What Are We Doing Once We Keep People Alive?

Earlier this week, I had the opportunity to testify in front of the PA Senate Judiciary Committee in favor of legalizing Fentanyl Test Strips. One of the other testifiers, talked about the role of harm reduction in his own recovery process. Harm reduction was life saving for him. As he indicated in his testimony, his insurer would deny care to treat his severe substance use disorder beyond a handful of days. Of course, it did not work. Harm reduction kept him alive in between short treatment episodes. Our treatment system was resourced to fail him and to not deliver proper lengths of stays to get him into recovery or even engage him in ways that kept him involved. I know from prior public disclosures that it took him multiple experiences. He eventually got a longer duration and better intensity of care a few years later. Now he has a life, a family, and a role in healing his community, what we should want for all who have SUDs.

People seeking help within our SUD care system should probably get a disclaimer that we do not have an SUD care system managed to meet the long-term recovery needs of persons with SUDs. We don’t focus enough on helping people heal after we keep them alive, or even engaged with us over the long haul. It leads to a viscous cycle. While there has been some progress, our care systems most often fail those with more complex and severe SUDs. It has never really been resourced to provide people what they need to get better over the long term. Most of the time, we provide short duration care and move people through those services as quickly as we can in a conveyor belt fashion. We do a Hail Mary for each person as they pass through. The very need for expanding harm reduction strategies stems from the fact that we never actually properly invested in helping people recover. We should do that, too.   

Back in 2013, my agency did a workforce survey, the Systems Under Stress Survey for our State Department of Drug and Alcohol Programs. That the statewide recovery community organization was charged with the roll of doing such a survey on how our systems served our community says a lot about how much we were valued at that time and how statewide recovery community organizations have a vital role to play in our system design, evaluation, and implementation.

We sent out surveys to the SUD counselors across Pennsylvania. We got over 1,000 back eventually, but the sample cut off was just over 800 respondents. Even in 2013, the SUD workforce was overburdened and not feeling like they had time to do the work to help people. They were stuck in piles of paperwork. We asked about goodness of fit between client needs and program capacity. Just under half of the respondents indicated that clients got lower levels of care than they thought as clinicians was needed and the people served needed more than they could offer given the resources they had. The funding mantra back then was you had to find ways to do more with less. The truth is when it comes to resources, you can only do less with less. Anecdotally listening to what the SUD workforce is saying right now, I suspect it has deteriorated even further since 2013. A number of these facets are on steroids in 2022.

My organization, PRO-A was the first RCO in the state of Pennsylvania to sign on to support increased harm reduction efforts. We did so even as we raised the need to invest more resources to keep people engaged with us and provide the care and support, they need to get well. Warm handsoffs help, but what happens next? We need harm reduction tools, but we also need a commiserate focus on what we do once we keep a person alive. We need to invest in keeping people engaged with us over the long term, particularly those with severe SUDs recovery. We should then help people flourish.  

I am not the only person who thinks so. Senior editor for the Journal Alcohol & Drug Dependence Dr Eric Strain in a February 2019 Op-ed, noted that “our failure to forcefully advocate that patients need to flourish is tacitly acknowledged through interventions such as low threshold opioid programs, provision of naloxone with no follow up services, and buprenorphine providers who only offer a prescription for the medication.” He suggests that we need to engage patients to support flourishing and help support things that have meaning in their lives. We are not investing in flourishing as he so eloquently points out. Can you imagine what we could yield if we did?

While addiction is one of our costliest social challenges in resources and lives, we also know that 85% of the people who reach five years of addiction recovery remain in recovery for the rest of their lives. We should focus on long term recovery as our functional system metric for severe substance use disorders. Get people harm reduction services and help them identify what has meaning in their lives and support them in their recovery process. Provide the proper care and follow it up with recovery management services. Start measuring what works for whom so we can develop protocols for long term wellness for those of us with an SUD. If we invest in critically needed harm reduction services, but not in long term recovery infrastructure, we won’t even be close to the point in helping people thrive. Investing in recovery pays dividends in saved lives, restored families and healed communities.

We should steer in that direction.   

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