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Ad d re ssi n g O u r O p i at e C r i s i s :

A S y s tem s L evel P r o c e s s fo r P re ve nt i o n a nd Tre a me nt

by

Er i n
MCC l el l a n d

PO Box 2824
Lo wer Bur r ell PA 15068
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BIO
Er in Mc Cle llan d has wo r ked i n t h e s u b s t a n ce
a buse fi e ld f o r n e ar ly 2 0 yea r s. S h e b eg a n h e r
a ddi ct io n wo rk as a n u n d er g r a d u at e res ea r c he r at
the Unive r si ty o f P i t t s bu r g h A l co h o l a n d S mok ing
Re se arc h L ab o rato r y u n d er t h e d i rect i o n o f
Mi c hae l Saye tte, P h . D. A ft er recei v i n g h er
Bac he lors De g re e i n p s y c h o l o g y fro m P i t t , s h e
worke d f o r the Ce nt er fo r A d d i ct i o n S er v i ces at
St . Franc i s M e d i c al C en t er o n t h e W r a p A round
Se r v ice s I mp ac t Stu dy, a s s es s i n g t h e ava i l a b il ity
a nd use o f wrap aro u n d s er v i ces fo r a d d i ct i on
pat i e nts i nvo lve d i n va r i o u s t y p es o f t reat m e nt.
I n 1998, she wo rke d a s a co u n s el o r at P i t t s burgh
Blac k Ac ti o n , I n c. t reat i n g m o s t ly bl a c k vet e ra ns
a nd you n ge r p ati e n t s ex p er i en ci n g o p i at e
a ddi ct io n . I n 2 0 0 2 , s h e co m p l et ed h er M a s t e rs
De g re e at Chatham C o l l eg e a n d d evel o p ed a
Commu n i ty B ase d S t r at eg i c A d d i ct i o n P revention
mode l. He r p ro g ram wa s d es i g n ed t o b et t er
ut i li ze e x i sti n g c o m mu n i t y res o u r ces t h ro u gh a
more ef f e c ti ve, strea m l i n ed a n d s ci en t i fi c
a pproac h f o r p reve n t i n g a n d t reat i n g o p i at e
a ddi ct io n .
I n 2003, she b e gan wo r k i n g at t h e In s t i t u t e for
Re se arc h, E d u c ati o n a n d Tr a i n i n g i n A d d i ct ion a s
the Prac ti c e I mp rovem en t C o l l a b o r at i ve
Coordin ato r, an e f f o r t d ed i cat ed t o red u ci ng th e
10 ye ar gap b e twe en b es t p r a ct i ce res ea r c h a nd
clini cal i n te g rati o n . D u r i n g t h at t i m e, Er i n
traine d wi th the P i t t s bu r g h R eg i o n a l H ea l t hca re
I nit iat ive u n d e r the d i rect i o n o f fo r m er Treas ur y
Se cre t ar y Pau l O N ei l l , u s i n g t h e s ci en t i fi c
me t hod an d le an p ro ces s i m p rovem en t s t r at e g ie s
to e li mi n ate me d i c a l er ro r s , i n crea s e
effe ct i ve n e ss, re d u ce wa s t e a n d i m p rove o u t come s
in he alt hc are an d add i ct i o n s et t i n g s. W h i l e at
I RETA, she was i nvo l ved w i t h t h e W h i t e H o us e
Office o f Nati o n al D r u g C o n t ro l Po l i c y s 2 5
Ci t ie s I n i ti ati ve, tar g et i n g t h e g reat er P i t t s burgh
Are a as o n e o f the t o p 2 5 m o s t s evere o p i at e
proble ms i n the c o un t r y. Er i n wa s c h a r g ed with
he lpi ng to d eve lo p t h e cu r ren t co n d i t i o n a n a lys is
of t he are as p ro ble m w h i c h i n cl u d ed , p rov ide r s ,
paye r s, law-e n f o rc em en t , s c h o o l s , ed u cat o r s ,
polic y make r s, p atien t s a n d t h ei r fa m i l i es.

