We Keep Pressing the Easy Button and It Still Is Not Working

“For every complex problem, there’s a solution that is simple, neat, and wrong.” – H.L. Mencken

A recent article, The addiction crisis is even worse than headlines can convey highlights how Americans are dying in a myriad of ways beyond overdose. Embracing overdoses as the primary metric has myopically focused us on what is one devastating facet of a much larger challenge. This is what we do in respect to addiction. We focus on one single facet and  wonder why we fail to make sufficient headway. We should be relieved that overdose rates declined nationally by nearly 4%, but we ignore other was of losing lives to addiction are increasing at our own peril. The analogy would be that we have successfully slowed the flow of water into a sinking boat from one breach and it is the only one we are focused on.   

We also lump the continuum of severity from mild to severe together, even as they differ in type of condition as well as extent of use. This is well explained by Jason Schwartz in his piece, Substance Use Disorders as a category, there are advocates in our space who call any positive change in respect to an SUD recovery. This is a set up for failure for those of us with the most severe forms, which I suspect is also part of why we see increasing rates of mortality beyond overdoses.

Despite this complexity, our systems increasingly lump all change from even the mildest form of substance use in which a person makes a life change and can successfully moderate their use under the broad umbrella term of recovery. Unfortunately, it leads to the false and far too often deadly premise that all substance use conditions require similar interventional and support strategies. Nothing could be further from the truth. Terming it all recovery is a symptom of our tendency to try and distill all related factors into simple, neat, easy and wrong frameworks of thought.

What gets lost in the oversimplification are often the needs of those with most severe forms of an SUD. These cases are at the heart of our national substance use challenge. They are most costly in devastated lives and expenditure of resources. It is so costly, it can be measured in the reduction of US life expectancy and a drain on our economy. We need to make room for all strategies under one broad model. We need to develop a unifying paradigm of both substance use conditions and their healing. That would be very hard to do, but easy is failing us.

It is important to highlight that millions of Americans find their way to healing from the continuum of a substance use conditions following a myriad of pathways. Healing across this continuum occurs with significant variation. Factors, including the severity of the condition, its stage of progression and the level of individual, familial and community recovery capital that the person has impact the pathway and the outcome. Healing from less severe forms of the condition in early stages in which the individual possesses a high level of internal and external resources can occur with limited and in some cases no interventional strategies. This has been at time referred to as spontaneous recovery.

We need to start by acknowledging a difficult truth. We do very little to help people properly heal from a severe substance use condition. Well over a decade ago, NIDA noted that treatment of 90 days or less for the average substance use disorder is ineffective. Many years later far too few Americans with an SUD get the minimum amount needed to have an impact. Those who do get treatment get small doses with little to support their long term recovery. We provide medication that can support healing as an important tool but call the medication for OUDs alone a gold standard, while ignoring the critical need for other critical elements of healing, including therapy and social support.

I recently heard Dr. John Kelly of Harvard Medical note in a presentation that if addiction was a fire, we know how to call out the fire trucks and initially douse the flames, but we do little to keep the flames from reigniting and nothing to rebuild the fire ravaged structure. I would add to that we ignore the fire when we see it smoldering and wait until we have a conflagration to send in the trucks. What we do is continually apply simple and easy solutions often too late, for short durations and in small doses. As in the analogy above, we sound the alarm, send the fire trucks but we fail to stay focused long enough to result in anything beyond the initial emergency response. Coordinated responses are not easy.   

One of the few things we could do to stem these horrific losses is focus beyond reducing overdoses and instead focus on getting more Americans into long term recovery. It would take a significant investment in our treatment and recovery support infrastructure and related workforce. That has not occurred as much of the money coming into our systems has focused on more limited interventional strategies and not long-term recovery. The easy button that is not working. We need to do so if ever we are to turn the tides on these devastating losses.

Easy solutions require less effort for both our systems and the persons they serve. Easy solutions make great soundbites. We tend to want to put things in neat columns and declare effective solutions that fit into simple-to-understand interventions and move on. They are cheaper to develop and measure. But easy solutions are failing us. We are ending up with a much more challenging problem. Easy solutions are akin to kicking the ball down the road so somebody else in the future can do the heavy lifting. We have kicked this ball down the field for a really long time. The cost of doing so in lives and treasure has mounted significantly. The costs of simple solutions has been anything but easy to bear in any way.

