Moving Beyond Narrow, Whack-A Mole Care System Design

While there is much we do not know about addiction and recovery, there are things we know well but do not apply to our care system design. I am going to attempt to cover three of those in this blog posts because they interrelate. The first is that we have long term drug use patterns that tend to shift every decade or so. As this 2019 NBC article reports, there is a tendency towards “generational forgetting.” Essentially, when current drugs get bad press, the younger generation learns to not use that drug and drug use patterns shift, often to classes of drugs that were popular in a prior generation. They learn from seeing in the media that the current drug is dangerous and use more of another drug. These trends tend to move from opioids to stimulants and back a decade or so later. An observation is we tend to “tool up” for the current drug and focus on it and then get surprised when the patterns shift back. I don’t really like the analogy of a drug war, but using this tired analogy we are preparing for the last war, over and over again by focusing on single substance concerns, e.g. the Opioid Epidemic.

The second point is that drug use tends to occur with multiple substances. As this Feb 2020 American Journal on Public Health paper states, polysubstance is common in persons with opioid use disorders, viewing opioid trends in a “silo” ignores the fact not only that polysubstance use is ubiquitous among those with opioid use disorder but also that significant changes in polysubstance use should be monitored alongside opioid trends.” As noted by the Journal of the American Medical Association in this April 2020 paper, opioid overdoses with co-involvement with alcohol and benzodiazepines are “common and increasing – reaching 14.7% for alcohol and 21.0% for benzodiazepines in 2017.” Adding to this dynamic is the trend we are seeing in finding fentanyl mixed in with cocaine and methamphetamine, increasingly complicating these dynamics through overdosed on substances that users may not have been aware was in the drugs they used. The most common drugs associated with co-involved opioid overdoses were Benzodiazepine, Cocaine and Methamphetamine.

Finally, we are seeing a shift in drug use patterns that will require comprehensive interventions. Focusing only opioids through medications only without focusing on whole person care may be setting us up for additional loss of life. As noted in this Wall Street Journal article  effective strategies to move people into recovery “will require deeper change than just cracking down on one substance or another” and that “It’s unlikely it will respond to a specific drug or age category. It will need a much, much more comprehensive intervention.” Last week a Science Daily article noted that methamphetamine overdoses deaths were rising rapidly across all US racial and ethnic groups, with  American Indians and Alaska Natives having highest death rates overall.  This paper examining methamphetamine use in persons in Medication Assisted Treatment in Oregon noted that patients perceived methamphetamine as a safer alternative to heroin, for continued drug use. We are also seeing empirical evidence that methamphetamine use is undermining the efficacy of medication assisted treatment, and dramatically increase the dropout rates for person on MAT.

Efforts to address our addiction epidemic have been well meaning. The focus of simply getting people onto a medication to reduce opioid related deaths has been well intentioned as it addressed an immediate need. This is understandable as short term, immediate focus is how people and systems think in a crisis. The point is, we are not in a short-term crisis, we are in a long term and complex disaster. We need to get out of the crisis mode of thought and think long term and focus on developing a comprehensive care system centered on getting diverse communities into and sustaining their recovery over the long term in ways that addresses the challenges we face.

It will not be possible to do this with broad inclusion of communities in recovery, who have been largely absent from policy discussions about us or how to strengthen recovery efforts at the community level. Recovery management models must center on strengthening community and not on redesigning care models focused on narrow, transactional services provided in individual and groups as units. One of the keys to designing a care system to meet our needs is understanding that recovery is contagious as Bill White noted in this 2010 paper on recovery as a contagion – “recovery is contagious only through interpersonal connection—only in the context of community. For those still in the life to find hope and recovery, they must take the unlikely risk of leaving their cocooned world or we must risk going to get them.”

I have suggested “Guiding Principles for Consideration on Treatment & Recovery for the Biden Administration” the roots of these recommendations can be found in the works of the like of Bill White, Robert Dupont and a lot of dialogue across our community. Perhaps our greatest mistake in addressing addiction in the United States is not thinking big enough or realizing that recovery is the probable outcome if we design a care system around supporting the needs of our communities. We have not done so historically, and it is time.

There is an old proverb, “the best time to plant a tree is 20 years ago, the second-best time to plant a tree is today.” 

Let’s plant that tree!