ADDICTED AMERICA: 4 Points to Ponder

My wife and I were discussing the state of affairs in America.  At least as they apply to our teenage daughters and their peers.  In addition, given my line of work, it is hard for us to have any conversation that does not circle back to drug addiction or some other type of sociological dilemma.  My wife ask a very simple, yet thought provoking question:

“Rich, if America is such a wonderful place to live with great opportunities, wealth and material possessions… why are we so addicted….why is everyone addicted to something and why are so many young people obsessed with altering their state of mind?   WHAT’S SO BAD THAT EVERYONE HAS TO ESCAPE?”  Therefore, in this post I set out to explore this issue of addicted America and the potential solutions to this ever expanding problem.

1.) Is America more addicted than the rest of the world? The short answer to this question is “YES-absolutely”.  There is no clear ranking in this area due to no universal agreement on what constitutes addiction.  However, the evidence suggests America is an over-achiever in terms of addiction.   Relative to the remainder of the world all wealthy and developed countries are more addicted than the undeveloped and poor countries of the world.  According to the U.S. News and World Report and the World Health Organization about 200 million people abuse drugs worldwide and use is much higher in richer nations.  America leads the way in certain areas such as illicit prescription drugs use (for example 80% of the worlds opioids are consumed by Americans) and Americans tend to “be more willing to try a wide variety of drugs”.  In terms of alcohol consumption we are “middle of the road” as Russia sets the standard in this area.

One thing is for sure.  The toll drug addiction is taking on America is obvious.  Overdose deaths have exploded.  When you see these statistics it certainly seems that addiction is a more significant issue in America than other parts of the world:

The World Health Organization looks at regions rather than countries.  Relative to other parts of the world North America far outranks other regions in terms of drug deaths:

An organization called World Health Rankings does assess country level data.  They found that in terms of drug deaths per 100,000 the United States is ranked third worldwide behind only Estonia and South Africa.  Therefore, I would answer yes we are living in ADDICTED AMERICA.  If you include “process addictions” such as pornography, gambling, compulsive shopping and internet gaming the issue is even more wide spread.

 

We live in a country that, on balance, is incredibly wealthy.  We are not torn apart by civil war, we have leisure time, we have access to clean water, food, and we have endless opportunities.  The issue of addiction is impacting all socio-economic classes so you can’t argue that it is poverty that accounts for these problems.  Addiction is just as likely to take out an affluent white suburban child as an inner city child.  Addiction is not relegated to any certain racial group.  It is the one unifying factor across America.  Regardless of race, political affiliation, socio-economic class we all love getting high.  Why are we so pre-occupied with altering our state of mind and changing our mood?

2.) Is America more addicted now than in the past? For centuries the current generation has suspected that the upcoming generation is going to be the downfall of society.  There is a phenomenon called intentional bias where a group can impose their version of reality onto a situation.  In this case, there is a danger that the older generation (I guess I’m part of that generation) would look fondly on the past as a kinder, gentler, more sober period of time.  Let’s take a look at the facts to see how things stand in terms of addiction.

• The war on drugs has been an abject failure: Despite aggressive policies and enforcement actions against every link in the chain of producers, distributors and users, the illicit trade has become more prolific than ever, exacting a painful toll on every area of society it touches. Over $1 trillion has been spent resulting in over 500,000 people in prison for drug offenses and an INCREASE in rates of addiction.  Well done America! (ONDCP, 2014)
• Illicit drug use in the United States has been increasing: In 2013, an estimated 24.6 million Americans aged 12 or older—9.4 percent of the population—had used an illicit drug in the past month. This number is up from 8.3 percent in 2002. The increase mostly reflects a recent rise in use of marijuana, the most commonly used illicit drug (SAMHSA, 2013)
• Marijuana use has increased since 2007.In 2013, there were 19.8 million current users—about 7.5 percent of people aged 12 or older—up from 14.5 million (5.8 percent) in 2007 (SAMHSA, 2013)
• On a positive note alcohol use has gone down. Rates of alcohol dependence/abuse declined from 2002 to 2013.In 2013, 17.3 million Americans (6.6 percent of the population) were dependent on alcohol or had problems related to their alcohol use (abuse). This is a decline from 18.1 million (or 7.7 percent) in 2002. (SAMHSA, 2013)
• However Opioid use has grown steadily year over year 1991 thru 2012:

• Heroin use, dependency and “initiates (newcomers to using heroin) has also grown year over year:

 

I would argue that the country is becoming more and more “addicted”.  Drugs are breaking through taboos and perceived risk is falling.  Heroin is very revealing in this regard as it is on the verge of becoming a mainstream drug.  The proliferation of prescription drugs and the associated issues makes it all the more challenging.  We are living in the era of ADDICTED AMERICA.

