Must the Past Be Prologue?

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COMMENTARY

The Past

The United States has had a long-standing romance with 2 approaches to substance use disorders (SUDs). Both, ostensibly, reduce abuse and dependence on opioids (OxyContin, heroin, fentanyl) and other drugs. These are Control and Consequences, which continue to prevail, meant to reduce drug use, social harm, and rising overdoses and deaths.¹

Control of substances has been the most popular, go-to approach in the United States. Control means controlling access to a substance of abuse. Prohibition, the war on drugs (twice, thanks to former Presidents Richard Nixon and Ronald Reagan), border interdiction, crop burning (where the substance originates), and buy and bust (agents acting as addicts buy substances and when they succeed the dealer is busted) are but a few of the methods used for controlling user access to drugs of abuse. Their application extends to heroin, opioid pill mills, fentanyl, cannabis, cocaine, and crystal meth.

The one thing these varied methods have in common is that they do not work! They never have.² Users find a way, dealers need the money, and smugglers abound. But they do make for great photo-ops of law enforcers standing in front of a make-shift table piled with kilos of seized heroin or cannabis, with rolls of rubber-banded money scattered about.³

Interrupting supply may make for temporary reductions in access or higher street prices, but they do nothing to reduce the flow or manufacture of these drugs of abuse. Cartels keep making more money—so much that it is hard for them to launder their illegally gained money.^2,3

Consequences range from hortatory pronouncements, to burned bridges by family and partners, to incarceration in jails and prisons. “Don’t you know that stuff will kill you?” “Don’t you know you’ll lose your job (or flunk out of school, ruin your marriage, and so on)?” are among the commonly used hortatory blasts, as if the addicted person did not know the consequences. Plus, these outbursts, which are meant to be helpful, also do not work, but, instead, drive the addicted person further away. With teenagers, we have seen how threats can backfire and drive a youth deeper into addiction (eg, the DARE Program).⁴

Using the criminal justice system—courts, jails, prisons, and parole—has become a thriving business in the United States, which has the highest rate of imprisonment in the Western world,⁵ with more than 1.2 million incarcerated individuals, primarily men and people of color. Today, 45% of convicted men and women are behind bars because of a drug offense, or offenses fueled by drugs.⁶ After all, don’t we have to “get tough on crime and get tough on drugs”? Yes, we do, if our aim is to squander money and lives, and to pour money into the coffers of for-profit chains of prisons. Yes, we do, if we truly do not want to help people enter recovery and leave crime behind. As has been said, “No one gets well in a cell.”⁷

The Prologue?

If “the past is prologue” and the past (up to and including the present) is a tale of failed approaches to SUDs, might a new bloom be on the rose bush of government? A joint statement and white paper on substance use and harms could not be timelier—or more needed. The United States has a lot to learn from Canada. The opioid (and other drug) epidemic has again come front and center as a public health, life-saving priority as the COVID-19 fog clears. A multitude of graphs of drug use, overdoses, and overdose deaths show the X-axis inexorably rising.⁸

The Joint Statement

According to the bi-country statement, this major policy initiative derives from “…a collaboration…in the areas of law enforcement, border security,* and health.”⁹ Hmm, health trails consequences and controls, as delivered by US criminal justice and border interdiction, respectfully? This does not look so good for “bending the curve” of substance use harm and death, because two-thirds of the group are proponents of failed policies. When it comes to reports and policy papers, he or she who writes, rules.

That said, according to the statement, increases in substance use harms and deaths “can be attributed, in part, to a decrease in access to supports and services for people who use substances at the onset of the pandemic. At the same time, increasing feelings of isolation, stress, and anxiety and an increase in the toxicity of the drug supply contributed to higher rates of deaths in both countries.”⁷ The pandemic succinctly identified 6 clear and actionable targets that will not change unless future policies and practices increase the first 2 and decrease the remaining. This seems to me to be the coordinates of a roadmap for the journey ahead, which would be mapped in the white paper.

The White Paper: Surveillance and Response

The impetus for this joint US-Canada policy paper was the COVID-19 pandemic, during which, both “Canada and the US experienced an increase in rates of substance use harms and deaths beyond already high pre-pandemic levels.”¹⁰ My comments here only refer to the US material in the report.

Succeeding in the 6 public health domains the report identifies requires change. Change is always hard. It is a good idea, then, to look to seize propitious moments to get started—like in the wake of a pandemic.

The white paper that the statement introduces⁹ looks into the rear-view mirror and describes actions taken during the upheaval that COVID-19 created: expand telehealth, and ease regulatory restrictions for dispensing and delivery of medication-assisted treatment (MAT) medications. What additional actions appear through the front windshield?

Opioid agonists, especially buprenorphine, have been shown to be, by far, the greatest lifesaver for opioid-dependent individuals—with the exception of naloxone recovery.¹¹ Buprenorphine has been saddled with and strangled by regulations and licensure requirements since it was released in the United States in 2002. A lot more is needed to scale up the use of buprenorphine. This was an opportunity to call for action.

I know the maxim, “you can’t manage what you can’t measure,” is fundamental to public health (and other) campaigns to reduce population-level illness and improve the public’s health. The joint paper’s title, “Federal Surveillance and Response,” alerts the reader to a report abundant with surveillance and shy on the response(s) needed to save lives and mitigate the economic and human suffering that COVID-19 inflicted on our country.

