Professional Voices Year in Review

By Dr. Richard Juman 12/31/15

The Fix's Professional Voices editor reviews 6 of the biggest issues in addiction and treatment from 2015. 

Addiction 2015: Downers and Highs

2015 may well be remembered as a turning point in our country's approach to addiction. Despite the grim statistics below, there are good reasons to be optimistic that a mature understanding of the complexities of addiction as a biopsychosocial phenomenon is taking hold among professionals, in the media and in the public eye. With nearly universal acknowledgement that the War on Drugs has not achieved its intended outcomes, there is a greater openness to looking at addiction as an adversary that won't be overcome with force but needs to be addressed on multiple fronts that include education, prevention, medical care, psychological treatment and broader culture change. The horrors of the opioid epidemic have overwhelmed resistance to Medication Assisted Treatment, needle exchanges and Naloxone kits, with consumers, law enforcement and governments now rapidly moving to make these life saving treatments more widely available. It's also become a lot easier for people—politicians, celebrities and regular people—to acknowledge the impact that addiction has had within their own families and social circles, which is chipping away at the stigma that has always been an unfortunate burden to those suffering from its effects.

For five years now, The Fix has been at the center of these issues, and it is gratifying to see the increase in media attention to addiction issues over this period. The world’s attitude towards addiction is shifting, significantly, and in a direction that makes me optimistic that we are gradually moving in the right direction. I am pleased to think that Professional Voices has participated in that evolution. In 2015 alone, we published critical pieces by many of the critical thought leaders in the addiction arena: Bruce Alexander, Lance Dodes, Edward Khantzian, Tom Horvath, Robert Schwebel, Barry Lessin, Debra Rothschild, Jeannie Little, Patt Denning, Robert Kent, Charles Morgan, Harris Stratyner and Barry Lessin, to name a few. In addition, 2015 saw the creation of Professional Treatment News, edited by John Lavitt, which covers all of the key developments in the addiction arena and has generated some of the most important interviews of 2015, including talks with Drug Czar Michael Botticelli and NIDA Director Nora Volkov. ​Listed below are some of the critical trends in addiction and substance use for 2015.

1. 2015 Has a Tragic Bottom Line. 2015 will go down as an abysmal year when it comes to what matters most—the prevalence of problematic substance use and the misery and death it caused in the United States. Despite all we now understand about the etiology of addiction, all of the different strategies and treatments that that are now available to those suffering and all of the money that we have spent on research, prevention and treatment, addictive behavior is more common than ever. And the devastation that it is wrecking is horrific, with ongoing increases in the number of deaths attributable to alcohol, sedatives, painkillers and heroin. We are, now more than ever, a nation of addicts. Addiction is destroying lives as never before in my neck of the woods, and in yours.

2. Tipping Point: (Almost) Everybody Agreed that the War on Drugs Has Failed. Just as (almost) everybody now acknowledges that climate change is real, (almost) everybody now agrees that the War on Drugs has been an abject failure. Initiated by Richard Nixon, who famously declared that “public enemy number one in the United States is drug abuse,” the scorecard for the War on Drugs is this: $1 trillion dollars spent has been spent with no discernable positive impact on the problem of addiction, just a huge incarcerated population and a legacy of violence and corruption for criminal justice and military systems on two continents. Even former U.S. drug czar Gil Kerlikowske acknowledges that the strategy hasn't worked: "In the grand scheme, it has not been successful. Forty years later, the concern about drugs and drug problems is, if anything, magnified, intensified." He also realizes that "we can't arrest and incarcerate addiction out of people." Despite Kerlikowske’s views, and those of President Obama, which clearly hope to move our government’s approach to addiction towards treatment and prevention, the federal government has continued to spend around two-thirds of its drug control funds on interdiction and law enforcement. Clearly the writing is on the wall, but it has not yet reached the budget process.

3. Shocking Trend in White, Middle-Aged, Middle-Class People. The demographic group that best highlights the ravages that addiction has wrought is non-college-eductated, middle-aged white people, particularly men. In sharp contrast to nearly every other demographic group in developed nations, where we are used to seeing significant increases in longevity, this group is actually dying sooner. The primary factors: drug overdoses, suicides and alcohol cirrhosis of the liver. Obviously, multiple negative factors—societal, economic and personal—are required in order to drive this dramatic decline in fortunes, but clearly the fingerprints of alcohol and drugs, particularly prescribed opioids, will undoubtedly be at the scene when the dust settles. One piece of corroborating evidence—the "pronounced age trend in those utilizing opioid treatment programs from 1996 to 2012, with adults aged 50 and older becoming the majority treatment population."

4. Addiction is a Big Issue in Presidential Campaigns. The toll that addiction continues to take on our society is reflected by the fact that it has become such a big part of the dialog on the presidential campaign trail. It’s important to voters, and they have kept candidates on their toes in town hall meetings and around their kitchen tables. This is particularly true in New Hampshire, where the first primaries are held, and where they call Heroin “the Ebola of Northern New England.” Both the Democratic and Republican campaigns are noteworthy for less punitive, more compassionate rhetoric around drug use.

