The Age Old Plague Continues
Gene Gilchrist
Louisville, Kentucky
In our recent posting, “The Ambulance at the Bottom of the Hill”, we told the story of how mischaracterization of a problem leads to spending our efforts on treating the results of a problem rather than treating the problem itself. We argued that prevention would do better than treating the results, in this case treating substance use disorder rather than treating crime that it causes after the fact.
This approach does not lead us to specific, clinical treatment for substance use disorder as much as it speaks to public policy and where we as a nation allocate our resources. Will we spend money on police, courts incarceration and so on after crime is committed, or on preventing crime before it occurs? As we noted in the previous article, the involvement of alcohol and drug abuse in crime is substantial. Certainly, there are other, major factors that contribute to crime. Here we focus on prevention through addressing alcohol and other drug abuse and addiction rather than other sources of crime prevention.
Previous Approaches For Addressing Alcohol and Drug Abuse
Our awareness and attention to addiction is not new. In the early history of this country social convention considered alcohol to be an issue of morals. Temperance societies existed across the nation allying with organized religion to promote abstinence. In the 19th century the national conscience was influenced by temperance organizations such as the American Temperance Society, and by abstinence groups such as the Sons of Temperance. Dry counties existed in nearly every state in the union, and North Dakota was the tenth State admitted to the union as a “dry” State. As late as 1900 entire states and jurisdictions within states considered laws and constitutional amendments voting back and forth to ban and/or allow the manufacture, distribution and sale of alcoholic beverages. While Carrie Nation and the Women’s Christian Temperance Union are the most noted advocates, it was likely more conventional reformers who, standing on the shoulders of a long history of battling demon rum, successfully ushered in prohibition with the 18th amendment ratified in 1919. We were not alone as prohibition was occurring across Europe at that time. Prohibition was a widely recognized failure. By some estimates more alcohol was consumed on a per capita basis in America during prohibition than any other time in the nation’s history. The passage of the 21st amendment in 1933 marked the end of abstinence as a national cultural tenet. Of course several religions frown on alcohol use as part of their faith tradition today including Islam, Jainism, Seventh Day Adventists, some sects of Hinduism, Buddhism, and The Church of Jesus Christ of Latter-Day Saints. 30% or more of Americans do not drink alcohol today.
Alternatives Outside the Field of Alcohol and Drugs
As we look to approaches other than prohibition, we might note approaches that have worked in American culture outside the arena of addiction. Consider the automobile. Automobile fatalities peaked in the U.S. in 1972 at 54,589. No one called for the prohibition of automobiles. Recognizing the deep connection to automobile transportation in the national culture, a combination of government, auto manufacturers and insurers, in varying degrees of willingness, introduced often innovative approaches to reduce crashes and the damage to life and limb caused by accidents when they did occur. That list would include seat belts and seat belt laws, the crackdown on driving under the influence, crash resistant glass, airbags, crumple-zoned front ends, changes in national perception such as promotion in “Unsafe At Any Speed” (Ralph Nader, 1965), highway surface improvements, improved road signage and striping, tire and suspension enhancements, anti-lock brakes, automatic braking, and improved vehicle chassis materials. Auto crash fatalities had decreased by one-third to 36,560 in 2018 despite a 15% increase in annual light vehicle sales during the period.
And we do have a comparison for a drug more addictive than any other and that was also deeply engrained in American culture – nicotine. Similar to the case against alcohol, the case against tobacco has a long history, is closely affiliated with religion and dates to the late 16th century. Sir Francis Bacon discovered the addictive nature of tobacco in the 17th century and entire cities in Germany outlawed smoking in that time period. In modern times, anti-smoking campaigns began anew in the 1950s with the rediscovery of a causal link with lung cancer. The report of the Advisory Committee to the Surgeon General in 1964, certainly orchestrated by the Surgeon General, called for remedial action across society and empowered Surgeon General Luther Terry to champion a multi-pronged approach that eventually included legislating the content of tobacco products, enforcing legal age restrictions, extraordinary State and federal taxes, smoke free zones including second hand smoke, and extensive media promotion of the scientifically proven deleterious effects of tobacco that included warning labels. A near national resolve to reduce the use and ill effects have reduced the percentage of smokers in the U.S. from 42% in 1965 to near 14% in 2017 with a commensurate reduction in deaths from smoking related illness.
Our society recognizes that certain things with known health consequences are deeply engrained in our society and will react badly to prohibition. Afterall, and as noted, there are some estimates that the greatest period of alcohol consumption on a per capita basis occurred during prohibition. We “get it” that they are not going to be banned, and perhaps should not be, but that there are steps we can take to reduce the damage.
