The United States had 93,331 overdoses in 2020 alone. Sadly, it seems as though most people are not very familiar with this number, and yet, it is not an overstatement to say that this is one of the greatest problems America faces in modern times.
The question I propose is not what’s causing it, but rather:
How can we begin to fix it?
Below I propose some potential starting points. As for these points, they’re just my ideas. I don’t claim to be an expert in all the causal fields of addiction. Nor do I have the authority or expertise to say these proposed ideas are the best, right, or only way to go. My goal here isn’t to present myself as an expert. Rather, it’s to get us all thinking and discussing new ideas and new directions to begin to stop this trend.
Over the next few years, it’s my goal to expand on these ideas and to develop this outline into a book called, “Checked Out: Checking In on the Americans We’ve Left Out.”
If we do nothing, nothing changes.
Problem 1: The Prevalence of the American Personal Responsibility Myth
In many ways, life is like a race that we’re tricked into believing give us all equal opportunities as American citizens. We’re taught that if you work hard enough, anyone can achieve success in America.
The trouble is, it’s not race analogy that’s wrong, it’s the thinking that we all have an equal chance to win that’s the myth. We DO NOT all start at the same starting line. Rather, life is race with a staggered starts that’s rigged from the beginning. To think that’s its more about personal responsibility than it is about starting point is the wrong lens in which to think about the world.
Idea for Improvement: Teaching “The Fundamental Attribution Error”
The Fundamental Attribution Error is basically this: When we see someone who’s successful, we tend to give credit to their circumstances. i.e. “George W. Bush became our president because his father was previously our president.” When we see someone who’s struggling, however, we trend to blame that person personally for their struggles. i.e. “Why doesn’t that homeless person just get a job already?”
But here’s the kicker: We practice the opposite when judging ourselves.
When we succeed, we tend to give credit to ourselves. i.e. “I worked hard to get where I’m at and I paid my dues.” When we fail, however, we tend to blame circumstances or others. i.e. “Sorry I was late. Traffic was awful.”
What does teaching the fundamental attribution error have to do with lessening addiction?
When we see a person struggling with addiction many of us tend to label that as personally responsible for their circumstances. What we may not see, however, is that injury that first led to using pain pills, or the sexual abuse, or the loss of a parent, etc.
It’s an oversimplistic narrative to say “Your life. Your responsibility.” We need to train ourselves and future generation to see the more with more nuance. This involves not just blaming the person, but taking the time to understand that person’s environment and upbringing to see how that may have influenced them as well.
Problem 2: A Strictly Biological Model of Health
In mental health treatment, it’s an over-reliance on the “Serotonin Story” of happiness, and an under consideration of the environment factors that are driving us towards unhappiness.
There are many more reasons why one may be depressed that just levels of serotonin, just as there are many more reasons why one stays addicted to opiates beyond just endorphin levels.
And this lens is not just prevalent in mental health leading to overprescribing, it permeates every aspect of American health care. The best way I’ve heard it described is, rather than a Bio-Psycho-Social Model, we trend to only use “The Bio-Bio-Bio Model of Health Care.”
To put this one other way, in the words of the late Dr. Neil Capretto, “Any doctor can say “yes” and take 3 minutes and write a script. It takes a really great doctor to say “no” and take 30 minutes to explain why.” Unfortunately, does our current medical model not incentive this type of treatment.
Idea for Improvement #1: Look at the Reasons for Behaviors a Community Level, Not Just an Individual Level
One person above all influenced to start to see things from a community level and not just an individual one. This person’s name is Dan Buettner.
Dan Buettner is a New York Times best-selling author whose company has developed an evidence-based program that uses the secrets of the “Blue Zones” to transform communities. “Blue Zones” are areas of the world where people live exceptionally long and/or exceptionally happy lives.
The Blue Zones Project® is dedicated to creating a nation of Blue Zones communities – healthier cities, states and businesses where people live longer, better. The program is based on the assumption that we spend 90% of our lives in a 20-mile “Life Radius®”. Within that life radius we focus on optimizing: More walkable or bikeable environments, more green space and parks, discouraging junk food and smoking through the city’s policies and ordinances, etc.
Long story, short, their scientifically proven interventions create environments that nudge people toward healthier choices every day.
Said another way, we need to stop just throwing pills at all of our problems and engaging in the harder, more meaningful work on improving our communities as a whole.
