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Some snapshots from the nation’s fight against drug abuse: President Donald Trump at every opportunity calls for the building of the wall, which he says will stop drugs (along with immigrants) from entering the country; he has also endorsed tougher criminal sanctions for traffickers, including the death penalty for major ones. Twenty-four states are suing Purdue Pharma (the maker of OxyContin) and other manufacturers of painkillers for their deceptive marketing practices. Federal prosecutors in Brooklyn are preparing to try Joaquin “El Chapo” Guzman, the Mexican cartel leader, on charges of drug trafficking, money laundering and horrific acts of violence. New York Mayor Bill de Blasio recently announced plans to open four supervised drug-injection sites in the city; San Francisco, Seattle and Philadelphia have similar intentions.
None of this, however, is likely to make much of a dent in an epidemic that last year claimed 72,000 lives due to overdoses, for they fail to address the truly urgent need in the fight against substance abuse: repairing and expanding a treatment network that is severely underfunded, badly splintered and completely overwhelmed. At a time of widespread anguish and hand-wringing about addiction, neither the president, nor Congress, nor governors, nor journalists are paying enough attention to the one thing that could truly make a difference: more and better treatment.
According to a 2016 report by the Surgeon General, only 1 in 10 people who needs drug and alcohol treatment gets it. Of course, not everyone who needs treatment wants it, but enough do to create shockingly long waiting lists across the country. In West Virginia, the state with the highest rate of overdose deaths, there are a mere 171 beds for detox (which weans users off drugs over a period of days) and 151 for longer-term residential treatment, forcing carpool moms and dads to drive up to five hours to find an opening. (The number of beds is expected to more than double thanks to new state and federal funding, but that’s still a fraction of what’s needed.) In New Hampshire, another hard-hit state, waits of four to six weeks are common for a publicly funded residential bed, while in Maine the primary detox facilities are the state’s 15 county jails. The small subset of users who have private insurance can generally gain quick access to facilities that cost up to $10,000 a week and (in the upper tier) feature saunas, yoga, rock climbing and aromatherapy. The vast majority who rely on Medicaid or are uninsured, however, face long waits for admission to facilities that often lack even basic medical, psychiatric and therapeutic services.
For those in the grip of drugs, the openness to treatment is often fleeting, and if a slot is not immediately available, they’re back on the street, snorting, shooting up, overdosing, landing in emergency rooms or worse. In New Hampshire, a heroin user was found dead in his apartment along with a list of rehab facilities on the table next to his bed, which he had called in vain. In Springfield, Massachusetts, beds are in such short supply that those seeking help sometimes have to get arrested so that a judge can mandate them to a facility. In Huntington, West Virginia, the parents of a 21-year-old woman spent 41 days trying to get her into a facility, without success; on the 42nd day, she overdosed and died.
Dr. James Berry, the director of the addictions program at the West Virginia University School of Medicine in Morgantown, says hospital emergency rooms throughout the state “are flooded every day with scores of people who are desperate for treatment.” The courts are similarly overwhelmed. “I get calls from various courts asking for help in getting people into treatment because it’s not available in local communities.” The three hardest words for a user to say are “I need help,” he observes. If they can’t get it when the window is open, the opportunity quickly fades. “Every community should be able to provide immediate access.”
But does treatment work? By now, there is a shelf-full of studies showing that it significantly reduces the harms associated with drug and alcohol abuse. According to the Surgeon General’s report, every dollar spent on treatment saves about $4 in health care costs and $7 in criminal costs. The savings mount when one adds in family anguish, days lost at work, child abuse and neglect, newborns going through withdrawal and homelessness. Needless to say, relapse often occurs; in fact, it is chronic. Yet even if people refrain from using drugs for a limited period, the benefit-to-cost ratio is high. And over time, many do return to a productive life.
