The Perfect Storm is Foundering Our SUD Interventional Infrastructure

“A story only matters, I suspect, to the extent that the people in the story change.” ― Neil Gaiman

Exactly twenty years ago, key SUD field leaders examined our SUD service infrastructure and published can the national addiction treatment infrastructure support the public’s demand for quality care?  It noted extreme instability across our entire workforce. There was inadequate infrastructure to meet our nation’s SUD Care needs. History shows us that we mostly kicked the can down the road on those and other challenges. It is a can that cannot be kicked any further.

The most severe tempests occur when dark clouds on the horizon from different directions merge into one massive gale, creating synergistic effects greater than the sum of each smaller storm. As noted in Loss of Institutional Knowledge – a Critical Tipping Point in the SUD Workforce Crisis, we have even higher turnover rates and fewer seasoned workers than when that paper was written 20 years ago. We are experiencing unsustainable infrastructure erosion. This recent article, Addiction treatment workforce breaking down, trade group reports is quite alarming. The trade group in Massachusetts is leading other states in documenting unsustainable labor trends that are likely widely experienced across the nation.

This is where we are right now. Several storm fronts have merged into an epic maelstrom of devastation.

Another dark cloud – we don’t seem to be quite sure if we should be helping people heal anymore. This stems from an oversimplified view of the Portugal Model as the answer to the failed drug war. That if drug use is normalized, problems associated with addiction go away. The model incorporates critically important harm reduction strategies and correctly centers  problematic substance use and addiction as a public health matter. There are many exemplary features of the Model, but problems do not simply go away with normalized drug use.  

As the Washington Post notes, Portugal is having doubts about its course. In that article, João Goulão, head of the nation’s National Institute on Drug Use noted that what they have in Portugal “now no longer serves as an example to anyone.” Addiction and crime are increasing, and people are not going into treatment. The piece notes that organizations that could serve to help people are now more focused on advocating for drug use as a human right, a dynamic I have seen closer to home. Advocates for drug use call abstinence recovery an elitist and unnatural state. These groups have shifted the very definition of recovery in reversionistic ways that now embrace problematic drug use as an equivalent to life sustaining abstinence. The normalization of problematic drug use has unavoidable consequences we must consider.

There are profound ethical issues here that simply have not been explored. For NIDA, recovery now includes the “lessening of substance use or switching to less risky drug use.” Any minor change in behavior is now essentially recovery. We should provide people clean needles, yet is a clean needle to inject methamphetamine into a decaying body recovery? This is use that kills users, devastate families, and erode communities. While harm reduction strategies save lives, some of the underlying ideology contributes to a “meet people where they are at, yet then leave them lying in the street gutters” dynamic. As author Sam Quinones notes in his piece on US Drug Policy in the Atlantic, harm reduction strategies alone – without getting people treatment, look perverse.

Those two storm cells are merging with a third all too predictable supercell. Addiction is a progressive condition. Wack-a -mole programming that focuses interventions on single substance strategies inevitably fail as tolerance develops and drug use patterns change. It happens because users mix different types of drugs to experience the synergistic effect of two plus two equaling sixteen as they develop tolerance. Increasingly, this means mixing very high potency drugs in manners that increase their lethality and make treatment much more challenging. Combinations such as fentanyl and methamphetamine or fentanyl and xylazine require the close coordination of medical, psychiatric, and addiction treatment strategies in structured long term care settings that we simply do not have to the extent we need them. We shuttered these programs a generation ago as we moved to provide single drug focused or low threshold, short term, acute care interventions. We should have seen this coming, yet we ignored the fundamentals of addictive drug use.

In short, we lack the service infrastructure we need. We lack the workforce we need to staff it. All underpinned by ideologically driven narrow intervention policies that ultimately can’t take us where we need to go, getting significantly more people into sustained recovery. While our situation is dire, we can alter course. We first must note that the intensity of storms is influenced by the underlying climate. Drug policy in America is that climate that has long been a battle of deeply divided ideological camps stretching back to before I was in grade school. Shifting from strategy to strategy that has not focused on recovery. Notions we can just lock people up and they would get well or that all substance misuse extends from underlying trauma. Focusing on getting kids to just say no, or stopping all the drugs at the border. Simmering underneath all these dynamics is the deeply held belief in America that people like me who have experienced addiction are deeply flawed and less than human. Unworthy of help and incapable of change.