“Surveillance”: I have worked in public health for more than 20 years and regularly turned to federal, state, and city (New York City) surveillance and related reporting systems. The number of these noted in this report is an epidemiologist’s dream:

• The US Centers for Disease Control and Prevention (CDC) National Vital Statistics System (NVSS)
• The State Unintentional Drug Overdose Reporting System (SUDORS), which includes emergency department data from the CDC’s Drug Overdose Surveillance and Epidemiology (DOSE) system
• The CDC’s National Syndromic Surveillance Program (NSSP)
• The CDC’s Morbidity and Mortality Weekly Report
• The Health Alert Network (HAN) Notice
• The CDC’s provisional mortality data in its wide-ranging Online Data for Epidemiologic Research System
• “Several large proprietary data sets that capture urine drug testing results [that] were used during the COVID-19 pandemic”⁹
• The use of internet- and/or phone-based surveys (ie, do not rely on in-person data collection)
• The Monitoring the Future (MTF) survey of 8th-, 10th-, and 12th-graders
• The Adolescent Behavior and Experiences Survey (ABES), conducted by the CDC
• PHAC Opioid-and Stimulant-related Harms Surveillance.

Forgive me if I have omitted any source noted in the report.

“Response”: As a former city and state government official, I admire the breadth and depth of this surveillance. My question is: How will any (or all) of these metrics translate, in real time, into beneficial actions by hospitals, clinics, government agencies, families, or communities that will reduce morbidity and mortality? How will these data sources improve any of the 6 problems, identified by the authors of the report, that would save lives and reduce family suffering and community burden?

The Bully Pulpit

Winston Churchill, a witness to many a crisis, famously said, “Never let a good crisis go to waste.” COVID-19, substance use, opioid overdoses and fatalities, supports and services evaporating, isolation and loneliness, depression and anxiety, and fentanyl all make for a deadly drug market. This is more than enough to warrant defining our time as a crisis—one to mobilize to combat the crisis today (and for the crises to come).

Did the US-Canada Joint Statement and its companion Substance Use Report miss an opportunity to exercise its bully pulpit? Or to take our nation(s) into battle against the opioid epidemic? The authors advanced 6 grievous problems or markers that fueled—and continue to fuel—the collapse of many a person, family, and community. Then the plot seems to have gotten lost.

Missing the (6) Mark(s)

I have been part of and witness to the tortuous path a government campaign must undergo for release and adoption. The gauntlet is stocked with lawyers and more lawyers, with “government relations” folks and advisors titrating politics, with elected officials with varied agendas, and always with financial folks calculating cost. This joint report may have endured such an ordeal, which is known for dilutions, substitutions, and politically driven compromises. When that is the outcome, “…government of the people, by the people, and for the people” will diminish or side-step the disruptive changes needed to beat an epidemic.

Yet the battle is far from over. Again, as Churchill said, “You can count on the Americans to do the right thing, after they have tried everything else.”

*Emphasis added by the author.

Dr Sederer is a psychiatrist, public health doctor, and non-fiction writer.

References

1. Sederer, LI. The Addiction Solution: Treating Our Dependence on Opioids and Other Drugs. Scribner; 2018.

2. Sederer LI. The folly of supply-side drug intervention. US News & World Report. April 19, 2016. Accessed October 1, 2022. http://www.usnews.com/opinion/blogs/policy-dose/articles/2016-04-19/substance-use-treatment-works-better-than-any-war-on-drugs

3. Sederer, LI. Follow the money. Lancet Psychiatry. 2016;3(5):413-414.

4. D.A.R.E.: teaching students decision making for safe and healthy living. D.A.R.E. America. Accessed October 1, 2022. https://dare.org/

5. Scommegna P. U.S. has world’s highest incarceration rate. PRB. August 10, 2012. Accessed October 1, 2022. https://www.prb.org/resources/u-s-has-worlds-highest-incarceration-rate/

6. Offenses. Federal Bureau of Prisons. Updated October 1, 2022. Accessed October 1, 2022. https://www.bop.gov/about/statistics/statistics_inmate_offenses.jsp

7. Black Lives Matter. Black Lives Matter. Accessed October 1, 2022. http://blacklivesmatter.com

8. National Institute on Drug Abuse: NIDA is the lead federal agency supporting scientific research on drug use and addiction. National Institute on Drug Abuse. Accessed October 1, 2022. https://nida.nih.gov/

9. Joint statement by the chief public health office of Canada, Dr. Theresa Tam, and assistant secretary for health admiral Rachel Levine, MD, on substance use and harms during COVID-19. US Department of Health and Human Services. September 27, 2022. Accessed October 1, 2022. https://www.hhs.gov/about/news/2022/09/27/joint-statement-chief-public-health-officer-canada-dr-theresa-tam-assistant-secretary-health-admiral-rachel-levine-md-substance-use-harms-during-covid-19.html

10. Sederer LI. What Canada gets about pot. US News & World Report. July 17, 2017. Accessed October 1, 2022. https://www.usnews.com/opinion/policy-dose/articles/2017-07-13/6-takeaways-for-us-pot-policy-from-canadas-marijuana-guidelines

11. Santo Jr T, Clark B, Hickman M, et al. Association of opioid agonist treatment with all-cause mortality and specific causes of death among people with opioid dependency: a systematic review and meta-analysis. JAMA Psychiatry. 2021;78(9):979-993.