Our Approaches to Alcohol and Drug Abuse Since Prohibition
To be certain, our collective consciousness recognizes the ill effects of alcohol and drugs. Our response, however, has not been effective. Choosing a war metaphor to engage a behavioral health problem was not a good start. We are losing the War On Drugs. Similarly, the slogan, “Just Say No”, while certainly well intentioned, failed to recognize the underlying causes of use including thrill seeking, social pressure, and the stress that has seemed to increasingly grip the population. Finally, the war on drugs has turned into a war on drug users resulting in mass incarceration costing the nation $24 billion to incarcerate 1.2 million non-violent offenders and disproportionately impacting people of color. During this time, the number of people with substance use disorder has not declined and schedule I narcotics have become more lethal.
The most successful approach to treatment has been the twelve step movement credited to Bill Wilson, a stockbroker in New York, and Bob Smith, a physician in Akron. Building on the work of the Washingtonians and the Oxford Group, of which they were both members, Bill W. and Dr. Bob started Alcoholics Anonymous in 1935 where today 1.5-2.0 million members choose among 115,000 meetings across the world. Similarly, Narcotics Anonymous reported 61,000 meetings world-wide in 2013. Lois Wilson and Anne Smith are credited with founding Al-Anon for the families of alcoholics and today Nar-Anon exists for families of those who identify as addicts. Despite the godsend that AA, NA, Al-Anon, Nar-Anon et al have been for the substance use disorder community, it is estimated that in the U.S. today there are 40 million Americans with substance use disorder (SUD), less than 20% ever encounter treatment of any sort, and less than 10% achieve one year of continuous recovery. The cost to the nation is estimated at $443 billion. We have a long way to go.
What Might An Approach Look Like
The current Surgeon General, Vice Admiral Vivek Murthy, has begun to use the plague metaphor to describe what others consider social issues such as mass killings via guns. He receives much criticism for stretching the definition of plague. When the Vice Admiral uses the plague metaphor in the arena of behavioral health, however, he is less open to criticism. We suggest that a plague metaphor would result in a more comprehensive approach to thinking about substance use disorder that, after all, kills over 600,000 Americans every year, year in and year out.
The pandemic approach suggested by Dr. Murthy, the campaign to improve auto safety, the coordinated effort to reduce smoking, and even the “all of government” and private partnerships in response to COVID-19 pandemic response give us patterns to approaching substance use disorder which we argue would be a better invest to fight crime. In these contexts, what are the elements of an approach? The answers are many, not always complex, not necessarily costly, and widely shared. Among them:
· Eliminate the Stigma: when your family member is diagnosed with cancer no one whispers that perhaps they lack moral fiber. Why should that happen with addiction that has been defined as a disease by the medical community since 1956? Sadly, the national consciousness retains elements of the moral underpinnings to substance use disorder. We need to recognize addiction as a brain disease and talk about it not in moralistic tones but in medical terms. Certainly, there has been progress, certainly we need more;
· Promote the Facts: our popular press, trying hard to promote the problem as important, inadvertently leads us to believe that the addict is young, dissolute, unemployed, homeless. Yes, addiction lives under the overpass but that is about 1% of the problem (we have done the math). The 2013 Member Survey of Narcotics Anonymous told us that the addict is in every respect just like your neighbor. Addiction, a brain disease, affects residents of the richest and the poorest zip codes the same. We know that promotion of the facts works as evidenced by our approach to nicotine. We need that kind of national approach for substance use disorder now;
· Problem Screening: reimburse primary care physicians and emergency room physicians to screen for addiction. In our annual well patient visit they screen for age related, gender related diseases and they are paid for it. Pay them in a way that encourages the screen for addiction. Current rates of $17.32 for Medicare and Medicaid are not an incentive and certainly not proportional to the problem;
· Deploy Genetic Testing: we have deployed such testing for heredity and even for dating sites, why not to screen for addictions? Genetic testing is a probability science that is being used for diagnosis and prophylactic treatment today. Reimburse physicians at reasonable rates (these tests can be processed for less than $100 today) and discuss genetic trait influences with all the blood relatives of addicts. Use these tests as a means to introduce addiction as a disease instead of a lack of will power;
· Stop the War: it failed. It is OK to say so. Move on to these strategies. Do not discontinue interdiction domestically and abroad but stop making war on people with a disease;
· Invest in Evidence Based Treatment: in fairness, this is happening now. Still, however, much treatment is based on an 85 year old model of waiting until the addict “hits bottom”. Imagine if your PSA came back with a sudden jump to 8 or your breast exam showed a suspicious lump and the doctor said, “let’s wait until this metastasizes.” Treatment works, there are many paths, let’s research them, refine them, discover more, promote them not abandoning twelve step approaches, and let’s have a nationally funded treatment strategy through the National Institutes for Health to do that;
· Promote Recovery Symbols: this is more difficult than it might seem. The traditions of AA and NA specifically admonish that “… we maintain anonymity at the level of press, radio and film” and the traditions are followed by many. Those traditions hold, also, that AA and NA are “… a program of attraction rather than promotion…”. Yet, the face of Michael Phelps, likely a paid spokesperson, for behavioral health treatment is popular. There are many celebrities talking about their recovery aloud today and some even mention AA or NA. Let’s engage AA and NA and Al-Anon and Nar-Anon in figuring out how to promote that treatment works including, possibly, the face of those in recovery. We promise you that there is an admired person near you who is in recovery, and you do not know it;
