The drug abuse problem in the United States is a product of two factors: supply and demand. Foreign suppliers see a market in the US and willing users make the import of drugs lucrative.
Among the legislative efforts to stem the tide are treatment modalities designed to help drug users with “substance abuse disorders” (SUDs) and therefore decrease the demand for illegal substances. Do these interventions work, and are they effective in the overall approach to addressing the drug problem in the US?
First, the non-monetary costs of our collective drug problem in the US. In 2020, 18.4 million Americans had illicit substance use disorder, and 92,000 died from the disease.
Direct health care costs for non-medical opioid use, driven by hospital inpatient and outpatient spending, total about $190 billion annually. Indirect tangible costs speak to productivity losses due to crime, premature death, diminished productivity (eg, from absenteeism), criminal justice expenses, public assistance programs, and many more. This category totals about $210 billion annually. Intangible costs, to my mind a hard-to-quantify figure but nevertheless real, total $1 trillion per year. These include decreased quality of life, dislocations to crime victims, and healthcare costs that accrue from medical complications of drug abuse (for instance, heart valve infections from IV drug use).
A dizzying array of interventions for those afflicted with SUD exists. These consist of individual counseling, group therapy, inpatient or residential treatment, and many more. Each may have advantages depending on the target population, but experts agree that pharmacotherapy (“medication assisted treatment”) is necessary for near and long term success. Many good studies exist to support treatment that includes a medication like methadone.
Methadone is an opioid that can suppress the craving for narcotics while not producing the “high” associated with heroin. If methadone maintenance, as opposed to continued use of, say, heroin, is part of a psychotherapeutic intervention, addicts have about a 50% better success rate at 12 months compared to interventions for addicts without use of drugs. “Success” is defined as a significant reduction in drug use as measured by frequent urine tests, decreased criminality, and higher rates of employment. Length of time on methadone maintenance is crucial—the longer the better. Also, prescribers need to know what they are doing, as methadone is a tricky drug to use and is dangerous in the hands of inexperienced providers.
There are many more interventions, a lot of them being tested today. For instance, research in high quality trials has established that providing immediate connections to an addiction medicine clinic, as opposed to merely giving contact information to needy patients, results in a 50% reduction in ER visits over 12 months for the patients who got immediate referral.
Estimated savings to society for each person effectively treated with opioid use disorder ranges from $25,000 to $105,000.
Complications in assessing effectiveness
Interpreting the above data requires care. For instance, 50% of people with serious mental health problems are illegal drug users, and 50% of illegal drug users have serious mental health problems. These patients are identified as having “dual diagnosis,” and I wonder how these people are folded into the overall stats on SUD treatment.
It is also important to appreciate competence and diversity of target groups. Just as with surgeons, some providers are better than others. I don’t know that an overall statistic about the benefit of treatment is meaningful, as differing populations probably derive differing success rates from similar interventions. Effective therapy for a white suburban population is surely different from an inner city black cohort. Nevertheless, it is obvious that effective tools are available to help most people struggling with illegal use of opioids.
Estimates of the percentage of people who need drug rehab but do not get it is as high as 90%. 30% of the US population believes that opioid addiction is untreatable, citing large rates of repeated relapse in addicts. But advocates for treatment of SUD point out that recidivism is part of treatment for drug abuse, in much the same way that people with cancer relapse, or diabetics lose control of their blood sugars. They assert that society needs to look at drug abuse as a treatable medical condition rather than a personal failing that individuals must overcome.
Given the significant resistance to the proven benefits of treatment of opioid drug abuse, more education for the general population is necessary. Effective treatment of illegal drug abuse is an important way to decrease the demand for the drugs.