“There is no greater tyranny against the minds of men that to allow the minds of their children to be destroyed by addiction disease because of our lack of courage and commitment at the time it is needed most. This is the time. If we fail now, we will have failed our future. This is the time to climb the mountain, make whatever sacrifice is necessary, and know that our cause is right and just.” – Senator Harold E Hughes, 1993 (In Memoriam)
Expanding access and retention of people in long term recovery within every community group in America across multiple pathways of recovery is a goal that would reap huge benefits for our entire society. As I have written about before, the single most important focus of substance use treatment and recovery policy in the United States should center on getting as many people as possible into long term, stable recovery. Substance use conditions cost us immense resources and tragic loss of life. If one adds it all up, it is probably our costliest domestic challenge. Paradoxically, people in recovery are significant contributors to the productivity and civic fabric of our nation. Few other challenges we face can yield benefits to our society as would a concerted effort to get more people into sustained long-term recovery from addiction. Surprising as it may be, it is an objective we have never focused on in a comprehensive way in this country. It is in part what Hughes envisioned a generation ago when he formed the Society Of Americans for Recovery (SOAR).
As I wrote in a Statnews piece in January 2020, few Americans get anywhere near 90 days of care, which is the minimum effective dose for the average person. Within the confines of existing insurance networks, short-term treatment of 28 days or less is all that most Americans are offered — if they can get any help at all. It is an inadequate care system designed to deliver less than what people need in many ways because we still moralize addiction and do not fully value people who have substance use disorders. So, we fail to invest in long-term recovery. These dynamics have created fragmented care systems with large gaps. We are not properly focused on the ultimate goal, achieving and sustaining long term recovery for all people who are addicted. A way to highlight what we are doing would be to consider how we treat an infection. Yet, instead of providing people enough treatment to clear the infection, we provide significantly less than that. Not only do fewer get better, but their challenges become more profound and resistant to intervention, requiring more resources and typically diminished prospects moving forward. And then we blame them for not healing.
Our current lens of resolution for our challenges has been a simple one. It views our primary challenge as opioids and to frame resolution as the reduction of overdose deaths. It ignores the reality on the ground in respect to broader drug use patterns, even in persons who have opioid use disorders, the vast majority are using multiple substances and will even shift to other substances over time. We are playing whack a mole inconsistent with the most effective long-term goal. Sustained recovery over the remaining life span. Like most everything else associated with these conditions, the reasons why are complex, yet in the broadest terms fall within what can be viewed as a reversed tragedy of the commons. While focusing on resolving addiction challenges would benefit everyone, no one group benefits in any other way than by ignoring the problem or only posing window dressing level efforts in respect to its resolution.
The tragedy of the commons is essentially about the pitting of short-term self-interest against long term whole community wellbeing. These are problems that generally transcend solutions using the tools at hand within the systems in place. Long term recovery is well within the tragedy of the commons as achieving it benefits all institutions, but individual, short-term interests prevent us from focusing on these objectives. A related concept is the free rider problem, in which individual interests take advantage of work done to strengthen community resources but are not contributive towards those ends. An example of a free rider problem in respect to substance use treatment is the tendency for private insurance entities to provide minimal care and shift costs to the public system as the person loses their job because their drug use begins to interfere with work performance.
SUDs are not the only area of healthcare that experiences these challenges. Avoiding the Tragedy of the Commons in Health Care explores how our multi-payer health system follow the tragedy of the commons pattern by each acting in its own commercial interest by restricting access to interventions. This results in a collective barrier that deprives patients of effective care. Paradoxically, if insurers act in a coordinated fashion, the free-rider problem could be addressed and an overall better outcome achieved that all society would benefit from. It would reduce the impact of poor health on our society and the insurers’ bottom lines. Fully focusing in long term recovery from substance use disorders, would pose significant benefit for all society if we delt with it in a more comprehensive challenge. But it is also true that people in long term recovery do not represent a profit center for any one single industry and therein lies one of our greatest challenges we have no champion industry focused on this goal.
Developing the commons of long-term recovery support has not been as successful as we had hoped. We have made progress, but even the gains made tend to degrade back to baseline over time as organizations reorient to short term care models for sustainability beyond the life of a grant. Service organizations who have attempted to focus on developing the infrastructure to support long term recovery quite often end up suffering from mission creep away from holistic strategies focused on long term recovery into more narrowly focused goals. This also occurs because grant funding and foundation money tends to have more narrowly focused goals which vary in ways that reduce the development of a cohesive system. They can also get trapped in fee for service models that make it difficult to achieve the goals that were originally envisioned. Addiction and dependency is the profit center there, not recovery. Over time, this dynamic moves organizations away from a holistic focus on long term recovery to bill for acute care Band-Aids.
What is “in the commons” in respect to long term recovery:
- Long term, whole person recovery focused research that examines recovery over the long term in order to understand what works for whom and under what conditions.
- Concerted effort to reorienting our entire care system to fully create and sustain the five-year recovery care model as the research is showing us is that this is the point at which 85% of persons will remain in recovery for life.
- Tools to hold our care systems accountable when disparate, short-term care is provided to ensure that applicable laws are in place and enforced to eliminate free riders.
- Full inclusion of people in recovery in the design, implementation, delivery and evaluation of services in order to ensure that care meets the needs across the full spectrum of diverse persons seeking help.
Barriers to Long Term Recovery as a Societal Focus:
- Vestiges of the moral model that view addiction as a characterological flaw are still very much with us. They subtly shift us over time from grassroot, community grounded efforts to top-down strategies. Recovery community driven efforts become a threat to paternalistic care models who see us as akin to “letting the inmates run the asylum.”