· Reimburse Practitioners Realistically But With Accountability: in too many States and for too many payors rates are too low to support meaningful treatment, adequate facilities and safe spaces. As a result, too many providers are self-pay only. That provides a barrier for too many people needing treatment and creates health inequities. Further, there are barriers in reimbursement recognition. For instance, only in 2024 did Medicare recognize payment to certified addiction counselors instead of a referral from a physician and treatment from a physician boarded in addiction medicine. This policy created barriers and promoted the most expensive route and overlooks the training, experience and expertise of addiction and drug counselors, psychologists, and family therapy professionals. After this change Medicare and other payors still reimburse this counseling at as low as $20 per half hour. One cannot make even a non-profit business go at those kinds of rates. Let us convene a panel to set realistic, evidence based approaches to treatment based on NIH research and pay rates and pay those across payors. At the same time, let us hold providers accountable for evidence based protocols and tracking outcomes;
· Focus On Adolescents: while adolescent alcohol and other drug use has declined for fifty years, still too many young people smoke, drink and try drugs while in middle school and high school not only beginning the addictive cycle but stunting brain growth. Further, the drugs available today are more lethal than ever. We should promote programs such as “Preventing Drug Abuse Among Children and Adolescents” developed by the National Institutes on Drug Abuse far more than we do today. No doubt high school education has done a good job; let’s do more;
· Arm Influencers: in addition to teachers and recovering people in the public domain, let’s reach out to ministers, civic leaders, elected officials and provide them with the facts and the tools they need to change the narrative. For instance, three of the last four Presidents do not drink and one of them all but told us he considers himself to be in recovery. We believe that public officials, ministers et al try but they do not have the information. In many cases they are not trained in the best way to approach this advocacy. Let’s help them;
· Epidemiology Strategies: this approach goes back to the typhus pandemic and “Typhoid Mary” and was deployed in the AIDS crisis and recently in the COVID-19 crisis. Let us deploy epidemiologists to do the research, determine the “hot spots” for drugs and alcohol and target community solutions to those issues. Why and how did Portsmouth, OH, Mud Flats, West Virginia, and Scottsburg, Indiana among others become addiction hot spots, what were the determinants, how did they respond, what worked, what did not, how do we deploy effective strategies to the next regions or to prevention?
· Deploy Medical Assisted Treatment (MAT) Wisely: no one flinches when they hear a TV commercial for “the patch” to quit smoking but discuss MAT and the reactions are wide ranging. Yet many counselors and physicians agree that withdrawal is too often a barrier to recovery and MAT has a place in the treatment protocol. With opioid use disorder treatment relapse exceeding 90%, traditional treatment is not working for enough of the population. Let us deploy MAT more broadly but wisely, not as an alternative addiction, always with counseling of some sort, and supervised. Where pharmaceuticals are resold to those receiving MAT treat it as the crime that it is. As we do this, let us revisit liability for physicians who deploy MAT the right way;
· Enhance Safe Prescription Practice: there are, no doubt, very few doctors recklessly prescribing. Those few should be ferreted out. The remainder need further help and support in understanding safe prescription practices. No patient should be prescribed a pain medication or an anti-anxiety drug without information clearly explained about dependence, addiction and treatment as well as access to treatment. Physicians are well underway with this. Let’s help them finish the job;
· Support Employers: today only 19% of employers have comprehensive drug policies and too many are willing to look the other way in times of low unemployment or in the case of critical skills. Let us help them by encouraging the expanded deployment of drug free workplace policies, encouraging treatment, and lowering insurance costs and liability when they do so.
These and other prescriptions can and should be done inexpensively. What is missing is the awareness and the will. What is implied is focus. We did it for automobiles, we did it for nicotine, we did it for AIDS, we did it for COVID-19, let us go at addictions with the same resolve and the same attention. Too simple? Then why aren’t we doing it?
Above all, let us change the narrative. Let us not be Mencken’s puritans but let us recognize that alcohol and drugs and enjoyment are not synonymous. A 2017 study showed that 80% of movies depict alcohol use. In another fashion, the “stoner” movies depict marijuana as a harmless drug that makes one humorously lovable. This bi-directional messaging tells us that movie makers think we want to see alcohol and marijuana in regular and harmless use and the audience learns that these drugs are cool, reinforces the association between mind altering substances and everyday living. Is that the narrative we want? Thirty percent of Americans do not drink alcohol, only 15-20% use marijuana regularly, very few use narcotics. That makes moderate to no drug use the norm not the “holier than thou” exception.
Finally, let us have hope. Treatment works. Millions of Americans with substance use disorder lead lives of recovery employed, loving, some partnered, parenting, church members, and active citizens. Let’s tell everyone – addiction is a disease, it is OK to admit that, treatment works, recovery is possible, recovery is joyous. We can do this.