Er in wa s a prog ra m dire ctor at SPHS Behav ioral


He a l th wh e re s h e s upe r vis e d mul tipl e out pat ient
prog ra ms incl uding th e Wome n a nd Family
Prog ra m. Wh il e th e re, s h e e mpl oye d lean
ma nufa ctur ing s trate g ie s to de s ign a process
improve me nt s ys te m th at s ub s ta ntia l ly reduced
b il l ing e r ror s , re coupe d l os t reve nue and
improve d e mpl oye e pe rfor ma nce without adding
a ny a dditiona l cos ts.
In 2006, Er in s ucce s s ful ly l ice ns e d the fir st and
only Or th omol e cul a r Re cove r y prog r am for
a ddiction in Pe nns yl va nia , Arc h e We l lness. Arc he
We l l ne s s wa s fe ature d twice in Indust r ial
Eng ine e r M a ga z ine in re cognition for it s use of
e ng ine e r ing pr incipl e s to improve e f fect iveness
a nd a ddre s s a ddiction at a l l l eve l s of t he human
condition. Not wil l ing to s uccumb t o common
cl a ims of ove r- re gul ation in th e s ub s t ance abuse
tre atme nt s ys te m by s ome provide r s , Er in set a
goa l to a c h ieve a pe rfe ct eva l uation in t he clinics
a nnua l s tate a udit. Sh e a c h ieve d it.

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E XE CU T IV E S U M M A RY
"Change is the law of life and those
who look only to the past or present
are certain to miss the future."
- John F Kennedy
My 20 ye ar c o mmi t m en t t o p reven t i n g a n d
t re at i n g ad d i c ti o n h a s b een fu el ed by a n
uny ie ld i n g, p assi o n fo r p ro ces s i m p rovem ent,
com passi o n f o r th e v i ct i m s a n d t h ei r fa m i lie s
and in c re asi n g f r u s t r at i o n w i t h t h e l a c k o f
e ffe ct i ve le ad e r sh i p t h at h a s y i el d ed fa i l u re of
t he U.S. d r u g c o nt ro l a p p ro a c h .
Ove r the p ast 2 0 yea r s , mu l t i p l e p o l i c y m a ke r s ,
e le ct e d o f f i c i als, p rov i d er s , co m mu n i t y l ea de r s
and so many o the r s p u t fo r wa r d T H EIR s o l utions
t o t his g rowi n g p ro bl em t o n o ava i l , a s t h e
proble m c o n ti n u e s t o wo r s en , rea c h i n g t h e ne a r
e pide mi c leve ls th at h ave n ow i n fi l t r at ed a nd
com pro mi se d many o f o u r n at i o n s s y s t em s. In
eve r y n ew p lan , ever y n ew p o l i c y w r i t t en , eve r y
new tre atme n t theo r y p ro p o s ed , we m a ke th e
sam e mi stake s over a n d over, yea r a ft er ye a r.
A ll t h e whi le, mo re p eo p l e b eco m e a d d i cte d,
ove rdo se s r i se, tre at m en t s t ay s d ecrea s e a nd
fundin g d o llar s g row m o re d i l u t ed . Ever y new
t ask fo rc e, advi so r y g ro u p a n d a d d i ct i o n re l ate d
ce nt e r s f o r e x c e l l en ce, a s Gover n o r Wo l f s
newe s t p o li ti c al en t re i n t o t h e fi el d ca l l s t h e m,
is plagu e d by the s a m e dy s fu n ct i o n s ca u s i ng us
t o re pe at o u r mi st a kes a n d y i el d t h e s a m e
re sults.
In t hi s p lan , yo u w i l l s ee n o n ew req u es t s for
fundin g, n o p ro p os a l s fo r a dv i s o r y co m m i tte e s
or le g i slati o n , n o bl a m e- r i d d en d i at r i b es
de m on i zi n g any o n e s y s t em s ro l e over
anot he rs, n o advo ca c y fo r o n e t h eo r y over
anot he r an d n o p ubl i c fo r u m s d es i g n ed t o
e xploi t a d i re p ro bl em s o l ely fo r t h e p u r pos e of
g e t t i n g e le c te d .