In the case of opioids, the treatment options include two medications, methadone and buprenorphine, that both have a well-documented record of helping stabilize users. Yet these treatments remain in pitifully short supply, particularly in rural areas that have been especially hard hit by the epidemic. Since methadone and buprenorphine (marketed under the name Suboxone) are both opioid-based, they are frequently dismissed as just another form of addiction, but this is misguided, for both reduce the craving for drugs and the symptoms of withdrawal and so help the drug-dependent function normally.
That making such treatment more accessible could help stanch the current epidemic is clear from the nation’s experience with an earlier one—the heroin wave of the late 1960s and early 1970s. In 1971, President Richard Nixon, intent on combating the crime associated with drugs—set up a special drug-abuse prevention office in the White House and authorized its director, Dr. Jerome Jaffe, to make methadone (and other forms of treatment) widely available. Clinics were quickly established across the country, and within 18 months almost everyone seeking treatment could find it. Both heroin use and the crime related to it sharply declined.
Unfortunately, during his 1972 reelection campaign, Nixon—wanting to look tough on crime and drugs—began shifting federal attention away from treatment to law enforcement and incarceration. In May 1973, New York adopted the Rockefeller Drug Laws, mandating long prison sentences even for minor offenses. Other states rushed to copy them, and the war on drugs was on. Prisons filled with low-level offenders, many of whom would have been more effectively dealt with through treatment. During the Reagan years, the national treatment network set up under Nixon crumbled. When the crack and cocaine epidemic hit in the mid-to-late 1980s, the treatment centers that remained were completely overwhelmed; waiting lists grew and crime rates and the associated costs soared.
Amid today’s exploding opioid use, we are paying the price for this long neglect of the nation’s treatment infrastructure. The Trump administration in its 2019 budget has proposed an additional $900 million for Health and Human Services to help address the epidemic—a mere droplet of what’s needed. To make treatment available on demand would require spending tens of billions of dollars annually for years to come. That might seem like a lot, but it’s modest compared with the estimated $450 billion that substance abuse costs the nation every year.
Some of the needed sums could be diverted from programs that seek to keep drugs out of the country, for they are generally futile. Despite all the efforts to seal the nation’s borders against drugs, they continue to pour in; heroin and cocaine are easily concealed and transported, and hypertoxic fentanyl can be purchased online with cryptocurrencies. The war on drugs in Mexico, meanwhile, is not only ineffective but counterproductive; the drive to dismantle the Mexican cartels has served mainly to destabilize the market, setting off bloody wars among traffickers, with countless civilian casualties. Our anti-drug efforts should be directed at reducing the demand for drugs rather than cutting off the supply—an approach that is not only more humane but also more cost-effective.
In addressing demand, it’s essential to offer a full array of services. The effectiveness of methadone and buprenorphine can be enhanced when accompanied by counseling. To treat the most serious cases, residential facilities (both long- and short-term) need to be vastly expanded. Supplementary services are needed to help those in recovery find jobs, housing and mental-health support. Outreach workers are needed to locate users and connect them with services. Central intakes need to be established in cities and towns to help connect people with services and track their progress through the system. More doctors and nurses should be trained to diagnose drug disorders and prescribe medications like buprenorphine. Treatment should be made more available in the nation’s prisons and jails, and schools should have counselors trained to watch for adolescents struggling with drugs and alcohol. Needle-exchange programs should be expanded and more closely connected with treatment facilities. And the treatment industry as a whole should be subject to stricter regulation and oversight. (Many centers are unlicensed and amateurishly run.)
All of this would require a vast expansion in staffing. Establishing treatment on demand could thus become a substantial provider of jobs, especially in regions where factories have shut down. Rehab centers could even be opened in shuttered industrial facilities.
Finally, news organizations need to rethink their approach to the drug issue. They too often focus on sideshows—the drug war in Mexico, police raids in big cities, the culpability of Big Pharma. (The number of opioid prescriptions nationwide actually peaked in 2012, and in 2016 they reached their lowest level in a decade, yet the epidemic continues.) Journalists should instead seek to expose the glaring gaps in the nation’s treatment system and dramatize the plight of those who want help but can’t get it—the real scandal in the fight against drugs.