“We Can’t Help Everyone” – the Mentality of Structural Bias


I am a huge advocate for the five-year care paradigm. I have written about it extensively, including a STAT news article early this year and a piece with Dr Robert Dupont among others.  Put simply, the five-year recovery paradigm is a call to reorganize our care system around the fact that people who reach five years of recovery have an 85% chance of staying in recovery for the rest of their lives. Addiction was a leading cause of death even before the COVID-19 pandemic, destroying communities and costing vast sums of money. Expanding the number of Americans in long term recovery would be a game changer in America. We must focus on long term recovery for everyone with a severe SUD.

The frequent criticism I hear back is that we cannot afford to help everybody.  

Why do we ask this question about how we treat persons with substance use conditions? This is not a criticism we hear about other chronic medical conditions. We are not triaging persons with heart disease, diabetes or cancer and deciding which ones get full care and who gets palliative care. We need to ask some hard questions about how services are being deployed and for whom we stop care for at less harm rather than focusing efforts at getting everyone into treatment and recovery. A look at access to care for marginalized communities might give us a hint at that.  

Where does the mentality of triages and rationed services lead? In the US, what history shows us is that it has leads to care durations well below the minimum effective dose in lower intensities than necessary. We intervene at later stages in the condition to help people than we do with other chronic conditions where we have adopted an early intervention mindset. We typically wait until adulthood to address SUDs, often delaying help until after the person has had significant legal or medical problems that stem from the condition. Adolescent care for moderate to low-income families is hard to get. Here in Pennsylvania, we have lost most of our programming for young people, it may be true in other states as well. Addiction typically takes hold in our young people, yet we delay interventions for years and allow the condition to worsen – and then, after incarcerating people we say don’t have the money to help them, at least those in the bottom tier of the socioeconomic system.   

Who are the worthy drug addicts and who are the unworthy drug addicts?  How does bias against persons with substance use conditions, so prevalent among health professionals influence outcomes?

What happens when we decide a person, or a marginalized group has too far to go to get recovery and we do not think  that they can make it?  What history shows us is that we provide less care and less opportunity to obtain and sustain recovery and greater barriers to obtain help. Such determinations very likely have a whole lot more to do with the biases within our care institutions than the potential of persons with substance use conditions to get better.

Serious questions need to be asked about how the Pygmalion Effect plays out in who gets care and where the resources go. One of the things we see is that recovery community organizations – programs run by and for people in recovery scramble for scraps while groups perceived as more worthy like academic or law enforcement associated groups get the lion share of the limited resources. These are structural biases that emanate from stigma against persons with SUDs.

We should be looking at a addiction from an entirely different lens and considering what we have to gain by focusing on trauma resiliency. One area we need to look at more deeply building out a care system that fosters the “better than well” and community recovery as a public health intervention. Instead of focusing on an acute service infrastructure. We should consider the three key component parts of a theoretical model of recovery as articulated by UK researcher David Best and they include:

Recovery capital – personal and social resources – the journey of growth
Social identity and social contagion in recovery – the role of friends and connections
Therapeutic landscapes of recovery – the role of location

We can and should have a national conversation on the economics of recovery and addiction, there is not doubt that we would find that not only is addiction our most profound public health problem, but it is also our greatest opportunity to save lives, restore communities and save vast sums of money. This conversation must start with the premise that everyone is worthy of help and that we cannot afford to do anything other than to develop a system of care focused on recovery with equitable access for everyone. 

Everyone is worthy, and we cannot afford to do anything less than focusing a system oriented to long term recovery for everyone who experiences an addiction.

Let’s start with that basic premise.