T h is is a re comme ndation for th e fol low ing :


1. A s ys te matic proce s s improve ment
a pproa c h to s ol ve probl e ms with in t he
cur re nt s ys te m, a s it e xis ts a nd is cur rent ly funde d.
2. An inte g ration s trate gy th at a l l ow s
l e a r ning to b e s h a re d a cros s our e xist ing
s uppor t s ys te ms more e ffe ctive ly and up t o
date infor mation to b e dis s e minated more
e fficie ntly. Promoting s h a re d l e a r ning
a cros s a l l s ys te ms.
3. An obl ite ration of th e my way or t he
h igh way ma ntra th at h a s pl a gue d this
probl e m for de ca de s , promoting one st rat e gy ove r a noth e r in orde r to a c h ieve a
pol itica l win ve r s us a n e ffe ctive, s elf-improving s ol ution.
T h e pa r tis a n a nd th e ore tica l ide ol og ies t hat have
inundate d th is dis cus s ion for th e pa s t half cent ur y
h ave cons ume d our time, our re s ources, and t he
l ive s of our l ove d one s for fa r too l ong. It is t ime
we re a l iz e th at th e cons ta nt de b ate s reg arding
a b s tine nce ve r s us me dication, 12- s te p ver sus
individua l th e ra py a nd tre atme nt ve r sus incarceration a re not only us e l e s s wh e n atte m pt ing t o solve
a probl e m, th ey a re wa s te ful a nd da m ag ing.
T h is pl a n is a ca l l for us to unify b e hind one
ina rgua bl e goa l : opiate a ddiction is a ser ious
probl e m in our s ocie ty a nd th e re s ources we are
putting towa rd s ol ving it ne e d to b e ut ilized in a
more s tre a ml ine d, data - dr ive n process. This
b e g ins fa r de e pe r th a n s imply c h a ng ing w hat we
fund a nd h ow. It s ta r ts with th e organizat ional
cul ture of our countr y, our gove r nment and our
communitie s a nd h ow we th ink a b out mult i-sy ste mic probl e ms , from immig ration, to nat ional
s e cur ity a nd of cour s e, h e a l th ca re a nd addict ion.
From th e re, we ca n work on a n e ffe ct ive, st reaml ine d proce s s th at incor porate s a l l a spect s of t he
probl e m, a l l th e s ta ke h ol de r s ne e de d t o enact real
s ol utions a nd th e re s ource s ava il a bl e t o fuel t hem.

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TH E P RO BL EM
A ddi c t io n h a s b e e n prove n t o be our most
expe nsi ve, p reve n ta bl e hea l t hca re i ssue. Fo r
ye ar s i t wa s m i s c o nst r ued a s a n i ssue t hat
a f f li c t s o n ly p o o r a nd m i nor i t y popul at i ons.
R e c e nt s u r ge s in overdose rat es, deat hs
cons i s t in g o f A m e r i ca ns from ever y ra ce a n d
soc i oe c o n o m ic s tatus have sl ow ly pushed th e
p roble m in t o t h e ma i nst rea m, fa r t oo l at e fo r
bas i c p reve n ti o n a n d t re at ment effor t s t o b e

effective. To d ay, th e o p iate an d ad dic tio n c r is is


h as reac hed ep id emic p ro p o r tio n s , in f il tratin g
all levels o f gover n men t in mu ltip le s ys te ms o f
o u r s o ciety.
T h e Un ited States ex p er ien ces an ave ra ge o f
1 1 0 d r u g overd o se d eath s ever y d ay a n d
overd o s e is n ow the lead in g cau s e o f a c c id e n ta l
d eath in th e co u n tr y.

