State of the Sector: Can We Seize the Opportunity?

A record number of people in the U.S. died of drug overdoses in 2021, over 107,622 according to estimates by the Centers for Disease Control. Alcohol-induced deaths are also up – to over 52,000 – though the full death toll from excessive use of alcohol likely numbers close to 140,000. The U.S. is in a full-blown crisis, and the need for drug and alcohol treatment has never been more urgent.

While the numbers seem overwhelming, I have hope for the future, hope that not only can we save lives but we can transform them for the better.

It was in 1994 that the AIDS/HIV crisis saw its high watermark for the greatest number of deaths in a year in this country. Yet, starting in 1995, that number started dropping as new innovations and treatments came on line to not only extend life, but eventually lead us to a place where an HIV diagnosis no longer means a death sentence. It became a chronic illness that could be managed and a life that could be fulfilled.

We are at a similar crossroads with substance use disorders (SUD), if only we have the courage to seize the opportunity.

Medical science and technical innovation are revolutionizing our understanding of addiction, and we in the field of addiction medicine must also transform how we approach treatment. Only if we follow the science and embrace innovation will we drive the outcomes and innovations that will turn this tide.

I believe, just as with AIDS and HIV in 1994, we will soon look back and realize that we have seen the high watermark in the number of lives lost to this disease. But, this will only happen if the entire treatment sector steps forward to seize the opportunity. We must transform the way we talk about and treat SUD in all its many shapes and forms. In particular:

We must break down the false walls between SUD and mental health.

Too many treatment centers are unprepared to address the co-occurring mental health issues that often accompany an SUD. The truth is that SUD and mental health are inextricably linked, and you cannot treat either unless you treat both together.

Most of the people coming to Caron for treatment exhibit co-occurring mental health problems, be that anxiety, depression, schizophrenia or other issues. Is it the substance use that causes the mental health issues, or is the mental illness leading someone to self-medicate through substance use? There is no way to tell without intensive work with each individual.

The connection between mental health and SUD will only increase in importance as we emerge from the COVID-19 pandemic. The whole world has undergone a traumatizing event, and all of us have seen our mental health suffer because of it.

SUD isn’t one disease, and we need to stop acting like it is.

Similar to cancer, SUD is a collection of diseases that may involve mental health issues, trauma, genetics, family history, environment and a variety of socio-economic factors. Every patient’s experience of SUD is unique, driven by different factors, and a one-size-fits-all approach to treating SUD will not be effective.

The real revolution in cancer care only came when we realized, for example, not only is breast cancer different from colon cancer, but there are many different types of breast cancer and each requires a totally different approach to treatment.

As a treatment sector, we often pay lip service to providing individualized treatment, but that’s not what most families experience. We contradict ourselves when we say this is a disease but demand “abstinence only” without regard for the medical complexities of the individual.

We're still placing too much value on abstinence when we should be focusing on quality of life.

The traditional black-and-white stance on recovery – that if you’re not 100% abstinent then you’ve failed – is at odds with our growing understanding of SUD as a chronic illness. There is more than a single path to recovery.

Abstinence is A goal, but it is not THE goal. Success is measured on a continuum of advancement on many different fronts.

When doctors evaluate how well someone is managing a chronic condition like cancer, diabetes or hypertension, they look at it through a multi-dimensional framework. Has there been an increase or decrease in symptoms or severity? Are patients improving or declining in functionality? Success is measured by evaluating a patient’s condition on all those fronts.

Abstinence is great, but it isn’t everything. Many people can't stay abstinent, yet they are highly successful in their lives and bring joy to those around them. Insisting on abstinence precludes people sharing in the collective success of being in the process of recovering.

We must end the controversy over MAT.

One of the more harmful side effects of the “abstinence only” stance is the rejection of medication-assisted treatment (MAT) as a viable means to enter recovery. If we are to follow an evidence-based approach to treating SUD – and we must – then MAT is a solidly proven approach to helping people achieve and, more importantly, stay in recovery. SUD causes physical changes to the brain, and MAT supports people in recovery as their brains heal.

Again, think of other chronic diseases. Diet and exercise can help slow the progression of type 2 diabetes, but does taking metformin in addition to diet and exercise mean that someone isn’t properly managing their diabetes?

We need to stop pretending that all treatment is equal and hold treatment centers accountable for their outcomes.

Too many treatment centers rely on methods that are outdated, unproven or – worse – proven to be ineffective. The science of addiction medicine has advanced to the point where we have a much better idea of what makes for an effective treatment. By this point, we should commit sector-wide that all treatment should be based on evidence-based methodologies proven to be effective.

Part of this is moving insurance reimbursement from a process-driven model to one that focuses on outcomes. Reimbursement should be based the on outcome of the treatment process. We’ve shown that value-based insurance models work for SUD. We’re able to know our outcomes for 30-and 90-days post-treatment at Caron and we’re held accountable for those outcomes. This should be the norm, not the exception.

Recovery has never been more probable

While we're losing around 200,000 lives a year due to this disease, we know that over 23 million people are living in recovery in this country at any given time. We also know that three quarters of people who suffer from a substance use disorder will, at some point in their life, get into recovery. And we know that recovery is not just possible, but it is probable.

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