Such is the menace of drug abuse in the United States that the federal government currently spends about $5 billion annually on substance abuse treatment. And if treatment is to be made available to each patient of substance use disorder (SUD), the government will have to spend a mind-boggling $700 billion approximately over the next decade. As a nation, there is a need to give much more attention to the problem that claims more lives than guns or cars or suicide and is the greatest contributor to homelessness, child welfare cases, crime, emergency room visits, and other social problems.
In this interview, Thomas Renfree, Deputy Director of Substance Use Disorder Services for the County Behavioral Health Directors Association of California (CBHDA), discusses why the authorities and the people need to move beyond the rhetoric of compassion and commit some serious resources to address this national epidemic. He outlines that effective treatment programs to help people in going addiction-free and saving their lives are available but need to be utilized and spread more judiciously. Read on.
Question: Last year, while addressing the issue of resistance exhibited by communities in the U.S. about the presence of mental health, alcohol, and drug treatment facilities in their neighborhoods, you had mentioned being baffled by the thought. Can you please elaborate?
Answer: The stigma associated with individuals in recovery from substance use disorder leads to a “not in my back yard” (NIMBY) mentality in some communities. This is rather baffling because while untreated alcohol or drug use disorder can lead to neighborhood or community problems, treatment and recovery are the best solutions to this problem. Undoubtedly, well-run treatment programs and recovery homes make any neighborhood a safer and better place to live in. Fortunately, fair housing laws and anti-stigma work on the part of treatment advocates have been successful (so far) in fending off most of these NIMBY efforts.
Question: What is your stance on the current situation of substance abuse in the U.S.? What are those five things, which if done at the societal/individual level, will make the difference?
Answer: As known, we are facing an epidemic of opioid (heroin and prescription drug) addiction in our country. Unfortunately, only about 10 percent of those who need treatment for alcohol or drug addiction are receiving any type of treatment. The best tools for addressing this problem at the societal/individual level are – (1) early intervention, especially for adolescents who are at the risk of developing a substance use disorder; (2) more resources for treatment, including youth treatment; (3) the development of a continuum of care that spans from prevention and early intervention through treatment and recovery support; (4) integration of substance use disorder treatment with primary care and full implementation of parity for SUD treatment with all other forms of health care; (5) expanded use of medication-assisted treatment.
Question: The IPAC Conference conducted earlier this year had a detailed mention of the implementation of screening and brief interventions for alcohol use in primary care settings (SBIRT). How do you think the SBIRT technique can help in giving the emerging health care landscape a new shape and form?
Answer: The greatest advantage of the implementation of SBIRT is to identify, in a primary care setting, those who are engaged in or at risk of developing an alcohol use disorder, in order to intervene early with these individuals and refer them to treatment as needed. We need to do a better job with health plans and primary care practitioners to help them establish linkages with SUD treatment providers. Also, SBIRT should be expanded to include other drugs in addition to alcohol.
Question: What improvements do you think the passage of the Affordable Care Act (ACA) has paved way for? Is any particular sector or segment of the society likely to benefit the most from it?
Answer: From the perspective of our field, the ACA is extremely important for (1) advancing parity for mental health and addiction treatment; (2) including mental health and substance use disorder treatment as one of the 10 essential benefits that health plans must cover; (3) giving states the opportunity to expand Medicaid in order to access more federal funding for services to low-income individuals who cannot otherwise afford private health insurance. Under the ACA, California (where one-third of the population is Medicaid-eligible) has been able to expand its Drug Medi-Cal benefit significantly in order to provide a continuum of substance use disorder treatment for Medicaid beneficiaries.
Question: In spite of enforcement of numerous laws pertaining to illegal drug use and implementation of several educational-cum-awareness programs, there seems to be no end to the fallacies and stigma that follow drug use. How do you think we can tackle the stigma?
Answer: Education can be a great tool here, so I think we need to keep up efforts to promote anti-stigma, public education campaigns. Over the last few years, these informational campaigns have helped reduce the stigma around mental illnesses, and with the same kind of effort around substance use disorders, I think we can gradually promote awareness about building a more treatment/recovery based approach to tackle the disease of addiction. Also, we need to work more with the primary medical community to get physicians and other health professionals to take more “ownership” of this issue, so that they are willing to speak out more forcefully about the need to treat addiction as the disease that it is. We have made some great inroads here (i.e. the Surgeon General’s recent report about addiction in America), but we still have a long way to go. One rather discouraging recent trend has been a reversion to “drug war” type of language and threats on the part of the current federal administration. This only serves to reinforce the concept of stigma around addiction, so treatment advocates need to step up our efforts to challenge the drug warrior mentality whenever it rears its ugly head.