One of my new favorite sayings to illustrate this whole concept is this: “I can talk about healthy dieting with a person until I’m blue in the face, but if they go home and only have access to McDonalds and Dollar General, I’m going to continue to be fighting a losing battle.”
Idea for Improvement #2: Stop Over- Emphasizing the Serotonin Story of Happiness
The serotonin story is this: Your therapist, your doctor, and the media all say, “It’s not your fault that you’re depressed. It’s your brain. It’s imbalanced.”
To be fair, this narrative was a societal step forward from the “You’re immoral, diseased, sinful, or totally self-responsible” for having mental health or addiction symptoms. It was progressive in that it got us rather looking at these things as medical conditions, however, it has its flaws as well. Most specially, it’s only a small part of the story, but it often gets represented as whole story and does not account for other influences.
From an incentive’s standpoint, this makes sense. Pills cost money, are profitable for Big Pharma, and take little work and require minimal change for the person taking the medication. Exercise, better nutrition, and commitment to therapy take significantly more work, and no one but you profit from practicing deep breathing or taking a walk around the block with a friend.
For our next step forward in the treatment of mental health and addiction, we ought to begin to look at depression and addiction primarily as a bonding issue and see how we can foster new, meaningful connections in a person’s environment.
Problem 3: Stigma
Though stigma has been reduced in recent decades, it’s estimated that of all the people struggling with addiction in America, only 1 in 10 people with addiction get appropriate treatment for their condition.
Idea for Improvement:
Treat Addiction More Like We Treat Depression
and Less Like We Treat Criminals
Why do we treat Suboxone different than Antidepressants?
The answer to this is simple: Because we look at addiction as criminal and depression as medical.
First, let’s first look at how we treat depression in America.
Say you’re feeling depressed. Perhaps it’s been ongoing for a while so you see your PCP or psychiatrist. You schedule an appointment and sit in a quiet waiting room. No one knows why your there and no one asks. You see the doctor and he or she prescribes you an anti-depressant. You can get your script later that day. You will get no hassles at the pharmacy. No dirty looks from the pharmacist. No one is going to hassle you about pre-authorization. There’s no required counseling. No medication call backs. And no one is going force you to come to a clinic on a daily basis to get your medication.
Now let’s consider the same scenario but with addiction to opioid addiction.
You’re struggling with addiction. It’s been a while so you go see your PCP. He or she can’t prescribe you suboxone so he or she refers you to a suboxone clinic. There’s a waiting list. You continue to use substances while you wait to avoid going through withdrawal, but eventually you get an appointment.
You go there and sit in a crowded waiting room. Everyone that’s there knows exactly why you’re there. You see the doctor for a few minutes and are treated like a number, not a person. You’re told you need to take an observed urine screen. You need pre-authorization to fill your script. You need proof of counseling to continue to refill your script. Your scripts last for one week at a time. You have to return to the doctor, then return to the pharmacy. There’s a cost each time you go. There’s a cost each time you pee. The co-pays add up. Every time you go the pharmacist, he or she gives you a judgmental look. A look that says, “I know why you need this medication, junkie.” You have to get counseling. You work 9 to 5 and the only counselor with evening hours is a decent drive away. This takes away time from your family and it’s another copay. Your work gets upset with you leaving all the time for “doctor’s appointments.”
As a society, if we truly want to say that addiction is a disease, then perhaps we should start treating it like any other medical brain-imbalance disorder. If we really want to curb the opioid epidemic, perhaps we should start treating suboxone, and other medicated assisted treatments, more like anti-depressants.
Problem 4: Our For-Profit Medical System
The CEO of United makes $77,000…
PER DAY! And he’s not even one of the highest paid!
In addition, American spends 18-19% of our federal budget spent on medical. Canada spends only 10-11% and has similar or better outcomes measures.
Idea for Improvement: Reduce the price of prescription medications. Cap CEO pay.
Approximately 3 in 10 adults report not taking their medicines as prescribed at some point in the past year because of the cost.
Two ways to lower prescription drug prices would be to allow Medicare to negotiate drug prices directly and penalizing drugmakers who raise prices faster than inflation. At present, Medicare is allowed to negotiate prices for every type of health care service except prescription drugs, which leads to increased costs for consumers.
Americans spend an average of about $1,300 a year on prescription drugs — more than any other country in the world. Prescription drug costs in the U.S. have risen by 33 percent since 2014.
We also ought to ban “pay for delay,” a practice in which brand-name drug manufacturers pay generic manufacturers to stay out of the market to avoid any competition that could reduce the price of the drug for consumers.