Chris Christie, who has made substance use a key issue in his campaign, has been a leader in this regard. Having lost a friend to addiction, he argues that “we need to start treating people in this country, not jailing them. We need to give them the tools they need to recover because every life is precious." Hillary Clinton has also spent a lot of time on the subject, noting that, “Plain and simple, drug and alcohol addiction is a disease, not a moral failing—and we must treat it as such.” Democratic rival Bernie Sanders has called for the complete decriminalization of marijuana. Most candidates, like most Americans, have had direct experience with addiction among family and friends, and most are in favor of education and treatment, as opposed to a continuation of the war on drugs.

Noteworthy exceptions to that trend are Dr. Ben Carson, Marco Rubio and Jeb Bush. Carson is on record as wanting to “intensify” the war on drugs, and Rubio has stated that he would enforce federal laws against marijuana, even in states that have legalized it. He has spoken out against “weakening of drug laws that have done so much to help end the violence and mayhem that plagued American cities in prior decades.” Several candidates have even directly addressed the issue of doctors who overprescribe opioids, with Sanders telling them to "get their act together and stop overprescribing...we cannot have this huge number of opiates out there throughout this country where young people are taking them, getting hooked, and then going to heroin." Clinton agrees that, "On the prescribing end, there are too many opioids being prescribed and that leads directly to heroin addiction."

5. Government Activism and Intervention is Increasing. The opioid epidemic has caused ​local and state ​governments to become much more proactive than they have been in the past. And their activism is decidedly in the direction of more treatment and, importantly, more harm reduction. Of course, prescription drug monitoring programs have become the standard across the country, but many state and local governments have passed laws to insure that Narcan, the opioid overdose-reversing drug, is much more widely available. Drug courts have become much more commonplace, as have Law Enforcement Assisted Diversion (LEAD) programs that steer drug offenders away from incarceration and towards resources such as drug treatment and other social services that can help them turn their lives around.

Governments have become much more activist in other ways as well, including taking unprecedented steps to improve the availability of evidence-based treatments such as Vivitrol and buprenorphrine. The federal government is moving towards lifting the 100 patient per physician cap on buprenorphrine, and seems to have an open mind about the possibility of allowing nurse practitioners and physicians’ assistants to prescribe it. Vermont, a state that has seen more than its share of suffering around the opioid crisis, has created legislation that requires physicians to “conduct and document a risk assessment, consider non-opioid and non-pharmacological treatments, and follow up with every patient to be sure treatment is working.” And its governor, Peter Shumlin, has been working with the governors of other New England states to encourage the federal government to “remove the barriers to treatment” desperatedly needed by their residents who are struggling with opioids. Finally, more states moved to allow needle exchanges as a means of preventing HIV and Hepatitis C transmission among drug users.

6. Psychedelic and Non-Traditional Drugs are Being Studied Seriously as Therapeutic Agents. In venerable research institutions around the world, researchers are looking at the efficacy of psychedelic and other “street” drugs in the treatment of a variety of health problems. Psilocybin, LSD, MDMA, ibogaine, mescaline and DMT are all being researched as possible treatments for problematic substance use, anxiety disorders, PTSD, end-of-life-distress in terminally-ill patients and other conditions. While the rigorous scientific study of these treatments is still in its early stages, anecdotal evidence seems to suggest that for many, the experience that they can provoke can have the type of profound impact that can significantly alter a person’s perception of their illness, situation or self-perception. It remains to be seen whether they will eventually find a place in the clinical arsenal of reliable medical interventions for serious psychiatric disorders. But the very fact that they are being rigorously researched represents a positive development towards searching for evidence-based interventions in directions that were previously off-limits.

For 2016, Professional Voices will continue to explore the essential questions about addiction. Is it a brain disease? Is it ​best understood as ​a disease at all? ​Are trauma and underlying psychiatric issues core elements of addiction? ​Is abstinence the best approach? Are 12-Step programs an important element in recovery? Where in the health care system should addiction treatment be imbedded—in medical settings, in mental health settings or in separate facilities? ​One could go on, simply because there is so much about addiction that we still don't understand. ​And we will go 2016. I wish you a happy and healthy New Year from Professional Voices and The Fix!​

Richard Juman—a licensed clinical psychologist who has worked in the integrated health care arena for over 25 years providing direct clinical care, supervision, program development and administration across multiple settings—is also former President of the New York State Psychological Association. [[email protected]] Find him on twitter—@richardjuman

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Dr. Richard Juman is a licensed clinical psychologist who has worked in the field of addiction for over 25 years. He has treated hundreds of patients as a clinician and also provided supervision, program development and administration in a variety of settings including acute care hospitals, long term care facilities and outpatient chemical dependency centers. Find him on LinkedIn and Twitter.