Substance Use Disorders: A Disease or Moral Weakness?

The photo shows blurred wine bottles
Photo/Jeff Frankel

A commonly held belief is that substance use disorders (SUD) are a choice that someone is intentionally making. However, a review of the recent literature indicates that it’s imperative that we break this erroneous bias to halt, and hopefully reverse, the epidemic of substance use disorders.

The ease of access to these substances, the prescribing practices of substances by healthcare professionals, the prevailing attitude toward people with substance use disorders, the lack of compassion toward those with substance use disorders, and social acceptance surrounding the use of some substances (like alcohol, nicotine, and caffeine) have all combined with other factors to lead us down the path where substance use disorders are an epidemic health problem in the United States.

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Dealing with this issue is complex and needs a multifaceted approach starting with understanding what substance use disorders are, why they happen, breaking current bias surrounding substance use disorders, changing how patients with substance use disorders enter the health care system, increasing the availability of funds for treatment of substance use disorders, and finally, legislative and administrative process improvements that could drastically change the future of substance use disorder patients.

In healthcare, a substance is defined as any psychoactive compound with the ability to cause health and social problems.1 These may be legal or illegal and fall into one of seven categories based on their pharmacological and behavioral effects: nicotine, alcohol, cannabinoids, opioids, depressants, stimulants or hallucinogens.1 All of the previous seven categories share three characteristics: they’re widely used, using any of these substances at high doses or in inappropriate situations can cause a health or social problem – immediately or over time, and prolonged, repeated use of any of these substances at high doses and/or high frequencies can lead to substance use disorder.1

Some readers may wonder where the bias against people with substance use disorders came from. The answer is unclear, but certainly popular media plays a role. People with substance use disorders are frequently portrayed in a negative role in movies. Typically, these roles include violent people, thieves, prostitutes, drug dealers, gang members, other morally corrupt individuals, and people who are just generally weak and/or lazy.2

Among the many reasons to break the bias surrounding substance use disorders, the most tangible reason is the fact that the substance use disorder epidemic is costing American citizens more than $420 billion annually and have a financial burden on the healthcare system of over $120 billion a year.1 Those are only the monetary costs, there are significant non-monetary costs as well that range from poor health, to being alienated by family and friends, and poorer educational opportunities. Most Americans are aware of the scope and severity of the substance use disorder epidemic, particularly as it pertains to opioids.1

However, the average citizen also tends to believe that there’s no hope of correcting this spectrum of disorders because they believe that people with substance use disorders are making a conscious choice to use these substances continuously, and therefore see this as just a moral failing and a willful disregard for their own health and the health of those around them. While substance misuse is potentially a lifestyle problem, once a person has undergone the physical and chemical changes in their brain, which can happen even after just one use, and become dependent on that substance, they are no longer able to make a conscious decision to stop using the substance that they’re dependent on. This is now a person with a substance use disorder.

One of the greatest risk factors for developing a substance use disorder is adolescence.1 That’s right, being a pre-teen or teenage child is one of the biggest risk factors for developing a substance use disorder. According to one article by The Academy of Medical-Surgical Nurses, one in 10 children ages 12 and up suffer from some form of substance use disorder. This is likely because of the way the adolescent brain develops, which makes them prone to engaging in “risky behavior,” and the fact that the pre-frontal cortex is not developed enough to stop and fully consider the consequences of their decisions.14

Thankfully, two major pieces of legislation have been created to help make access to healthcare easier and more affordable for people with substance use disorders. They are the Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act (ACA) of 2010. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits.15 The ACA provides greater access to SUD treatment through major coverage expansions, regulatory changes requiring coverage of SUD treatments in existing insurance plans, and requirements for SUD treatments to be offered on par with medical and surgical procedures.

As such, the ACA allows an arsenal of tools for states to not only address use disorders for all substances, but the opioid epidemic in particular.16 Prior to these two pieces of legislation, substance use disorders were treated independently and outside of mainstream media, but many people are still unaware of them and their rights to coverage and access to medical care provided by them.