T HE SYNDRO M E O F A D D IC T IO N
O ne of the g re ate st d efi ci en ci es fa ci n g o u r
nat ions o p i ate p ro bl em i s a s everely m i s i n for me d,
unsci e n ti f i c u n d e r st a n d i n g o f w h at t h e s y n drome
of addi c ti o n i s. A d d i ct i o n h a s m a ny fa cet s th at
i nclude b i o c he mi str y, p hy s i ca l h ea l t h , co g n itive
f unct ion i n g, so c i al p er cep t i o n s , b eh av i o r a nd
e nv i ronme n tal i n f lu en ces. In o r d er t o effec tive ly
addre ss thi s p ro ble m , a l l fa cet s n eed t o b e
consi de re d .

5.Wh e n a pe r s on us e s more opiate s, t he body s


natura l opiate l eve l continue s to de crease
ca us ing re cove r y to ta ke l onge r. T his is how
tol e ra nce to opiate s occur s. Wh e n t he body s
inte r na l s ys te ms b e come too dis r upt ed,
with drawa l s ymptoms wh e n th e dr ug is not
pre s e nt. At th is point, th e motivation for t he
a ddict to us e opiate s is more to e l iminat e
with drawa l s ymptoms th a n a ctua l ly g et t ing hig h.

He re are so me b asi c i n a r g u a bl e p o i n t s t o
consi de r:

6.With drawa l s ymptoms of opiate addict ion are


s eve re, fl u- l ike s ymptoms , e xa ce rb at ed by an
incre a s e d pa in pe rce ption, ma k ing t he condit ion
s e e mingly intol e ra bl e.

1. W he n a p e r so n pu t s l a r g e a m o u n t s o f a
c he mic al su b stan c e i n t o t h ei r b o dy, t h e
subst an c e fac i li tat es b i o c h em i ca l c h a n g e.
2. The hu man b o dy p ro d u ces i t s ow n , n at u ra l
for m o f o p i ate s. T h erefo re, h u m a n b ei n g s
alre ady have a re c ep t o r s y s t em t h at q u i c k ly
re spond s to o p i ate p a i n k i l l er s a n d h ero i n .
3. W he n the c he mica l s u b s t a n ce b ei n g p u t into
t he bo dy i s a p re sc r i p t i o n p a i n k i l l er, t h e s ta r ting
poi nt f o r mo st he ro i n a d d i ct s , t h e c h a n g e th at
occur s c o n si sts o f i n t en s e eu p h o r i a a n d a
de cre a se i n the b ody s n at u r a l o p i at e l evel s.
4. W he n the d r u g l eaves t h e b o dy, t h e b o dy s
nat ural o p i ate level w i l l b eg i n t o r i s e a n d re tur n
t o nor mal.hi ghway m a n t r a t h at h a s p l a g u e d th is
problem f o r d e c ad es , p ro m o t i n g o n e s t r at egy
ove r a n o the r i n o r d er t o a c h i eve a p o l i t i ca l win
ve r sus an e f f e c ti ve, s el f- i m p rov i n g s o l u t i o n.

7.Ove r time, a n a ddict e xpe r ie nce s severe


b ioc h e mica l imb a l a nce s a nd de ficie ncies, sleep
dis turb a nce s , h a ir l os s , s k in conditions,
dige s tive probl e ms , cognitive impa ir ment ,
compromis e d s ocia l s k il l s a nd me ntal healt h
is s ue s.
Opiate a ddiction a ffe cts more th a n just t he
inte r na l opiate s ys te m. C ons is te nt use of opiat es,
a l ong with poor phys ica l ca re, de te r iorat es t he
b ody a nd its s ys te ms. An a ddict wh o is sit t ing in
g roup th e ra py for 4 h our s wh il e e ndur ing severe
ma l nutr ition is going to e xpe r ie nce pain,
s ignifica nt dis comfor t a nd continue d crav ing s for
opiate s , ma k ing re cove r y a s l ow, g ra dual and
c h a l l e ng ing proce s s.