We are facing the perfect storm of overwhelming need swamping a system of care in deep distress. Now is the time to move towards solution. We need to get much more intentional about helping people heal while deeply investing in our SUD workforce. We need to find ways to shore up fissures in our ship that make our system unseaworthy.

A partial list may include:

• We need to finally get serious about investing in recovery beyond our traditional treatment model, inclusive of recovery community in all its diversity.
• Recovery camps with long standing anti-MAT beliefs need to modify their stances. Medication appropriately taken is consistent with abstinence recovery.
• Harm reduction camps would need to accept that for some in severe need, compulsory care is required.
• Law enforcement strategies would need to be modified to support healing and not leave those caught in the crosshairs of our criminal justice system with life changing consequences that are as harmful as addiction itself.
• Policy makers would need to radically revise our entire care system in ways that deliver much more robust services in more fluid ways than have ever been provided in our history.
• Makers of addictive drugs must be required to take active responsibility for the impact of their products on our communities in ways that would deeply cut into their profit margins as we are their target consumers.
• All institutions must acknowledge that drug use and related stigma is endemic across society. “Those people” are our coworkers, our family members and often who we see when we look in the mirror.  We all harbor negative perceptions about substance use and addiction in ways that will require deep culture change to unpack and address in order to move forward in meaningful ways and to effectively address our collective needs.

Addiction is as multifaceted as is the healing from these conditions. There are no simple and perfect models that encompass all explanations for causation or effective interventional and ameliorative strategies. We will not find a panacea, we have spent well over a hundred years looking for it, it does not exist. The only solutions that can work would require us to accept and embrace multifaceted interventions that ultimately help people heal. This would require a radical departure from the paradigms of yesteryears to build a whole greater than our individual elements.

The storm is upon us, we shall adapt and prevail or not and suffer greatly. Our storm is not the only one we have faced; but quite likely the most destructive one to ever befall us. We shall face it together or suffer it divided. Riding through this storm would require us to overcome the iatrogenic obstacles we ourselves have created in our walled off ideological camps. It is a large storm, and so requires a greater degree of change than any of the tempests that have preceded it. We cannot escape the storm, we can only steer through it, together. We should. Many lives depend on it.

Sources

Can the national addiction treatment infrastructure support the public’s demand for quality care? (2003). Journal of Substance Abuse Treatment, 25(2), 117–121. https://doi.org/10.1016/s0740-5472(03)00156-9

Clay, R. (2018, October). How Portugal is solving its opioid problem. https://www.apa.org/monitor/2018/10/portugal-opioid

Faiola, A., & Catarina Fernandes Martins. (2023, July 7). Once hailed for decriminalizing drugs, Portugal is now having doubts. Washington Post; The Washington Post. https://www.washingtonpost.com/world/2023/07/07/portugal-drugs-decriminalization-heroin-crack/

Priority Scientific Area #2: Develop and Test Novel Prevention, Treatment, Harm Reduction, and Recovery Support Strategies. (n.d.). National Institute on Drug Abuse. https://nida.nih.gov/about-nida/2022-2026-strategic-plan/priority-area-2

Quinones, Sam (2023, June 1). America’s Approach to Addiction Has Gone Off the Rails – The Atlantic. Scribd. https://www.scribd.com/article/649886351/America-s-Approach-To-Addiction-Has-Gone-Off-The-Rails

State House News Service. (2023, June 2). Addiction treatment workforce breaking down, trade group reports. Retrieved July 9, 2023, from https://spectrumnews1.com/ma/worcester/news/2023/06/02/addiction-treatment-workforce-breaking-down–trade-group-reports

Stauffer, William. (2023, May 5). Early Notes From the Post Pandemic Addiction Tsunami. https://recoveryreview.blog/2023/05/05/early-notes-from-the-post-pandemic-addiction-tsunami/

Stauffer, William. (2022, May 15). Loss of Institutional Knowledge – a Critical Tipping Point in the SUD Workforce Crisis. https://recoveryreview.blog/2022/05/15/loss-of-institutional-knowledge-a-critical-tipping-point-in-the-sud-workforce-crisis/