Lastly, if we were to tie maximum CEO pay to a 20 to 1 ratio of the average worker pay (or something like that) this may help level out health care costs from disproportionately lining the pockets of upper administration.
Problem 5: Big Pharma and Direct-to-Consumer Advertising
Perdue Pharma was sued 600 million dollars for the misrepresentation of OxyContin as “virtually non- addictive” Whereas this may seem like a lot, it’s essentially equivalent to a 2% fine which is NOTHING to them.
In addition, did you know that Big Pharma spends more on marketing rather than research and development? There are only countries in the world that allow DTCA and they are the US and New Zealand.
The effects of DTCA particular upset me several years ago when “Blu” e-cigarettes were advertised by Jenny McCathary directly appealing to young consumers. This made ecigs looks sexy and got, yet again, another generation of young people hooked on nicotine. Here, I thought we had learned our lesson are Joe Camel…
Idea for Improvement: Eliminate DTCA
From what I can see, drug makers have two major categories of significant expenses: research and development, and marketing. Their claim is that these two costs are what cause drug prices to be as high as they are. I say we help them out and eliminate some of the cost of their marketing by banning direct-to-consumer advertising.
When we think of DCTA we usually think of tv ads, but the term applies to magazines and online platforms as well. In the United States, ad spending by drugmakers reached $5.2 billion in 2016.
Besides the cost, why is DCTA harmful?
It has been argued that direct-to-consumer advertising can influence the doctor–patient relationship, including patients bringing up their need for an advertised, name-brand drug as their primary concern during a doctor visit
It has also been demonstrated that direct-to-consumer ads have contributed to the frequency of requests made by patients towards their physicians to prescribe analgesic drugs, including opioids.
Lastly, pharmaceutical companies will advertise for their most profitable products, many of which are unnecessary “me-too” drugs. In the words of Danish physician Peter C. Gotzsche, “There is no need for marketing, as the products should speak for themselves.”
Problem 6: Overprescribing
In terms of overprescribing, in one year, there more opiate scripts written in Ohio than there were people in the state of Ohio. In addition, 200 million scripts were written in 2014 for a US popular of 327 million. That’s A LOT of opioids!
Idea for Improvement: Increase Access to Medicated Assisted Treatment
To be honest, this is actually a problem area in which we’ve made vast improvements upon in the past several years. We’ve implemented the PDMP (prescription drug monitoring program) to cut down on doctor shopping and to crack down on pill mills. We’ve also increased access to Narcan and implemented the Good Samaritan Law to help reverse overdoses and encourage people to seek medical treatment if overdosing without fear of criminal punishment. Many of these efforts get to the root of the problem as well, to stop addiction before it starts.
For those who are already hooked, however, where we still have room for improvement is to increasing access to MAT (Medicated Assisted Treatment). As of now, PCP’s cannot prescribe suboxone. To become a suboxone prescriber, one must take a training and get an XDEA licensure. This limits the number of prescribers and thus limits people’s access to this medication.
If someone has become medically dependent on opioids, whether it was due from overprescribing, length of prescribing, or misuse, to me, it doesn’t matter. What does matter is that we’re doing all that we can to get people help who are hooked, and increasing access to MAT would be a great step to reducing overdoses.
Problem 7: Trauma
Trauma is more correlated with addiction than obesity is to heart disease.
Let that sink in for a bit.
One’s ACE score (adverse childhood events) is more directly correlated with likelihood of addiction than increased weight is linked to heart disease.
Idea for Improvement: Improve Our Social Safety Nets to Reduce Marginalization
In order to break the cycle generational trauma, we need some folks on the margins of our society and more inclusion in the working/middle class. Many folks don’t have this opportunity because they can’t afford to work (see picture), they don’t have access to a college education or technical school, or they become dependent on government assistance and would ultimately lose that safety net if they were to find work.
In my opinion, a starting point where would be to implement a universal basic income (UBI). For those unfamiliar with the idea, UBI is basically capitalism that doesn’t start at zero.
Unlike conditional welfare, disability, or unemployment programs, UBI would be unconditional for all U.S. citizens, regardless of income, employment status, etc. and would not ever be removed.
The trouble with our current systems is that people all too often falls through the cracks of a various society safety nets. With UBI, you can’t fall below a raised floor.
If we want to lessen overdoses in our society, raising the economic floor of every American would eliminate abject poverty and give us all more opportunity to achieve the American Dream. It would allow for more economic class fluidity and let people break out of poverty thus giving us a better shot at ending the generational cycle of poverty, trauma, and addiction.