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FACTO R S TO C O N S ID ER
Addiction is far from just a healthcare or genetic issue. It has
become entrenched in nearly every aspect of our society, in
one way or another. The failure to adequately incorporate
this issue into many of our nations systems is largely why
attempts to solve this problem keep failing. A comprehensive addiction prevention program must include:
Healthcare Addiction has serious physical health aspects
that are often overlooked or completely ignored. We often
choose to medicate the effects of these problems with mental
health medications instead of treating them medically.
Insurance companies, doctors, and treatment providers must
start to recognize this aspect of addiction. Screening, Brief
Intervention and Referral to Treatment (SBIRT) strategies
have long been researched and proven as an effective protocol for identifying and treating addiction in its early stages,
but are not universally implemented by physicians.
Mental Health Mental health treatment and therapy is
often an essential component of an effective prevention and
recovery program. At this time, access to mental health
treatment is severely lacking and treatment stays and insurance coverage are grossly inadequate.
Employment Communities that experience larger rates of
unemployment or under employment are more vulnerable
to pre-conditions of a serious drug problem. In Western
Pennsylvania, we are seeing increasing unemployment and
poverty rates as more factories are closed and jobs lost. Lost
jobs decrease the local tax base and consumer base. And less
money is available to fund schools and municipal expenses or
support the local small businesses. All of these conditions
play a significant role in developing and maintaining a drug
problem.
Education How our schools educate and discipline
students on this issue is an essential factor in identifying
addiction early and treating it in a timely manner. Screening,
Brief Intervention and Referral to Treatment strategies have
long been researched and proven as an effective protocol for
identifying and treating addiction in its early stages, but are
not universally implemented. SBIRT strategies can be taught
and implemented in the education system as well.

resources needed to prevent and treat addiction. Increasing


poverty rates are turning once prosperous communities into
down-trodden dens of drug distribution and consumption.
Nutrition A well-nourished body is more resistant to the
biochemical damage of substance abuse than a malnourished
one. A body that is poorly nourished due to any number of
factors can fall more vulnerable to some mental health and
addiction related health issues.
Criminal Justice Incarceration of addicts has proven not
only to be ineffective, it can be detrimental to recovery. At
times, it can be life threatening when you consider that a
majority of overdoses occur after periods of abstinence or
incarceration. The let them die mentality that some have
taken in respect to addicts and overdoses is a far more
expensive mindset than a rehabilitative one. The expenses of
first responders, coroners activities and autopsies become
very expensive and cumbersome to our municipal budgets.
Prevention and early treatment have been proven to reduce
the significant financial burden of substance abuse on our
communities, first responders and municipalities.
Pharmaceuticals While the pharmaceutical companies
are not innocent in the opiate epidemic, demonizing them
wont solve the problem of prescription drug abuse in our
country. Working with them to develop policies that encourage a blame-free exchange of information, conducive to
greater transparency, is essential. But holding them accountable and punishable when they directly violate best practices
or guidelines set by their FDA approval is appropriate and
necessary.
In 2014, there were approximately one and a half times
more drug overdose deaths in the United States than deaths
from motor vehicle crashes (4).
Opioids, primarily prescription pain relievers and heroin,
are the main drugs associated with overdose deaths.
In 2014, opioids were involved in 28,647 deaths, or 61% of
all drug overdose deaths; the rate of opioid overdoses has
tripled since 2000.

Poverty Poverty decreases access to valuable social,


political, legal, medical, mental, financial, and educational
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Center for Disease Control:


