One Suggested Approach To A Community Strategy

Perhaps, like us, you have a certain distaste when people know what will not work but do not offer their own suggestions. We have in the past, and twice recently, critiqued things that in our opinion will not work. Let us not be among those who do not offer our suggestion. Admittedly, there is not much new in our prescription. As you will see, our suggestion is to be comprehensive and persistent.

First, in general terms the efforts we have tried as a nation. Our awareness and attention to addiction is not new.  Early in our history alcohol was a  moral issue.  Temperance societies existed across the nation allying with organized religion to promote abstinence.  While the Women’s Christian Temperance Union is the most noted advocate, it was more conventional reformers who, standing on the shoulders of a long history of battling demon rum, successfully ushered in prohibition in 1919.  Prohibition was a widely recognized failure.  By some estimates more alcohol was consumed on a per capita basis in America during prohibition than any other time in the nation’s history.   

The War on Drugs started here in Kentucky with a focus on “The Cornbread Mafia”. The war on Drugs has been unsuccessful. By any measure there is more drug use now almost fifty years later, drugs are more dangerous, more money is being spent on interdiction and on incarceration than ever before. At the same time we have created a “war on drug addicts” incarcerating thousands at great expense and disproportionately people of color. Enlisting a war metaphor to address a behavioral health condition was a shaky start.

“Just Say No” was certainly a sincere effort at working on the demand side of this issue. Perhaps that is how things work in Mrs. Reagan’s Bel Air, but in most of America the draw of alcohol and drugs and the underpinnings of drug use are not the result of rational, informed decisions by the user.

The most successful approach to treatment to date has been the twelve step movement credited to Bill Wilson and Bob Smith. Bill W. and Dr. Bob started Alcoholics Anonymous in 1935 where today perhaps 2 million Americans choose from widely available meetings.  Similarly, Narcotics Anonymous reported 61,000 meetings world-wide in 2013.  Lois Wilson and Anne Smith are credited with founding Al-Anon for the families of alcoholics and today Nar-Anon exists for families of those who identify as addicts.  Despite the godsend that these communities have been for the substance use disorder, it is estimated that in the U.S. less than 10% of people with the disease achieve recovery when measured as one year without using.

The development of methadone in the 1950s began the pharmaceutical approach and has been very successful in many though not all respects. Today medically assisted treatment is in wide practice and making a very real contribution.

There have been successful approaches to other national issues outside the arena of addiction. Automobile fatalities peaked in the U.S. in 1972 at 54,589.  No one called for the prohibition of automobiles.  A combination of government, auto manufacturers and insurers, in varying degrees of willingness, introduced often innovative approaches to reduce crashes and the damage to life and limb caused by accidents.  That list would include seat belts and seat belt laws, the crackdown on driving under the influence, crash resistant glass, airbags, crumple-zoned front ends, highway surface improvements, improved road signage and striping, tire and suspension enhancements, anti-lock brakes, automatic braking, and improved vehicle chassis materials.   A key element was a change in national perception due in some part to “Unsafe At Any Speed” (Ralph Nader, 1965). Auto crash fatalities had decreased by one-third to 36,560 in 2018 despite a 15% increase in annual light vehicle sales during the period.

Another case study exists for a drug more addictive than any other and also deeply engrained in American culture - nicotine.  The case against tobacco also has a long history, is closely affiliated with religion and dates to the late 16th century and  Sir Francis Bacon. In modern times, anti-smoking campaigns began anew in the 1950s with the rediscovery of a causal link with lung cancer.  The report of the Advisory Committee to the Surgeon General in 1964 called for remedial action across society and empowered a multi-pronged approach that eventually included legislating the content of tobacco products, enforcing legal age restrictions, extraordinary State and federal taxes, smoke free zones including second hand smoke, and extensive media promotion of the scientifically proven, deleterious effects of tobacco that included warning labels.  A near national resolve to reduce the use and ill effects have reduced the percentage of smokers in the U.S. from 42% in 1965 to near 11% today with a commensurate reduction in deaths from smoking related illness. 