Reason 8: The War on Drugs Creates a War for Drugs
This statistic is a few years old, however, in the US we spend $41 billion on policing and punishing drug-related crimes, and only $4 billion on all of treatment, education, prevention and job placement programs combined. Now, this stat may be slightly outdated, but regardless, this ratio ought to be the opposite of what it is.
Idea for Improvement: Invest More in Drug Treatment and Mental Health
Indeed, according to NIDA, for every dollar we spend in treatment, we save $12 in reducing court and preventing health costs.
In my opinion, we don’t need to defund the police. Rather we need to fund treatment programs and social workers who are better trained to deal with mental health issues and homeless so we don’t end of making these things police issues because of lack of treatment.
On the mental health side, it is still incredibly difficult to find a mental health provider. We ought to consider having a federal system that allows for reciprocity so a licensed clinician can treat a client across state lines. We also ought to be expediting the process of getting therapists in-network with insurance companies so that the supply of mental health providers can more quickly catch up to the demand and ultimately save lives. Lastly, if we had a system of universal health care, less clients may become displaced from treatment because of losing or switching insurances.
Lastly, we ought to consider the federal legalization of marijuana as legalization provides great tax revenue to be returned in the form of improved regulation, and perhaps, invested into drug treatment.
Problem 9: Accessibility of Fentanyl
If we can’t keep it out of our jails, we can’t keep it out our walls.
With unregulated labs in China producing it, and a global marketing spreading it, we’d have a better shot at lower overdoes with decriminalization, legalization, and/or regulation that we would with our current system of punishment and penalties.
Idea for Improvement: Help Persons Struggling with Addiction Re-integrate into the Community
If you’ve never seen the Rat Park study, you owe it to yourself to watch this video: https://www.youtube.com/watch?v=C8AHODc6phg
The basic gist of the video is that we ought to look at addiction more as a bonding issue than as a chemical hijacking issue. The basis for this argument references the Rat Park study. The Rat Park study was done by Dr. Bruce Alexander in the 1970’s who saw a flaw in the traditional study the demonstrates the chemical hook of drugs. Here’s a quick summary of each study.
Traditional study: Put a rat alone in a box. Give it access to heroin or cocaine. Watch the rat get hooked on the drug, fixation on the drug, and then consume the drug until the point of its death.
Rat Park Study: Do the same thing, but rather than the rat being alone, put in rat into Rat Park where it has access to play balls, spin wheels, food, sun, socialization, and sex. Then, insert drugs into one of the water sources.
In the Rat Park Study, rather than get fixated on the drugs and die, as is the typical result from the traditional study, in Rat Park, the rats mostly shun the drug laced water. They consume it 75 percent less and none of them die.
What’s the conclusion to take from this?
If we continue to throw people in jail for having addiction issues then give them felonies making it harder for them to re-integrate into society, all we’re doing is perpetuating a greater likelihood of continue to bond with drugs!
What can we do about it?
Rather than prisons, we can offer prevention programs, treatment, education, job incentive programs, and fundamental assistance to foster greater societal integration and less stigmatization.
Problem 10: Improving technology and social media
Social Media doesn’t turn off when the school day ends. Teen and pre-teen suicides have increased 56-70% between 2006-2016.
This constant stream of dopamine is too much for the adolescent mind to take in. In turn, it creates an unrealistic social comparison and feeling of “not enough” that can often lead to depression or drugs.
Idea for Improvement: Create a System that allows for Less Work and More Family Time
COVID-19 had mixed effects on the mental health of teenagers. For teenagers of a lower socioeconomic status, COVID hurt these teens as they were less likely to have quality internet access and the disconnect from school was a larger risk factor. For teenagers from more affluent families, however, the break from school activities and allowance to slow down and spend more time with family was actually better for the mental health.
Far too many students, in my opinion, are overstressed, overscheduled, and overfocused on resume building to get into college. Perhaps this is because they’re a reflection of us, their parents.
For so many parents, giving their kids access to screen time and technology is simply a survival mechanism. When both parents work, and perhaps work upwards of 50 hours per week, there’s not a lot of energy left for more active parenting activities like walks around the neighbor, trips to the local park, or reading books.
Many recent studies have suggested that a 4-day work week is just as productive for most workers as a 5-day work week. Assuming these studies are correct, moving to a 4-day work week could be a win-win. Workers could give 100 percent for 4 days, instead of 70 percent for 5 days, and then could have 3 days off for family or personal time instead of two or less.