January 1, 2016 / 64(50);1378-82

FACTO R S TO C O N S ID ER
Immigration All too often, our discussions on immigration fail to identify the relationship between our current
immigration policies and our addiction problem. The opiate
production and supply chain that is overcoming many
countries, encourages and forces illegal immigration as
people come to the United States as refugees, victimized by
the global drug trade. Politicians often like to cite the
amount of drugs that enter the country from Mexico as a
catalyst to ignite xenophobia and fear. But the larger picture
of opiate imports demonstrates that Mexico is just one piece
of the problem and the Middle East demonstrates a significant global opiate supply chain that is often conveniently
omitted in policy discussions.
National Security and Terrorism A large portion of our
opiate supply comes from the Middle East and is in some
measure, the result of U.S. foreign policy decisions. The
peripheral effects of the War on Terror on our drug supply
were not considered in the foreign policy strategies before
and throughout the wars in Iraq and Afghanistan. Our
country has paid a hefty price for that negligence ever since.
Furthermore, opiate sales are a significant funding source for
terrorist networks and their activities. Any future national
security policies or efforts must include considerations for
the global drug trade.
Armed Forces andVeterans The impact that opiates and
substance abuse has on our fighting men and women during
and after their service is significant and receives far less
attention than they deserve. But a greater issue is connecting
veterans with the services already available to them. Too
many of them are experiencing poverty, unemployment,
mental health issues, addiction and homelessness. In many
cases, available services are not reaching them, predisposing
them to more significant substance abuse issues. Ensuring a
system that more readily connects veterans with available
services can help alleviate substance abuse and mental health
issues that all too often afflict our fighting men and women.

SYSTEMIC DAMAGE
We have chosen to culturally divest in most of the systems in
the past 20 years which has begun to undermine our
progress as a society. In education, we have moved away
from ensuring our children are thoughtful, innovative
individuals toward ensuring they can pass a standardized test.
Our performance measures in education are no longer
designed to determine how effective our students are as
productive citizens. They are designed to identify the
socioeconomic issues that stifle growth and ultimately punish
the students for them. Case data showing a students overall
improvement and identifies areas of concern as opportunities
to be cultivated is a student-centered approach. The
blame-ridden measures we employ now, are politically
centered and serve nothing but a political end.
We have divested similarly in healthcare, mental health
treatment, poverty, jobs, nutrition and care of our veterans.
This is not to say we have directly taken money from these
efforts. But we have diluted the effectiveness of those dollars
but developing a national culture of blame-ridden,
ideological, political worldviews about how a system
SHOULD operate as opposed to pragmatically improving it
from within through a systematic, problem solving approach.
The aftermath is a society where our dollars are less effective
at solving most of our problems, as the systemic ails that
plague us on multiple levels such as an opiate epidemic,
become harder to solve.

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ADDRE SSI N G T H E P RO BL EM
In the heat of an election season, politicians everywhere are
promoting plans, policy papers and even legislation to show
they care about this issue, which may in fact be true. But
what most of these efforts show, is that very few policy
makers, if any at all, have the first clue how our drug control
policy and the massive industry that is financially fueled by it,
is failing.
We see a number of elected officials innocently throwing
more money into this system guised as a solution to the
problem. But rarely do they demonstrate a sound, systems
level analysis and thorough process map of the entire problem and a targeted solution. This is the failure, not only with
the opiate problem, but with most of our nations greatest
problems.
Our efforts should first identify where our problems are in a
systematic way. Here are just a few for local prevention
efforts to consider:
1. Organizational Culture of Healthcare
The overarching organizational culture of healthcare has
become a major catalyst to a number of our problems. In a
true, free market economy, customers create demand and
reward the best service providers with their business. But
that is not the case in healthcare. How many of us ask our
doctor, So what are your success rates? How many times
when being prescribed a test do we ask, Now how much is
this going to cost because I need to determine if its worth
it.
The fact is, the average person uses more pieces of data to
pick a restaurant than a healthcare provider. Healthcare
payer plans and provider services are not administered in a
free-market mindset. The result is, peripheral services that
are perceived as less urgent, like substance abuse and mental
health treatment, are sacrificed in healthcare plans. As
consumers, we are more inclined to simply go with the flow
instead of taking an active role in how our healthcare dollars
are spent. The result is a provider and payer system that
focuses more on making money than it does addressing
qualitative performance indicators in our care.
Data has shown that when healthcare systems work to reduce
medical errors and hospital acquired infections, streamline
care, decrease wait times and improve medical compliance,

