term. We need to remove as many bureaucratic burdens as we can and allow people the time to focus on the core of the work – assisting people with their treatment and recovery. We should move our care system towards long term recovery orientation while addressing system shortfalls.  If there was a convenient time to focus on these challenges, we would have already done it. In the absence of an ideal time and in recognition of our decaying workforce and the nature of the crisis we are in, I would humbly suggest that right now is the time to reimagine our workforce and begin to build out a workforce to meet the challenges ahead.

What do you think?

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