Surgeon General Vivek Murthy recently suggested applying the pandemic metaphor to alcohol and other drug use, abuse and addiction. This thought suggests a comprehensive, informed and persistent effort. This seems helpful to us and here are a few planks that we might include:

·       Eliminate the Stigma:  when your family member is diagnosed with cancer no one whispers that perhaps they lack moral fiber.  Why should that happen with addiction that has been defined as a disease by the medical community since 1956?  Sadly, the national consciousness retains elements of the moral underpinnings to substance use disorder.  We need to recognize addiction as a brain disease and talk about it. Certainly, there has been progress, certainly we need more;

·       Promote the Facts: our popular press, trying hard to promote the problem as important, inadvertently leads us to believe that the addict is young, dissolute, unemployed, homeless.  Yes, addiction lives under the overpass but that is about 1% of the problem.  Addiction, a brain disease, impacts residents of the richest and the poorest zip codes the same.  We know that promotion of the facts works as evidenced by our approach to nicotine;

·       Problem Screening:  reimburse primary care physicians and emergency room physicians better to screen for addiction.  In our annual well-patient visit they screen for age related, gender related diseases and they are paid for it.  Pay them in a way that encourages screening for addiction.  Current rates are not an incentive and certainly not proportional to the problem;

·       Deploy Genetic Testing: we have deployed such testing for heredity and even for dating sites, why not to screen for addictions?  Genetic testing is a probability science that is being used for diagnosis and prophylactic treatment today.  Reimburse physicians at reasonable rates (these tests can be processed for less than $100 today) and discuss genetic trait influences with all the blood relatives of addicts.  Use these tests as a means to introduce addiction as a disease instead of a lack of will power;

·       Stop the War:  it failed.  It is OK to say so.  Move on to these strategies.  Do not discontinue interdiction domestically and abroad but stop making war on people with a disease;

·       Invest in Evidence Based Treatment:  in fairness, this is happening now.  Still, however, much treatment is based on an 90 year old model of waiting until the addict “hits bottom”.  Imagine if your PSA came back with a sudden jump to 8 or your breast exam showed a suspicious lump and the doctor said, “let’s wait until this metastasizes.”  Treatment works, there are many paths, let’s research them further, refine them, discover more, promote them not abandoning twelve step approaches, and let’s have a nationally funded treatment strategy through the National Institutes for Health to do that;

·       Recognize Many Paths To Recovery: certainly the surest, safest approach is abstinence. However, not everyone gets to that point at the same pace. Further, there are those who may never get to sustained abstinence. That was recognized in the AA “bible”, Alcoholics Anonymous in 1939. Further, we treat other chronic diseases such as COPD and type 2 diabetes as chronic diseases where compliance with the best recommendations is often imperfect. Again, this does not imply abandoning abstinence as a goal for many if not most;

·       Promote Recovery Symbols:  this is more difficult than it might seem.  The traditions of AA and NA specifically admonish that “… we maintain anonymity at the level of press, radio and film” and the traditions are followed by many.  Those traditions hold, also, that AA and NA are “… a program of attraction rather than promotion…”.  Yet, there are many celebrities talking about their recovery aloud today and some even mention AA or NA.  Let’s engage twelve step communities in figuring out how to promote that treatment works including, possibly, the face of those in recovery.  We promise you that there is an admired person near you who is in recovery, and you do not know it;

·       Reimburse Practitioners Realistically But With Accountability:  in too many States and for too many payors rates are too low to adequately support treatment, adequate facilities and safe spaces.  Too many providers are self-pay only.  That provides a barrier for too many people needing treatment and creates health inequities.  Further, there are barriers in reimbursement recognition.  Policies that underfund or exclude treatment create barriers, promote the most expensive route, overlook the training, experience and expertise of addiction and drug counselors, psychologists, and family therapy professionals. Let us set realistic, evidence based approaches to treatment based on research and pay reasonable rates across payors;