Using the administrative process to change the way we care for people with substance use disorder could rapidly, and profoundly impact the amount of care available to, and the ease of access to healthcare. According to an article by Matthew Lawrence in The Journal of Law, Medicine, and Ethics, “Care for under-treated illnesses through risk adjustment could be implemented administratively, without legislation, in federal adjustment systems: Medicare’s privatized component, Medicare’s pharmaceutical component, and the individual and small group market.”9

Now that we have at least granted them access to the healthcare system, we need to be aware that it could very well be the health care system that got them into their current predicament. A well-meaning physician may have prescribed a patient an amount of opiates for legitimate pain but may have inadvertently forgotten to advise the patient about what the medication actually does, how long it takes to work, what to do if they miss a dose, or what to do if the patient’s symptoms aren’t relieved by the medication dose prescribed. Physicians should be asking themselves and their patients whether the patient’s likelihood of dependence is overshadowed by the benefits of pain relief.10

Patients suffering from substance use disorders, in particular the ones who were led into addiction by the healthcare system, suffer from profound social inequality that leads to poor healthcare according to the Harm Reduction Coalition (n.d.a.).2 Even healthcare workers contribute to the inequality experienced by people with substance use disorder as they are also susceptible to the stigmas mentioned previously.2

Frequently, healthcare workers will attribute a patient’s complaint and reason for going to the ED or calling 911 as an attempt to obtain more narcotics. This is often referred to as “seeking.”18 The downside to this is that a negative interaction with a healthcare provider increases the likelihood that the patient will have a negative attitude toward the treatment options available to them for their problems.2

Another problem is that even if the healthcare provider doesn’t hold a negative bias toward these types of patients, it can be too emotional and uncomfortable of a topic for the healthcare provider, so they won’t bring up the topic at all.2

Research suggests that the best approach to treating these disorders and avoiding further harm to the patient from their disorder is for family and healthcare providers to have a non-judgmental attitude.2 It’s also very important to avoid using the term “addict.” Labeling someone as an addict increases their feelings of shame and further alienates the patient. This label drives patients back to the company of others who are using substances. This then increases the likelihood that they will continue to suffer from their disorder and suffer greater harm.5

Research suggests that substance use disorders are preventable through early recognition of a problem and then rapid interventions. This is especially true in the adolescent patient population.2 However, with the current stigma around substance use disorders, and the social inequality that it creates, patients with substance use disorders aren’t getting the help they need even when they do seek it.

If the family and friends of people with substance use disorders, healthcare workers and lawmakers don’t wake up to the fact that this is an epidemic disease, we will continue to alienate, shame, and fail to help these people. Letting our ignorance stop us from changing the injustices of the world is a travesty of the highest order. If we can’t be motivated to help our own families, to truly embrace the spirit of helping others, and end the bias of substance use disorders, then we have lost what it is to be human. That that is worse than any disease known to mankind.

References

1. McLellan AT. Substance Misuse and Substance use Disorders: Why do they Matter in Healthcare? Transactions of the American Clinical and Climatological Association [Internet]. 2017 [cited 2019 Nov 5];128(V. 128; 2017):112–30. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5525418/

2. Bartlett R, Brown L, Shattell M, Wright T, Lewallen L. Harm reduction: compassionate care of persons with addictions. Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses [Internet]. 2013 [cited 2019 Nov 5];22(6):349–53, 358. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4070513/

3. Grant BF, Stinson FS, Dawson DA, Chou SP, Dufour MC, Compton W, et al. Prevalence and Co-occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders. Archives of General Psychiatry [Internet]. 2004 Aug 1 [cited 2019 Nov 5];61(8):807. Available from: https://jamanetwork.com/journals/jamapsychiatry/article-abstract/482045

4. Magruder K, Elmore D, McLaughlin K, Nordanger DO, Tiegreen S, Wilson S, et al. A Public Health Approach to Trauma: Implications for Science, Practice, Policy, and the Role of ISTSS [Internet]. International Society for Traumatic Stress Studies; 2015 Mar [cited 2019 Nov 5]. Available from: https://www.istss.org/getattachment/Education-Research/White-Papers/A-Public-Health-Approach-to-Trauma/Trauma-and-PH-Task-Force-Report.pdf.aspx