3) Why is substance misuse exploding in America at the current time? If you agree that addiction has escalated and is reaching epidemic proportions that next most logical question to ask is…why?  I can offer only my humble take on the situation.  So for your consideration I offer the following factors as coming together to form a perfect storm:

A pill for everything: Our current culture promotes a pharmaceutical solution for nearly all human conditions.  We live in a world that sends the message “take a pill for everything”… and then we are surprised when kids or young adults take pills recreationally.  Why wouldn’t they?  Prescription drugs have become a mainstream recreational option for kids who want to “party”.  Taking a pill to improve your quality of life is completely normal and promoted.  This is not to say that medication is unnecessary.  Many people need legitimate support.  However, over-prescribing is without question common practice.

I recently saw an animated commercial that depicts a woman and a giant pill with Opioid written on it.  The pill has arms and legs and can walk around with the woman. The two of them spend the day together at the park, taking art lessons, and going to the pharmacy to pick up their prescription to treat Opioid Bowel Syndrome.  I thought I was living in some alternative universe when I saw this commercial.  I could not believe my eyes.  The not so subtle message is that pills are your friend.  It’s going to be very hard to convince young people otherwise.  This is a completely different cultural norm.  As recently as 15 to 20 years ago prescription drugs were seen as being “hard” drugs.  There was a taboo around the use of prescription drugs.  Well…that ship has sailed.  Prescription pills are mainstream and viewed as safe because they “come from a doctor”.  For example, according to National Institute of Drug Abuse 27% of teens and 16% of parents think using prescription drugs to get high is safer than using “street drugs”.   Game on.

The Age of Anxiety: Anxiety has been present since the beginning of time, however, it is clear that anxiety has become a modern day plague.  There are variety of reasons for this reality.  One major contributing factor is the rise of information and the constant stream of negative outcomes lurking around the corner.  Parents can request tests for birth defects while the child is still in the womb so the worrying and waiting for results can start before birth.  The constant access to news and the sensationalized nature of the news also contributes to the information overload.  If a child is kidnapped it is broadcast over all the cable channels and parents go into lock down mode.  In the past year we were told of imminent doom.  Experts told us that Ebola was going to cause a pandemic, that ISIS was coming for us, that price of oil is too high to sustain the economy.  Now the reports are that prices for oil are too low to sustain economic growth.  Global warming is going to lead to widespread famine and destroy life on earth.  Unseasonable cold temperatures in other parts of the world are cause for a whole other set of concerns.  There was a time when there were only 3 networks and the news was only on at 6 pm.  There was not 24 hours access.  Today you can watch the play by play destruction of the world.  That’s a little anxiety producing.

A second contributor to collective anxiety is over-stimulation.  The constant     connection to technology, entertainment, and organized activities (especially for kids) leads to a packed calendar and endless to do lists.  It is very hard to “calm down” when you are continually engaged and pulled into cyber-world.  Quiet time is very difficult to come by.  In addition, social media is tailor made for superficial image driven virtual interactions that contribute to a continuous feeling of being less than.  People can easily fall into a pattern of thinking that they are not doing as well as their counterparts.  This produces social anxiety and perceived pressure to “do better”.  Add all of this up and it is easy to see that people would be attracted to the numbing effects of psycho-active substances.  Taking the edge off is more attractive than ever.

The Age of Disconnection: In his book, Bowling Alone, sociologist Robert Putnam discusses the deterioration of the American community.  His thesis is that a major demographic shift has occurred over the past 50 years and this has contributed to a major change in outlook and attitude where community is concerned.  Specifically, the “greatest generation” has died off replaced by the baby boomers, the baby busters and now the millennials.  This has contributed to a steady disinterest in the traditional institutions that held people together.  Putnam is not being negative about these generational shifts he is critical of the institutional responses to the generational shift.  There is no problem with a changing attitude, however there is a major problem when society does not adjust along with the changing attitude.  For example, the American political institutions, educational system and healthcare system has remained unchanged despite these major demographic shifts.  The last time a demographic shift of this magnitude occurred was “the Gilded Age” (1870 thru 1900) and the social problems that arose were unprecedented to that point in American history.  Rapid economic growth and industrialization lead to massive immigration and domestic relocation.  Crime, poverty, and blatant inequality carried the day.

