Building an Effective American Public Health Infrastructure to Combat the Opioid Crisis and Other Substance Use Disorders

John F. Kelly

Not a day goes by currently without at least some mention of the current opioid crisis and seemingly never ending increases in heartbreaking overdose deaths. Although this tragedy has taken center stage receiving a fairly constant media spotlight, the opioid specific focus is occurring in the context of a broader enduring and endemic problem related to alcohol and other drug use disorders. The United States is not alone with these top, substance-related, public health problems - most middle and high-income countries around the world suffer similarly from these major challenges. These confer a prodigious burden of disease, disability, and premature mortality as well as economic losses. Alcohol by itself, for example, remains the third leading cause of preventable death in America killing more than twice the amount killed by opioids each and every year, and alcohol is responsible globally for 3.3 million deaths annually – ten times more than all illicit drug-related deaths combined. Problems with stimulants such as methamphetamine and cocaine have not disappeared, remaining highly prevalent, and cannabis use disorders have doubled in prevalence in the last 15 years. Approximately 22 million Americans meet current criteria for a substance use disorder with about 2 million of these having an opioid use disorder - just under 1% of the population; in contrast, about 15 million of these 22 million cases suffer from an alcohol use disorder.

Recently, there has been national policy debate about the need for increased spending on transportation infrastructure to the tune of 1.5 trillion dollars. This is deemed necessary in order to maintain and enhance public safety. Yet, despite staring squarely in the face of a current preventable public safety and public health crisis that is killing hundreds of thousands of Americans right now each year - substance use disorder - the proposed financial federal appropriations to address it amount only to a few billion. Opioid overdose deaths, by themselves, now total more than all those Americans killed in motor vehicle accidents. To address the current crisis and the more enduring public health problems related to alcohol and other drugs, it is necessary to invest in more than asphalt; we need to invest in American lives.

There are many reasons for this disparity in funding for the current public health and safety crisis. Some of it is the stigma and discrimination that are assiduously a part of addiction. Also, however, is the way we believe we should treat addiction. Embedded in our cultural psyche is the idea that addiction is an acute condition that can be fixed with more “beds” or “28 day rehab” stays.

I liken this mentality and all too common approach to addressing addiction to that of dealing with these issues like we would a burning building. We see it as an emergency and have begun to pour resources into extinguishing the fire — in fact, we’ve become experts at helping people initially stop their drug use, putting out the fire, with “more beds” and 28-day “rehab” stints. Admit, treat, discharge. Yet, we know that initially stopping substance use is actually the easier part; staying stopped and achieving remission is the critical challenge. We’re far less accomplished in preventing the fire from restarting — at preventing relapse. Part of the reason for this is that we’ve done a poor job of providing the needed “architectural planning” and “rebuilding materials” (i.e., the social, physical, human, and cultural resources that aid and support recovery, known as recovery capital). Beyond clinical services, such resources can often take the form of education and job access and training, and serve as the foundation to rebuilding a gutted life once the initial fire of addiction is out. Even more challenging in addition to the lack of architectural planning and provision of building materials, has been the denial of “building permits". The residual tolls of a drug-related past criminal record block many seeking addiction recovery from being able to open a bank account, get a student loan, find housing, or obtain employment. Without such building permits that facilitate access to these fundamental resources, it is hard to imagine how we might instill hope for the future for those already trying so hard to navigate the physical and psychological demands of early remission from addiction. Such barriers serve only to increase hopelessness and relapse risk, and thus stymie long-term remission and recovery efforts.

One of the many noteworthy things we’ve learned from research during the past 30 years, is that even after achieving one full year of stable remission from a substance use disorder it can take many more years before the risk of meeting criteria for a substance use disorder in the following year is no greater than that of the general population (i.e., 15%). These facts from epidemiologic and clinical studies highlight the need for more than just acute care stabilization. They indicate a need for the availability, accessibility, and affordability of medications and other continuing care resources that can support remission over the first 4-5 years of remission, and that ensures strong linkages between different levels of care and community-based recovery support services. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) has been emphasizing the need for the development of recovery oriented systems of care (ROSC). This systemic framework approach encompasses long-term support addressing the many needs of those beginning recovery. It is what is needed to enhance more assertively the chances of long-term remission and quality of life on the road to recovery.

Transportation infrastructure? Yes, it is needed. But, just like the crosses we may see on the side of the highway, more than one thousand newly bereaved families are added to the list of casualties each and every week purely from the current opioid crisis alone. Addiction public health infrastructure that can prevent, intervene, and effectively support long-term remission is the current priority.

About the Author

John F. Kelly, PhD, ABPP. is an Elizabeth R. Spallin Associate Professor of Psychiatry in the Field of Addiction Medicine at Harvard Medical School. He is also the Director of the Recovery Research Institute and Center for Addiction Medicine at Massachusetts General Hospital.