5. Crapanzano K, Hammarlund R, Ahmad B, Hunsinger N, Kullar R. The association between perceived stigma and substance use disorder treatment outcomes: a review. Substance Abuse and Rehabilitation [Internet]. 2018 Dec [cited 2019 Nov 5];Volume 10(v. 10; 2019):1–12. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6311321/

6. Alderfer MA, Wiebe DJ, Hartmann DP. Social behaviour and illness information interact to influence the peer acceptance of children with chronic illness. British Journal of Health Psychology [Internet]. 2001 Sep [cited 2019 Nov 5];6(3):243–55. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1348/135910701169188

7. American Psychological Association. PsycNET [Internet]. Apa.org. 2019 [cited 2019 Nov 5]. Available from: https://psycnet.apa.org/record/2011-25014-001

8. Lawrence MJB. Regulatory Pathways to Promote Treatment for Substance Use Disorder or Other Under-Treated Conditions Using Risk Adjustment. The Journal of Law, Medicine & Ethics [Internet]. 2018 Dec [cited 2019 Nov 13];46(4):935–9. Available from: http://eds.b.ebscohost.com.libraryresources.columbiasouthern.edu/eds/detail/detail?vid=2&sid=9e983c5a-2f0a-4dd5-9e95-1d5b29006b4f%40pdc-v-sessmgr02&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=134282667&db=asn

9. Olsen Y, Sharfstein JM. Confronting the Stigma of Opioid Use Disorder—and Its Treatment. JAMA. 2014 Apr 9;311(14):1393.

10. Dowell D, Kunins HV, Farley TA. Opioid Analgesics—Risky Drugs, Not Risky Patients. JAMA [Internet]. 2013 Jun 5 [cited 2019 Aug 27];309(21):2219. Available from: http://cpsa.ca/wp-content/uploads/2015/07/opioid-analgesics.pdf

11. Gostin LO, Hodge JG, Noe SA. Reframing the Opioid Epidemic as a National Emergency. JAMA [Internet]. 2017 Oct 24 [cited 2019 May 9];318(16):1539. Available from: https://jamanetwork.com/journals/jama/article-abstract/2652445

12. Annual Reviews. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction [Internet]. Annual Reviews. 2019 [cited 2019 Nov 13]. Available from: https://www.annualreviews.org/doi/full/10.1146/annurev-publhealth-031914-122957?url_ver=Z39.88-2003%F0%9D%94%AFid=ori%3Arid%3Acrossref.org%F0%9D%94%AFdat=cr_pub%3Dpubmed&

13. Volkow ND, Collins FS. The Role of Science in Addressing the Opioid Crisis. New England Journal of Medicine [Internet]. 2017 Jul 27 [cited 2019 Nov 13];377(4):391–4. Available from: https://www.nejm.org/doi/full/10.1056/NEJMsr1706626

14. EBSCO. Caring for Families with Substance Use Disorders.: EBSCOhost [Internet]. Oclc.org. 2015 [cited 2019 Nov 14]. Available from: http://web.b.ebscohost.com.pencol.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=3&sid=19655dc2-9df0-4216-b01a-e1da765933b6%40sessionmgr102

15. Centers For Medicare and Medicaid Services. The Mental Health Parity and Addiction Equity Act (MHPAEA) | CMS [Internet]. Cms.gov. 2010 [cited 2019 Nov 20]. Available from: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet

16. Abraham AJ, Andrews CM, Grogan CM, D’Aunno T, Humphreys KN, Pollack HA, et al. The Affordable Care Act Transformation of Substance Use Disorder Treatment. American Journal of Public Health [Internet]. 2017 Jan [cited 2019 Nov 20];107(1):31–2. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5308192/

17. Taylor & Francis Group. Family-Based Interventions for Substance Use and Misuse Prevention [Internet]. Substance Use & Misuse. 2009 [cited 2019 Dec 11]. Available from: https://www.tandfonline.com/doi/abs/10.1081/JA-120024240

18. Grover C, Elder J, Close R, Curry S. How Frequently are “Classic” Drug-Seeing Behaviors used by Drug-Seeking Patients in the Emergency Department?. Western Journal of Emergency Medicine [Internet]. 2011 Dec 15 [cited 2021 Feb 18];13(5):416–21. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3556950/

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