This impact around these demographic shifts is made more significant by technology.  The way people “connect” has fundamentally changed.  Our younger generations do not know what it is like to have to find a “land line” to make a call.  They have grown up with the internet being a given, even a necessity.  Communication via text and the utilization of social media is second nature.  In addition, it is possible to be in a room with several other people and to not be there at all:

All of these factors contribute to a fractured, disconnected society.   The founding father of the functionalist perspective in sociology, Emile Durkheim, coined the term anomie to describe social disconnection.  It has been a generally accepted principle that when people feel disconnected within society problems are sure to follow. It is easy to see how a disconnected society is fertile ground for the spread of drug addiction.  Getting high is one way to cope with the void that comes along with lack of community.

The Gilded Age did not end until society developed different institutions in response to these demographic shifts.  This was the beginning of a new political structure and the age of the progressive era was ushered in.  This was also the period of time where labor unions came on the scene and community agencies such as the YMCA were established.  These were intentional efforts to change the “way things were done” to fit the reality of fundamentally different culture.  Unfortunately society has been unwilling to make a shift in response to our current dilemma.  If you drill down into drug and alcohol services you find the same fundamental organizational structures that have existed for 50 years.  There are very few innovative and culturally relevant options.

The Legalization of Marijuana: Regardless of your opinion on marijuana it is clear to see that the legalization of marijuana has created conditions ripe for the expansion of drug use overall.  Stating the obvious: legalized marijuana means more people will use the drug and, ostensibly, some of these people will develop dependency.  More people using marijuana means more people with problems related to marijuana.  I don’t know how anyone can argue that logic.  The secondary issue is that legalization of marijuana contributes to a permissive attitude toward other drugs.  For example, among young people there seems to be a steady decline in the number of drugs that are “off limits”.  I understand this is a “slippery slope” argument and I am not typically a big fan of the slippery slope argument.  However, in this case I believe we are on a slippery slope.  Perceived risk regarding marijuana is relatively non-existent among teenagers.  Everyone, (even if they don’t use marijuana) seems to think marijuana is harmless.  Why would this perception stop at marijuana?  Prescription drugs are already on the way to being considered non-threatening.  Cocaine and heroin are sure to follow.  All of this contributes to a very lax and cavalier attitude surrounding drug and alcohol use.

4)  What do we do about the addiction crisis?  The short answer is “something different”.   Let’s follow the lead of our predecessors that brought us out of the dark times of the Gilded Age and create new institutions and structures to address the addiction issue.  We need to come up with a culturally relevant response to our changing societal conditions.

We must embrace the reality of multiple pathways to recovery: According to the Partnership for Drug Free America there are around 25 million people living in recovery in America.  According to the Alcoholics Anonymous world service website there are around 2 million members WORLDWIDE.  Narcotics Anonymous doesn’t have a membership total.  NA does, however, report on total number of meetings worldwide.  If you factor in average meeting attendance you can approximate total membership.  If you are generous in terms of that average attendance you could ballpark another 1.5 million Narcotics Anonymous members.  Let’s say that these numbers are understated and for sake of argument you push the total 12-step membership to 5 million WORLDWIDE.  That means that are at least 20 million people living in recovery in America that are maintaining that recovery through some means other than 12-step meetings.  However, 95% of our rehabs are based on the 12-steps.  We need to promote and nurture alternative pathways.

We must move away from a segregated and antiquated addiction treatment system toward integration with healthcare in general: We should treat addiction like any other chronic disease.  There is no state department of diabetes.  There is no state department of heart health.  Why do addicts and alcoholics require their own separate state department?   I believe that full integration into a holistic health system is the ultimate answer in this fight against addiction.  If we make the care of substance use disorders a routine part of healthcare you will see the stigma fall and the numbers seeking recovery rise.  By the way I would make the same argument regarding mental health. I believe that mental health is closer to this being a reality than substance use disorder treatment.  Mental health services are already integrated into the larger healthcare systems in many organizations.

We must change the primary service delivery location from office based to community based: This is the most obvious adjustment.  We know that 90% of people in need of services do not access services due to denial of the problem.  We have traditionally sat back and waited for these people to show up at our clinics.  Well that is just straight silly.  The 90% non-compliance rate has not changed for 40 plus years of being studied.  It’s not going to happen.  The 90% are not coming to us…let’s go to them.  More on this in later posts.

I realize that there are people who will read these recommendations and write it off as impossible and inappropriate.  I hope that is the case because we know that when the traditional institutions push back on ideas the ideas are truly innovative.  Maybe these ideas are not the solution.  But there is one thing for sure: the current modus operandi is not the solution.  I welcome criticism and alternative ideas.  But please make sure they are NEW ideas.