US Surgeon’s General Report – First In The Series.
After a year or so of back and forth, Congress finally passed ground-breaking legislation funding $1 billion to help fight our national epidemic of addiction, signed into law December 13, 2016 by President Obama.
US Surgeon General, Vivek Murthy, was a huge proponent of the bill and his comprehensive report “Facing Addiction in America” (the “Report”), was a key impetus to achieving this landmark accomplishment. While the law is couched in terms of battling our country’s mental health crisis, it has the potential to be a game-changer in our battle against addiction because there is such high commonality between addiction and mental health issues (over 40%, according to the Report). Now, I realize, $1 billion might seem like a mere drop in the bucket, considering the gravity of the problem, but this law creates a new dynamic that will change the face of how we, as a nation, view, diagnose and effect addiction treatment in the 21st century. However, as they say, the devil’s in the details, so let’s examine some of the major provisions to get a better understanding of what to expect.
Implementing Change Will Take Time
To begin with, change won’t happen overnight. It remains to be seen exactly how the funds will be allocated and the programs implemented. Moreover, the law also involves creation of an entire new subgroup of the judiciary to specifically deal with substance abusers. While we might not ordinarily be pleased with a delay, in this instance it could actually be positive, giving us in the addiction treatment community time to get directly involved in policy groups to assist in the roll-out. After all, few people have more experience on the front lines of addiction. As professionals already providing and supervising treatment, we have a lot to contribute.
The success or failure of this national initiative then depends on a number of factors, which really all boil down to implementation. The focus will be on:
- The creation of Drug Courts intended to divert drug and alcohol addicted offenders into treatment, rather than incarceration.
While Prevention and Treatment are clearly different programs, requiring distinct approaches, their implementation share much in common, so it’s useful to examine a single philosophy in their analysis. Both Prevention and Treatment rely upon the following to achieve success:
- The quality of the program.
- Adapting the program to local requirements, while maintaining its integrity.
- The inclusion of local stakeholders, invested in the success of the program.
- Hiring and retaining quality, qualified instructors.
- Educating and training instructional staff.
Quality Of Program
While treatment policies and procedures share a lot in common from therapist-to-therapist and from treatment facility-to-treatment facility, there is no national standardized practice on how to prevent or fight addiction. That’s not necessarily a bad thing, because no two people are alike. However, as our industry continues to expand upon methods with demonstrated success and experiment with others that show promise, the rigors of this new government program combined with upcoming success based reimbursement, will likely force more rigid programming upon us. The Report classifies “Evidence Based Programs” as ones whose success is supported by results-oriented proof. While it singles out certain programs, the Report does not take a specific position on which to choose. Those programs, however, do provide insight into general guidelines and principles favored by the Department of Health. The Report also interestingly notes what it calls the “Prevention Paradox” that a LARGE number of people at SMALL risk (i.e. the population at large) may give rise to more cases of disease than a SMALL number of people at LARGE risk. However, here too it does not take a definitive position, (i.e. children of addicts predisposed to the disease). Which group should we message with prevention and encourage toward early treatment? The Report does leave some open-ended questions unanswered, its analysis does provide clues on what we can expect from the new law.
Once a program model has been selected, the Report recognizes that localization can have a huge impact in maximizing the program’s success. Our country is markedly different from region-to-region and from city-to-city. We also need to account for age, ethnicity, socio-economic factors, community priorities, differences in communication styles, and a whole host of other factors. Furthermore, the Report points out something I call the “Implementation Paradox.” Studies have proven that successful implementation of localization has a greater impact on both prevention and treatment, but, the further the program strays from its core principles, the more it diminishes its efficacy. It describes a tightrope walk of balance in trying to maximize the benefits of localization without diminishing the overall strength of the program. When you throw in the fact that people with lower incomes, and ethnic and racial minorities are disproportionately affected by addiction, it’s easier to understand the conundrum and importance of getting things right.
Involving Community Stakeholders
After identifying a program and localizing it, we still need to get the community to buy into the program. The greater the involvement of neighborhood faith based groups (churches, synagogues, mosques, etc.), sports programs, after-school groups, business leaders, civic organizations and the like, the greater traction can be anticipated in successful prevention and treatment. If local sports leaders give a guest speech, local priests, rabbis, imams and pastors are there for support, and local businesses are willing to train and hire, it creates a biosphere of success, on which to base and grow. There is an abundance of truth in the expression, “it takes a community to raise a child”. The more successful we are in garnering comprehensive community involvement, the deeper the roots and longer the limbs of a prevention and treatment program.
Every program is only as successful as its weakest link. Most people in the addiction treatment field are dedicated and highly motivated, many of them in addiction disorder recovery themselves. Some, however, are less than committed or don’t have the requisite background, personality or experience to handle a program. Instructors also need to be able to communicate and relate to the particular local community. A freshly minted PhD of a different ethnicity than the local community, may not be the best choice to motivate older people living in an inner city neighborhood. Our target in considering qualifications are people who can best communicate with and convince the local communities on the urgency of the message, while staying true to the core message itself.
As previously noted, programs that can find a delicate balance between fidelity to the initial Evidence Based Program and adaptation for local needs, will achieve the highest levels of success. This concept is very similar to what we see in franchised facilities in the business world. People go to McDonalds around the globe because they know what to expect in terms of general uniformity. Yet, in France the Quarter Pounder is called the Royale because they use the metric system, and in China they serve more rice and pork dishes to satisfy local tastes. The realities of capitalism have pushed McDonalds (and others) into that delicate balance. They also have a standardized way to train employees, starting with principles espoused at McDonalds University. The better job McDonalds does in creating balance and training, the greater its financial success. While prevention and treatment are not driven by the same profit motive, it can still benefit from lessons learned. The better balance WE have in fidelity, localization and training, the greater our likelihood of success.
This final component of the new law, intended as a pilot program, is probably the most interesting. County and State courts have been operating something similar for decades, experimenting with diversion programs in an effort to reduce overcrowding in prisons and lower criminal justice costs and, almost as an after-thought, increase treatment for substance abusers and those with mental health issues. The concept is simple. On a case-by-case basis, a judge, in consultation with prosecutors, will have discretion to determine the extent to which a defendant warrants diversion into a treatment program as an alternative to prison. What is different for the Federal courts though is, that the new law seems to suggest creation of wholly separate and distinct courts to handle these matters, unlike the State and County courts in which all judges have this as an option.
The New Law Review
After reviewing the new law in its totality, I think the main conclusion to draw is that this is just the first step of government involvement in the process. Once the $1 billion is set in motion, it creates programs that must continue to be fed on an ongoing basis. Perhaps a prevention program can be started and wound down without much fanfare, but treatment programs and an entire new subsection of judiciary can’t just be eliminated once the funds have run out. The extent to which these programs are re-funded in the future will depend, to a great extent, on their success and the public’s enthusiasm to keep funding these projects. That’s why it’s critical we get involved in creating programs specifically designed to help the government achieve its objectives and demonstrate clear and definite results. Once the evidence is incontrovertible, it will free up more resources to assist us in the ongoing battle to help make drug and alcohol addiction a much more manageable chronic disease because, at the moment, there unfortunately is no cure.