costs go down. But these efforts require us to create a


culture of habitual excellence that identifies errors instead
of covering them up, encouraging transparency instead of
using it to assign blame and solving our problems at their
root cause instead of band-aid policy efforts that only
temporarily mask the issue. These problems are not the fault
of any one President, political party, administration or
government agency. They are a cultural mindset that we as a
nation have been embracing for many decades, and we all
must take responsibility for changing our perspective
2.Third Party Payers
The type, intensity, frequency and duration of addiction
treatment has diminished over the years as the third party
payers have systematically discouraged innovative treatments
and reduced overall access to treatment. What was once a
90 day, inpatient stay with a progressive reintegration into
society over 6 months, has been reduced to a mere 14 days
with little to no outpatient follow-up. The standard of a
multidisciplinary treatment model that encompasses all
aspects of addiction has now been reduced to medications
and sporadic outpatient follow-up. Professionally conducted
family support services have been reduced to community-based support systems. The entire treatment model has
been slowly and systematically obliterated as growing
healthcare costs have caused third party payers to cut
reimbursements. Innovative treatment approaches, despite
scientific evidence of efficacy, are rarely reimbursed and only
offered on an unaffordable, self-pay basis.
The argument that the current private health insurance
reimbursement structure encourages innovation and
advancement is a fallacy in the substance abuse and mental
health services discipline. The current reimbursement
system has made addicts and mental health patients the
unwanted step-children of the healthcare industry, causing
the burden of these conditions to be transferred to our
general society, our local governments and the American
taxpayer.
3. Pharmaceutical Industry
While medication for addiction can be effective and pharmaceutical treatment in mental health care is often necessary,
sacrificing advances in comprehensive therapeutic approaches that address all aspects of addiction is decreasing the
effectiveness of our treatment system. Right now, most of

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ADDRE SSI N G T H E P RO BL EM
the research and effort to advance treatments for addiction
lies in drug therapies. But drugs dont change addictive
thinking and behaviors. Drugs dont alter addictive environments. Drugs dont miraculously cause addicts to develop
coping skills. And drugs dont repair the biochemical
damage that years or decades of substance abuse causes to
the human body. So it is understandable that a treatment
mindset based solely on group therapy and medications is
failing to yield any progress solving this problem.
The more comprehensive addiction treatment strategies used
in other industrialized nations are often trivialized and
ridiculed in the American medical industrial complex. The
predominant assumption of American addiction treatment is
that the root cause of addiction is a biochemical deficiency of
Prozac or Lithium.
As long as our insurance reimbursement structure is geared
toward medicinal therapies over qualitative ones, the power
of the purse will continue to steer treatment away from
more comprehensive, multi-disciplinary prevention and
treatment models and facilitate further dependence on
medications and yield further systemic ineffectiveness.
4. Advancements in Treatment Methodologies
In the early part of the 20th century, as AA was being
developed as a spiritual guide and support system for
addiction, a complimentary, multidisciplinary treatment
approach was also developing. But around the same time
that a third party payer system was being developed and
marketed for sale to employers, the recovery field began
moving away from the more complicated methodologies that
addressed all aspects of addiction, to a more simplified
approach based purely on a medicinal and group based
model. This mostly occurred because, it was cheaper.
Addiction treatment methodologies have gone virtually
unchanged for the past half century.
As the payer system fails to reward innovation in treatment
methodologies and drug companies continue to corner the
market on treatment approaches, the overall treatment
system will remain stagnant. Without drastic change to the
way this entire system functions, it is unlikely that treatment
approaches outside of drug therapies will change much in
the 21st century.

