Treating addiction has only recently become a business fueled by data. For decades, there was very little in the way of psychological study data to work with, and counselors had to play their hunches.
That’s changed, and for good reason. The more information that SUD (Substance Use Disorder) counselors have, the more effective their interventions can be. Evidence-based practices are the core of the curriculum you will find in every substance abuse counseling degree, at every level, anywhere in the country.
So there was a great deal of hope in the addiction treatment world when the National Institutes of Health announced in 2018 that they were allocating almost $343 million toward the HEALing Communities Study.
Spread across four states hardest hit by the opioid epidemic, the study went in-depth in 67 different communities backed by elite research universities in the SUD world like Columbia and The Ohio State University. The goal was to determine the effects of data-driven interventions pitting a committed, community-based public health intervention in the crisis versus business as usual.
HEALing Communities was the largest addiction prevention and treatment study ever conducted. It promised, and delivered, a wealth of new information on the impacts of community-driven substance abuse treatment across a range of demographics.
When the results of the study were published in the New England Journal of Medicine in June of 2024, however, the results weren’t what anyone had hoped for.
What if Everything Counselors Are Taught About Inclusion in Drug Addiction Treatment Is Wrong?
Researchers found that there was basically no difference in opioid-related overdose deaths between the control communities and those that went through the data-driven intervention process. In other words, all the hard effort didn’t pay off:
- Developing community coalitions
- Conducting overdose education
- Distributing naloxone
- Creating training guidelines for interventions
- Offering medication assisted treatment
This is all textbook stuff, right out of any addiction counseling degree program you care to pick. It all resulted in the same depressing number of deaths as doing nothing different at all.
The target reduction rate for overdose deaths in some states was 40 percent, but ended up at less than half that number.
To be sure, the data developed over the broad-spectrum study is valuable stuff for both policy-makers and on-the-street addiction counselors. It’s going to fuel valuable new investigations for decades. Unfortunately, it’s in the form of a negative result, a path not to follow.
It’s true that researchers estimated some 483 deaths were prevented through intervention—not enough to be statistically significant, but real lives saved.
That’s nothing to sneeze at. But in a world where making economic investments in treatment means a trade-off between depth and breadth, the correct question to ask is whether the same money and effort could have been used to save more.
It’s Uncertain What the Exact Factors Were That Derailed HEALing Communities
As with most real-world studies, there are plenty of reasons that the interventions might not have succeeded. The skyrocketing rates of fentanyl on the streets during the period of the study might have been one of them—low-dose intranasal naloxone is a miracle counter for heroin overdoses, but against potent lab-made fentanyl, it’s not as effective.
The study period also may have been too short for the long-term objective of medicated opioid addiction treatment. It can take years of methadone therapy to truly get addicts past the greatest risks of relapse. Two years of observation might not have seen the full benefits of that approach.
But some people are calling into question the essential premise of a strategy that is built around harm reduction and de-stigmatization.
Stigmatization Was a Big Part of How America Triumphed Over Nicotine Addiction
An article in Psychology Today throws out an interesting point of comparison between today’s fight against illicit opioid use and the historic prevalence of nicotine abuse.
Nearly half of all American adults were cigarette smokers in the 1960s. As of the CDC’s 2019 National Survey on Drug Use and Health, that number was below 20 percent, and continuing to fall on a steady trend line down. It’s an unqualified success in fighting addiction and saving lives.
Around 12% of American adults smoke cigarettes today, compared to around 50% in 1965.
The path to reducing nicotine addiction didn’t run through harm reduction strategies and new treatments, however. It took a concerted effort to stigmatize smoking and, by extension, smokers, to drive down demand and reduce nicotine and tobacco use.
It’s a great victory in American addiction treatment, but it came with an explicit social cost. Cigarette smokers came to be seen as second-class citizens, barred from social spaces, sneered at by restaurant patrons, resented by co-workers. They felt ostracized, segregated, and looked down upon.
There are real mental health consequences that come with those social perspectives. Yet, as with any social norm, there’s also additional motivation to conform. Some studies correlate stigma with increased attempts to quit; others show greater stigma increased cessation care from medical providers and social support for those in recovery.
Are lives saved from reductions in lung cancer worth ostracizing tobacco users?
It raises an interesting question: has the rush to de-stigmatize addiction to get opioid addicts into treatment inadvertently lowered the social bar for becoming addicted to opioids in the first place?
Untangling the Reasons People and Communities Recover From Drug Epidemics
Nicotine is as addictive as heroin and barriers to acquiring a dependency were all but nonexistent.
But because cigarette sales were legal and consumption open, there were also easier paths to regulation than there are with illicit opioids today. It’s also the case that tobacco production and distribution was centralized and organized, with large companies that could be targeted for legal action.
While opioid distributors are certainly the targets of legal action today, the process isn’t nearly as easy or effective as pursuing a Fortune 500 company.
The actual campaign that took smoking from cultural habit to social faux pas was long and complex. In fact, in terms of the timeline involved, there’s still room for the fight against opioid addiction to outpace the decline of nicotine consumption. It took around 40 years for smoking rates to decline by half; we’ve only been into the opioid epidemic for around 25 so far.
But studies have shown that the stigmatization of tobacco use played an important role in the success of that campaign.
It even suggests that ongoing disparities in tobacco use between White populations and Black and Latino groups may tie back to lower levels of stigmatization in those populations… a conclusion that might strike many modern addiction counselors are almost entirely contradictory to their training.
How Much Stigma Is Too Much Stigma in Substance Use Disorders?
You can certainly make the argument that people addicted to opioids and other hard drugs already face plenty of stigmatization in American culture. In fact, the prevailing view today is that such stigmas are a serious barrier to treatment.
The modern recognition of addiction as a kind of chronic disorder has gone a long way toward developing humane, compassionate treatment methods. But maybe it hasn’t gone far enough in making opioid consumption an unacceptable social choice.
The reality of opioid use is no more glamorous than the reality of smoking cigarettes. Yet it’s a fine line between stigmatizing opioid use and stigmatizing addicts.
Smokers are smokers, but opioid addicts have become people experiencing opioid addiction. Does the language influence acceptance of more than the person?
It’s certainly the case that stigma against opioid addicts at the macro or mezzo levels can reduce funding, de-prioritize assistance policy, and reduce options for treatment.
Yet it’s less clear that stigma at the micro, or personal, level is equally counterproductive. And, if the campaign against smoking is any indicator, it could even be motivational.
These are not questions that many modern researchers in addiction science are eager to confront or unpack. PsyD and PhD in Addiction Science students aren’t lining up to look at the impacts of making opioid users feel worse about their habit. Yet they may be important for developing a truly effective broad-spectrum campaign against opioid addiction… one that could be as effective as the one against smoking.