Indeed, in having just one same sex role model being present in the life of a child can act as a huge protective factor to counteracts the risk of drugs and depression.
Problem 11: Job Displacement
“Work saves us from three great evils: boredom, vice and need.” – Voltaire
Work is of great importance to our mental health and yet the American Labor Force Participation rate is less than 60 percent. With unemployment acting as one of the greatest correlates of depression, this is terrible news for people’s mental health.
In addition, since 2000, on the whole we’ve lost 5 million jobs manufacturing jobs: Four million to automation and one million to outsourcing.
Whether it’s in automation in manufacturing, cashier-less checkout lines, out scoured call centers, or Amazon sales leading to retail apocalypse, we’re trying to do more with less, but there’s a very real human consequence to this.
Idea for Improvement: Redefine How We View Work
Currently our GDP values the work of a stay-at-home caregiver at $0. It values volunteer work at $0. It values caring for an elderly parent at $0. If we were to implement UBI, this would inherently recognize the value of these activities as work.
In addition, we ought to strive to find the sweet spot of the right amount of work. According to Adam Grant, the right amount of free time per day is 2-5 hours. The trouble is that many of us don’t have nearly enough of that, while others have far too much. If UBI we instituted, this would allow some of us to take off the gas, while also allowing others to work part time without fear of losing this benefit.
Reason 12: Income Inequality
If you were born in the 1950’s, you had a 90 percent change of doing better than your parents financially. If you were born in the 1990’s that became a 50/50 change. Now, the odds are that if you’re born today, you will likely not do as well as your parents financially.
Real wages haven’t changed in 40 years.
The average student leaves enter the work world with 38,000 in debt into a world where 40% of people with a degree are unemployed or underemployed.
America’s top 10 percent now average more than 9x as much income as the bottom 90 percent. Put another way, 400 individual Americans at the top own the wealth equivalence of 150 million Americans, or roughly half of US citizens.
If a monkey were hoarding all the bananas while others monkeys starved, we’d assume something was wrong with it. In America, we often accept this as commonplace behavior.
Idea for Improvement: Implement UBI
In case you haven’t picked up on this yet, I’m an unapologetic advocate for UBI.
UBI isn’t socialism. It’s capitalism that doesn’t start at zero.
It was advocated by Martin Luther King Jr as a means to lessen racial inequalities. Still today the average African American family has 1/10 the wealth of an average white family. UBI would help reduce this disparity.
It was advocated by conservative economist Milton Friedman who referred to it as a negative income tax. It passed the house in the Nixon years.
It was recently made popular again by presidential candidate, Andrew Yang, who was the last person of color to make the Democratic Debate Stage.
It seems as though no politician will talk about income inequality because to do so might upset their biggest donors who they relay to run campaigns. Fortunately, I’m not a politician. I’m a social worker, and as such, I recognize that those nations with the least amount of economic inequality are actually they healthiest and happiest. And personally, I’d rather be happy and healthy than rich, sick, and unhappy.
Reason 13: Dissolution of the Community
We’re facing a loneliness epidemic where we generally now have increased floor space in our homes, but fewer close friends than ever.
We now live in a time where 36% of Americans are seriously lonely as defined by feeling “frequently” or “almost all of the time” lonely.
Idea for Improvement: Reconstructing Our Lives to be More Connected
Prior to Covid, America was already the most overworked industrialized nation on earth.
According to research gather by NSA speaker, Joe Mull, the data prior to the pandemic was already startling: 76% of us worked more than 46 hours a week. We averaged 137 hrs/yr more than the Japenese, 260 hrs/yr more than the British, and 499 hrs/yr more than the French.
Globally, workers averaged 20+ paid vacation days/yr. In France & Finland, it’s 30. The average American worker gets just over 9. Yet, only 44% of Americans use all their vacation time each year. The #1 reason for not taking time away? “I’m afraid of falling behind at work.”
We don’t need another professional trainer telling us how to do self-care, we need more time to care for ourselves and spend time with our families.
We need more trust in our government and medical institutions.
We need less negative news media and more bold initiatives to take our society into the 21st century, and to once again be a leader on the world stage.
We need to rebuild our tribes and get back to defining our homes as our community and not just our households.
We need to care about those who are most vulnerable and strength them.
We need to create an America where we everyone has the opportunity to thrive and flourish.