5. Misinformed Policy Makers


Most policy makers are reluctant to address the role that
third party reimbursement and pharmaceutical sales play in
the failure of our drug treatment system. This is partly
because, they simply arent aware of how paralyzed the
system is by the extraordinary amount of money that flows
through it.
The Affordable Care Act made some small steps forward,
ending lifetime caps on addiction treatment and eliminating
addiction as a pre-existing condition. While this helped
eliminate significant treatment barriers, it did little to
advance the overall quality of care. Future policy efforts
should emphasize performance measurement and outcomes
in addiction recovery to advance the field and reward
innovation and dynamic treatment approaches.
6. Lack of Integration and Customization at the Local Level
Local addiction prevention and treatment efforts often suffer
for two reasons: 1) they do not effectively utilize all the
resources and information available to support effective drug
control and 2) they employ cookie-cutter, one-size-fits-all
approaches that are not properly customized to the needs
and resources of their area.
Good local drug control efforts are best implemented at the
county level for two reasons: 1) the payer structure typically
operates on a county basis and 2) the law enforcement
approach starts with a county elected District Attorney.
Any effort involving coordination among multiple government, community and private organizations must start with a
full analysis of the specific problem and available resources.
The problem and the resources available to solve it differ
significantly from county to county. Counties can experience varying levels of treatment availability, funding, criminal justice programs, community resources, supply and
demand of drugs and poverty. These and many other factors
dictate what an effective drug control policy will look like.
In most cases, efforts to implement effective drug control
fail because they lack a substantive process, not overarching
resources, motivation or effort.
Once the current condition of a countys drug problem and
available resources is completely assessed, a systematic plan
to address those problems utilizing available resources can be

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ADDRE SSI N G T H E P RO BL EM
designed. As this plan is implemented and resource
short-falls are identified, they can be addressed in a specific
and targeted fashion as opposed to simply throwing money
blindly at the problem. In Pennsylvania, state budget
decisions to address addictions should include detailed
recommendations from each county, be based on an accurate
current condition of the problem and an efficient use of
available resources to directly address each issue.
A thorough current condition analysis should be performed

by a professional who is well versed in the drug control


ystem and can effectively communicate with all stakeholders
in the process. This person should understand drug control
policy and participating agencies and organizations at the
local, state and federal level. Organizations like the Center
for Disease Control, the National Institute of Drug Abuse,
the White House Office of National Drug Control Policy and
the Federal Drug Administration have resources, policy
guidelines and scientific data that is rarely utilized when
developing a comprehensive drug control plan.

CO N C L U S IO N
When addressing any large, systemic issue, such as our drug
problem, we must change our cultural views on how we
identify and solve problems in our society. The current
system of blaming each other and arbitrarily throwing money
and regulations at different targets is not working. But its up
to us to demand more than just talking points and money
from our electeds. We must demand leadership and an
understanding of what is actually happening in our society,
what our problems are and the leanest, most efficient way to
solve them. We must set real, aspirational goals and work
toward them.
The problem of addiction is diverse and composed of
malfunctions and misperceptions across many of our nations
systems. A perspective that sees only one aspect or approach
does not penetrate the systemic mass of this issue. In any
prevention and treatment effort, we must include all
stakeholders and ensure that every aspect of the problem is
represented.
A multidisciplinary prevention program should start on the
front line by the people charged with its execution. A
current condition of the problem and the resources available
to solve it should be developed. Once problem areas are
developed and all resources are appropriately allocated,
requests for additional support should be sent up the chain
to the state and federal government agencies as well as
through grant applications and soft money donors.
Finally, a mechanism for shared learning must be developed
and utilized to share effective as well as failed approaches

throughout the region, the state and eventually across the


country. Shared learning should be as transparent as
possible. Exploring techniques that have failed is just as
important as sharing what has worked if we are to avoid
repeating mistakes and slowing the overall progress of drug
prevention and treatment efforts.

I honestly think the skill shortage in our society, maybe in


the world of civilized people, is real leadership.There are a
whole lot of people who I suppose are leaders by
designation, but I dont honestly know a lot of people who
are leaders in the sense that they will articulate goals at
what I call the theoretical limit and then help their people
to acquire and practice the skills that are necessary to what
I call habitual excellence. Its really hard to find leaders
who understand the concept of habitual excellence, which
means a leader should expect every aspect of his
organization to perform at the known level of possibility.
Having that kind of leadership and a leadership that is not
about punishing or blaming people, but about using every
single instance of anything gone wrong as a basis for
organizational learning is really critical to this.There are a
lot of people working on pieces of these ideas but,
unfortunately, there isnt a national movement yet.
Hopefully, soon there will be.
-Paul ONeill
Former Alcoa Ceo &
US Treasury Secretary

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