In respect to drug use, we tend to see solutions residing in broad and simple strategies, such as:

• Just say no (the War on Drugs)
• Just say yes (Drug Normalization)
• Any change, even the smallest improvement in a substance use condition is recovery

This dichotomy is illuminated in recent discourse on the Oregon experiment on Measure 110 to decriminalize drugs was being seen by some as a failure and by others as not having gone far enough. This latter point being asserted as that if we legalized all drugs and made the supply safer, that demand would go down. This seems to ignore two facets of market economics, one being that increasing supply and making it more appealing to use tends to increase demand. The other point being that drugs are quite profitable. Legalizing the supply would increase the innovation by illicit sellers to reduce the costs and “improve” their product by making it pack more punch in each dose to stay competitive. This would lead to a market share war between legal suppliers and illegal suppliers. Legalizing drugs as a solution would be about as effective as the notion that initiated the war on drugs. The belief that we could punish people so much that they would stop using drugs. We did so even as we knew at the time that substance use can interfere with cognitive processes and override the capacity to weigh consequences. That was too complex to factor into policy solutions.    

We are failing persons with the most severe forms of substance use disorders and it is costing us dearly. Persons with opioid and other substance use disorders live and die on our streets, with horrific costs to the entire community. 

Deaths from alcohol use disorder are increasing precipitously. Alcohol alcohol-associated liver disease (ALD), will more than double over the next two decades. We are also seeing an increase in older adult substance use conditions. All of these trends will require more expensive, more complicated, and more intensive care if we are to support their resolution. The situation we face is hard, in no small part a result of our historic and ongoing focus on easy solutions. Kicking the can down the road had led to nearly intractable challenges.

Can we identify any strategy that has been fully and effectively deployed to prevent, reduce, treat, or heal substance use disorders and their impacts on our society? I am hard pressed to come up with one. Instead, we have:  

• Lack of prevention strategies that work in all diverse communities across all life stages.
• Lack of harm reduction tools and strategies in place across all community, medical and human service organizations
• Treatment of the proper intensity and duration on demand, when needed and without barriers.
• Recovery support resources grounded in our communities that can support recovery processes across the life span.
• Research oriented to understanding and developing strategies to implement and augment effective recovery strategies for our diverse communities across America.

Consider how we do so for other challenging issues in our society not tainted with negative perceptions about the condition or those impacted by it. We spend significant resources on cancer, from preventing it through our understanding of risk factors, to early detection, a myriad of short- and long-term treatment strategies that can be used in various combinations in order to obtain the most benefit. Family and ancillary support and long-term care and surveillance to support additional care if there is a reemergence of the cancer. An infrastructure supported by billions of dollars in research to improve our responses. We do all of this, even though it is hard, and it is expensive because we see this as a priority in ways we have never seen substance use conditions and their healing.

The general public does not understand the complexity of the challenges we face, but they can see what we are doing is not working. We all are readily able to see the erosive nature of these challenges in their communities as it impacts economic capacity and community safety. The easiest from a policy perspective that we have historically embraced is to lock people away, so they are off the streets and out of mind. Making drugs more accessible led to the opioid epidemic a simple solution that was also catastrophic. Simple solutions we excel at; despite all of the horrible consequences they have on our entire society.  

We need a unifying paradigm of substance use conditions and their healing. A paradigm inclusive of substance use condition categorization with a corresponding model of prevention, harm reduction, treatment and healing strategies  required for us to substantively improve long term, healing oriented outcomes. What really makes this hard to do is bringing together all the different groups with goal of identifying enough common ground to develop consensus on what that looks like. Complex problems require complex solutions. Such solutions in our space would not be easy, but clearly, easy is not working.

Sources

Centers for Disease Control and Prevention. (2019, December 30). The Cost of Excessive Alcohol Use. https://www.cdc.gov/alcohol/onlinemedia/infographics/cost-excessive-alcohol-use.html

Hoffman, J. (2024, May 15). Overdose Deaths Dropped in U.S. in 2023 for First Time in Five Years. The New York Times. https://www.nytimes.com/2024/05/15/health/drug-overdose-

Mineo, L. (2023, September 22). Cost of treating liver disease tied to drinking projected to double over 20 years. Harvard Gazette. https://news.harvard.edu/gazette/story/2023/09/cost-of-treating-liver-disease-tied-to-drinking-projected-to-double-over-20-years/#:~:text=With%20high%2Drisk%20drinking%20on

National Institute on Drug Abuse. (2014). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). https://nida.nih.gov/sites/default/files/podat-3rdEd-508.pdf

New Report Confirms U.S. Life Expectancy has Declined to Lowest Level Since 1996. (2022, December 20). https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/20221222.htm

Owens, C. (2024, May 31). The addiction crisis is even worse than headlines can convey. Axios. https://www.axios.com/2024/05/31/us-addiction-crisis-drug-use-disorder-mental-illness

Sabet, K. (2024). Oregon Makes a U-Turn on Drug Decriminalization. WSJ. https://www.wsj.com/articles/oregon-makes-a-u-turn-on-drug-decriminalization-cede4a40

Schwartz, J. (2022, January 19). Substance Use Disorders as a category. https://recoveryreview.blog/2022/01/19/substance-use-disorders-as-a-category-3/

White, W. L. (1998). Slaying the dragon: The history of addiction treatment and recovery in America. Chestnut Health Systems/Lighthouse Institute.