·       Focus On Adolescents:  while adolescent alcohol and other drug use has declined for fifty years, still too many young people smoke, drink and try drugs while in middle school and high school not only beginning the addictive cycle but stunting brain growth.  Further, the drugs available today are more lethal than ever.  We should promote programs such as “Preventing Drug Abuse Among Children and Adolescents” developed by the National Institutes on Drug Abuse far more than we do today.  No doubt high school education has done a good job; let’s help them do more;

·       Arm Influencers: in addition to teachers and recovering people in the public domain, let’s reach out to ministers, civic leaders, elected officials and provide them with the facts and the tools they need to change the narrative.  For instance, three of the last four Presidents do not drink and one of them all but told us he considers himself to be in recovery.  News to you? We believe that public officials, ministers et al try but they do not have the information.  In many cases they are not trained in the best way to approach this advocacy.  Let’s help them;

·       Epidemiology Strategies:  public health traces back to “Typhoid Mary” and was deployed in the AIDS crisis.  Let us deploy epidemiologists to do the research, determine the “hot spots” for drugs and alcohol and target community solutions to those issues.  Why and how did Portsmouth, OH, Mud Flats, West Virginia, and Scottsburg, Indiana become addiction hot spots, what were the determinants, how did they respond, what worked, what did not, how do we deploy effective strategies to the next regions or to prevention?

·       Deploy Medically Assisted Treatment (MAT) Wisely:  no one flinches when they hear a TV commercial for “the patch” to quit smoking, or GLP-1 for obesity but discuss MAT and the reactions are wide ranging.  Yet many counselors and physicians agree that withdrawal is too often a barrier to recovery and MAT has a place in the treatment protocol.  With opioid use disorder treatment relapse exceeding 90%, traditional treatment is not working for enough of the population. Let us deploy MAT, always with counseling of some sort, and supervised.  Where pharmaceuticals are resold  to those receiving MAT, treat it as the crime that it is.  As we do this, let us revisit liability for physicians who deploy MAT the right way;

·       And speaking of prescribers, we believe that most prescribers are sincerely trying to help and are aboveboard. As we know from the sad episode with a national pharmaceutical company, that is not universally true. Where mischief happens pursue it to the maximum extent allowed;

·       Support Employers:  today only 19% of employers have comprehensive drug policies and too many are willing to look the other way in times of low unemployment or in the case of critical skills.  Let us help them by encouraging the expanded deployment of drug free workplace policies, encouraging treatment, and lowering insurance costs and liability when they do so;

·       Redefine the reason why: every system is perfectly designed to get the outcome it does. Axiomatic, certainly, but what it means is that there are “benefits” across society that result from or accept abuse and addiction for a small portion of the society. Yet, all estimates of the “cost” to our society exceed $400 billion annually. Of course, addressing substance use, abuse and addiction is a moral imperative but if that were enough, we would have solved this long ago.

These and other prescriptions can and should be done inexpensively.  Much of this has been tried to some extent. In our view, what is missing is the awareness and the will.  What is implied is focus and persistence.  We did it for automobiles, we did it for nicotine, we did it for AIDS let us go at abuse and addiction with the same resolve and the same attention.  Too simple?  Then why aren’t we doing it?

Above all, let us change the narrative.  Let us not be Mencken’s puritans but let us recognize that alcohol and drugs and enjoyment are not synonymous.  A 2017 study showed that 80% of movies depict alcohol use.  In another fashion, the “stoner” movies depict marijuana as a harmless drug that makes one humorously lovable.  This bi-directional messaging tells us that movie makers think we want to see alcohol and marijuana in regular and harmless use, but the audience then learns that these drugs are cool, reinforce the association between mind altering substances and everyday living.  Is that the narrative we want?  Thirty percent of Americans do not drink alcohol, only 15-20% use marijuana regularly, very few use narcotics.  That makes moderate to no drug use the norm not the “holier than thou” exception. 

Gene Gilchrist

November 2025