- While society has begun to see that we do recover, there are also macro level countertransference dynamics in play. In essence driven by societal wide collective negative experiences with loved ones who had addiction challenges with a trail of carnage not easy to look past as it is seen as a self-inflicted condition. These views reinforce the moral lens and hold that, essentially, “you did this to yourself and hurt other people, why should we help you?”
- We have a dominant service mindset, which is an orientation towards professionalism at the expense of people’s capacity to address their own community needs. The commodification of recovery as a means to extract money at the expense of community as a primary change agent and discards the premise that people recover in community.
So how do we move forward with the work of long-term recovery in ways that stay true to the vision of developing an infrastructure to support long term recovery in America? Government has traditionally been a resource for developing and sustaining the commons in this arena. For it to work, there needs to be the vision and effort over the long term to develop it in a nonpartisan way within government. Fundamental to achieving that end, it is necessary for governmental institutions to possess deep understanding about recovery and a commitment for authentic collaboration with communities of recovery.
History also shows us that private interests and politics can interfere with these dynamics as they have more narrow interests. Such efforts would not bear fruit without collaborative efforts well beyond government. The insurance industry would collectively benefit from a broader focus on long-term recovery and if there was a change in paradigm to focus on it, they would realize the gains as all other groups would. This is an area that would require broad cooperation across government and non-governmental entities.
One promising practice is the focus on what are called Recovery Inclusive Cities. The strategy is not just limited to cities and can occur in towns, boroughs and villages. They are inclusive in that they leverage the value of recovery to support stronger communities in all the forms it takes. As an example of what value this can offer, the UK 2015 Life in Recovery survey measured people in recovery and the general public identified some of the significant benefits in respect to community and civic engagement. In their survey of over 800 participants, 79.4% reported volunteering in community or civic groups in recovery. In contrast, only 42% of the general public engages in these same activities. Communities with high levels of community and civic participation which are elements of what are known as social capital tend to have lower crime, higher employment, better overall health than communities with lower rates of social capital. What the combination of these factors suggest is that communities with more people in recovery are the kinds of communities we all want to live in. Strengthening recovery community is foundational to the health and welfare of the larger society.
Despite all of these challenges, the vision of a long-term care and support system is well worth the effort. Hughes saw it a generation ago and we should also. It would have dramatic benefits for our entire society. Benefits to pursing a long-term recovery care and support model include reducing social costs like incarceration, reducing healthcare expenses and slashing social service demands.
As Harold Hughes, a man who made immense contributions to our efforts to extend recovery efforts though the passage of the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 and the founder of the first national recovery community organization said, just a few years before his passing, “this is the time to climb the mountain, make whatever sacrifice is necessary, and know that our cause is right and just.”
Sources
Best, D., Albertson, K., Irving, J., Lightowlers, C., Mama-Rudd, A., & Chaggar, A. (2015). The UK life in recovery survey 2015: The first national UK survey of addiction recovery experiences. https://shura.shu.ac.uk/12200/1/FINAL%20UK%20Life%20in%20Recovery%20Survey%202015%20report.pdf
Best, D. (2024). Inclusive Recovery Cities: A visible and inclusive way to challenge stigma. Leeds Trinity University. https://www.leedstrinity.ac.uk/blog/blog-posts/inclusive-recovery-cities-a-visible-and-inclusive-way-to-challenge-stigma.php
DuPont, R. L., Compton, W. M., McLellan, T. et al. (2015). Five-Year Recovery: A New Standard for Assessing Effectiveness of Substance Use Disorder Treatment. Journal of Substance Abuse Treatment, Volume 58, 1 – 5. https://www.jsatjournal.com/article/S0740-5472(15)00198-1/fulltext
Edney, J. J., & Harper, C. S. (1978). The commons dilemma. Environmental Management, 2(6), 491–507. https://doi.org/10.1007/bf01866708
Griffiths, M. (2019). The Tragedy of the Commons. Iveybusinessjournal.com. https://iveybusinessjournal.com/publication/the-tragedy-of-the-commons/
Hardin, G. (1968). The Tragedy of the Commons. Science, 162(3859), 1243–1248. https://doi.org/10.1126/science.162.3859.1243
In Memoriam Remembering Harold E Hughes (2024). Well.com. https://people.well.com/user/woa/harolde.htm
Mattke, S., Liu, H., Hoch, E., & Mulcahy, A. W. (2017). Avoiding the Tragedy of the Commons in Health Care: Policy Options for Covering High-Cost Cures. Rand Health Quarterly, 6(2), 1. https://pmc.ncbi.nlm.nih.gov/articles/PMC5568155/
Stauffer, W. (2020, January 2). Addiction treatment is broken. Here’s what it should look like. STAT News. https://www.statnews.com/2020/01/02/addiction-treatment-is-broken-heres-what-it-should-look-like/
Stauffer, W. (2020, August 9). Supporting Long term Recovery and the Tragedy of the Commons. Recovery Review. https://recoveryreview.blog/2020/08/09/supporting-long-term-recovery-and-the-tragedy-of-the-commons/
Stauffer, W. (2023, September 23). Caring Enough to Count – How We Die from Drug Misuse and Addiction in America. Recovery Review. https://recoveryreview.blog/2023/09/23/caring-enough-to-count-how-we-die-from-drug-misuse-and-addiction-in-america/
Stauffer, W. (2025, March 31). Revisiting William White: A History of Contempt: Countertransference and the Dangers of Service Integration. Recovery Review. https://recoveryreview.blog/2025/03/31/revisiting-william-white-a-history-of-contempt-countertransference-and-the-dangers-of-service-integration/
Recovery Review 
I’ll put this here for future readers to find and explore, as related to this topic.
5 Year Continuing Care System for High Severity, Complexity, and Chronicity SUD’s: Clinical Targets, Methods, and Increments of Time – Recovery Review
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