Question: Looking at the current situation of substance abuse in the U.S., what necessary steps do you think the government and federal agencies should take to reduce the incidents of drug overdose fatalities?
Answer: Expand the availability of naloxone (the opioid overdose antidote) in all areas of the country, including rural and frontier communities, and provide more training for first responders; implement and provide funding for more prescription drug monitoring programs, and pass legislation requiring all prescribers to use these systems; support the development and use of abuse-deterrent medications; expand access to medication-assisted treatment; continue funding at increased levels, the Substance Abuse Prevention and Treatment Block Grant.
Question: Do you agree that addiction is an adaptation to a troubled society?
Answer: I think this may be one reason among many. Certainly the data shows that there is an increase in drug addiction in communities that have been devastated by job loss, poverty, loss of economic and social opportunity, and other social troubles. But there is no easy answer to why individuals self-medicate, or why some people get addicted while others do not. A recent SAMHSA report indicates that the main reasons adults misuse prescription drugs are to relieve physical pain and tension, and cope with life problems.
Question: A recent study by the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) found a 25 percent decline in the prevalence of problematic cannabis use among youth. Do you think legalization of cannabis has anything to do with it?
Answer: I have seen this study, and it also indicates an increase in problematic use of other drugs by the youth, such as prescription medications. So, there is the “whack-a-mole” effect, where decreases in one area of drug abuse are counterbalanced by problems in another area. I think it is too early to tell what kind of effect the legalization of recreational marijuana will have on youth cannabis use. Since marijuana is becoming less of the “forbidden fruit,” it may turn out to be less attractive to risk-taking adolescents. But we need to keep an eye on data relating to youth access to and use of cannabis in those states where recreational marijuana is legal.
Question: Do you think that by stopping the act of glorification of substance abuse in cinema and advertisements worldwide, addiction in the youth can be brought down?
Answer: I think that adolescents are influenced more by their peers than by anything they might see in ads or movies. Stopping the glorification of substance use in movies or ads may have a slight beneficial effect, but young people are spending a lot more time on social media now than they are at the movies or watching TV, so that is where we should focus our efforts.
Question: What do you think is in a worse state now – the use of alcohol and illegal drugs or the misuse of prescription drugs?
Answer: While the misuse of prescription drugs may be the fastest-growing form of drug abuse, in raw numbers alcohol is still by far the most misused substance, and contributes more to personal, family, and social devastation than any other drug – legal or illegal.
Question: Even today, for most individuals who are unemployed and suffering from addiction/mental health issues, the only available health insurance options are ACA and Medicaid. Is there anything else which can be done to alleviate the misery of the afflicted?
Answer: Self-help and 12-step support groups have perhaps not been getting as much attention lately as public and private treatment programs. But for many people struggling with addiction, these 12-step or social recovery model programs have been a life-saver and should be utilized more.
Question: Recently, the CEO of Olark Live Chat, a Michigan-based company, commended an employee for being honest about her taking the day off from work to focus on her mental health. How do you think he or anybody else of his stature would have responded had the employee mentioned the reason as “going for addiction treatment?”
Answer: I read this story and given the impression I had of this CEO’s character and integrity, I would like to think that he would have had the same kind of compassionate response to this employee if her situation had involved addiction. I am not naïve enough to think that every employer would be so understanding with an employee who needs addiction treatment, mainly because the stigma around addiction is still greater than that relating to mental health. But I personally know several CEOs who have family members or friends struggling with addiction, and who would be fully supportive of their employees taking time off for treatment because they understand that addiction is a disease, just like other health-related conditions that merit treatment.
About Thomas Renfree
Tom is the Deputy Director of Substance Use Disorder Services for the County Behavioral Health Directors Association of California (CBHDA). Prior to this, he represented County Alcohol & Drug Program Administrators Association of California (CADPAAC) for almost 14 years, first as a legislative advocate, and then as an Executive Director. In this role, Tom was active in statewide efforts to increase local government funding and support for alcohol and drug prevention as well as treatment services. He has prior legislative experience of working with two other public policy associations, including the California Association of Psychiatric Technicians. Tom holds a bachelor’s degree in history and political science from the University of California. As part of his leadership goals, Tom is committed to work toward building a better public understanding of substance use disorder issues, and to help in the advancement of public support for behavioral health programs.
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