Seeing these photos and reading the accompanying stories online, I was inspired by the celebration of cancer survival. And it made me look forward to a time when we might a see a similar article, celebrating people in recovery from substance abuse.

Today, there’s a stigma associated with addiction that makes articles featuring those in recovery few and far between. But if the history of cancer is any indication, I am optimistic that this may change. With all the pink ribbons and walks for the cause, we often forget that not too long ago, cancer was heavily stigmatized. In the early 70s, when my grandfather was diagnosed, I remember my relatives discussing his condition in whispers. The word “cancer” was something you could only say in a hushed tone. This changed when doctors developed effective cancer treatments and a greater percentage of people survived. Consequently, the public perception of cancer changed from a death sentence to an illness that could be controlled and—in many cases—conquered.

Similarly, while it has not disappeared, the stigma of AIDS is nowhere near what it was in the 1980s. This is, in large part, due to the development of anti-retroviral treatments, which slow the progress of HIV and allow those with HIV to lead productive and satisfying lives.

As with cancer, AIDS, and other chronic illnesses, I believe we’ll see the stigma of substance abuse decrease when the public recognizes that we have effective treatment. Scientists have suggested that public opinion shifts when thirty percent of those who need treatment receive it. We have a long way to go on that front, given that 25 million Americans meet criteria for substance abuse, but only 2.3 million receive treatment. However, with healthcare reform making it possible for many more people to get the help they need, I am confident that we’ll see that gap shrink in the next three to five years.

As more men, women, and young people receive successful substance abuse treatment, I foresee greater understanding that addiction is a chronic illness—but the future for those struggling with this disease is far from hopeless. Like cancer survivors, people in recovery can go on to lead productive, rewarding lives. As a treatment professional—and especially, as someone in long-term recovery—I know that this true. Since entering treatment 27 years ago, I have accomplished goals that I never imagined possible.

My story is not unique. I invite you to share your own journey in the comments section below. How has recovery changed your life?

Deni Carise, Ph.D.
Chief Clinical Officer, Phoenix House
Adjunct Clinical Professor, University of Pennsylvania
Senior Scientist, Treatment Research Institute

Speaking to reporters from American media outlets in Mexico City—the capital of a country wracked by drug-related violence—Mrs. Obama acknowledged that warning our kids to “just say no” isn’t enough to halt the spread of illicit drug use and trafficking.

“If young people don’t have an alternative in their lives, they’re going to choose drugs, they’re going to choose the drug trade,” she said. “My experience shows that young people will make different decisions if they have better opportunities.”

Mrs. Obama’s comments were dead on. We need to give kids the opportunities for success that they deserve—and this means changing the lopsided spending of federal and state dollars on the consequences of addiction, rather than on education, prevention, and treatment. According to the CASA report “Shoveling Up II,” in 2005, federal, state, and local spending as a result of substance abuse and addiction was $467.7 billion. Of this whopping figure, more than 95 percent of these taxpayer dollars went toward the medical, public safety, criminal justice, and other costs of addiction—with less than two percent allocated to treating and preventing it.

Among other products of this misguided strategy is a sprawling, overcrowded prison system. Of the 2.3 million inmates crowding America’s prisons and jails, 85 percent meet criteria for substance abuse or have a history of it. Illicit drugs are implicated in three quarters of all incarcerations. In 2005, federal, state, and local governments spent $74 billion on imprisonment, court proceedings, probation, and parole for adult and juvenile drug offenders. Not surprisingly, because less than one percent of this funding went to providing treatment, inmates with substance abuse problems were more likely to land in prison a second time.

If we want to end this vicious cycle for the next generation, we need to redirect public dollars so that fewer young people choose drugs in the first place. It is inmates who struggle with substance abuse who are most likely to have begun their criminal careers at an early age. For this reason, investment in education and prevention is crucial. Research has shown that a high quality early education can have a huge impact on a child’s success. One study of disadvantaged children found that participation in pre-k dramatically reduced juvenile and adult crime later in life, with a benefit cost-ratio of 16 to 1. Many states are recognizing that funding early education can lower prison costs down the line.

Of equal importance is ensuring that those who do get into trouble with drugs receive the help they need. Today, only 11 percent of all inmates with drug problems receive treatment. CASA researchers found that if our country provided treatment to every inmate who needed it—and just over ten percent stayed sober, crime free, and employed—we’d break even in a year.

I am pleased that the Office of National Drug Control Policy is aware of this need to re-think our nation’s drug strategy. And I’m especially grateful to Mrs. Obama for her willingness to engage in the public debate. As advocates for drug reform, we need more leaders like her to step up and speak out about this critical issue. Only then can we hope for meaningful change.

Howard P. Meitiner
President and CEO, Phoenix House

No doubt, the changes will be profound.  But, the question I and many others in the field have been pondering is, How will healthcare reform impact substance abuse treatment and the way we deliver care? 

We know that in any given year, about 2.3 million Americans receive treatment in our substance abuse “specialty care” treatment system.  However, according to the latest National Survey on Drug Use and Health, 25 million meet criteria for Substance Use Disorders (SUDs).  One of the primary reasons why more than 90 percent of those who could benefit from treatment don’t receive it is that they lack insurance or other means to pay. Now that an estimated 95 percent of the country’s legal population will have healthcare coverage—and, thanks to the Wellstone/Domenici Parity Act, insurers who cover substance abuse treatment must do so at the same level of benefit they provide for other medical conditions—we’re likely to see a marked increase in the number of people seeking help.  But insured patients want to make choices.  So, how will our field adapt to meet their needs?

With parity and healthcare reform bringing substance abuse treatment into the realm of general medical care, one crucial priority is to develop partnerships with medical organizations.  In the years to come, hospitals, doctor’s offices, and, in particular, Federally Qualified Health Centers will be the entrées to reaching new populations that we may never have been able to reach in the specialty care system.  This will also give us the opportunity to deliver new services such as brief treatments, behavioral interventions, and, for those who need specialty care, to provide appropriate referrals.

These referrals are likely to include individuals who have drug or alcohol problems, but who are not acutely ill.  Therefore, another priority for our field is the development of a workforce that can serve these new types of clients.  Currently, clients come into treatment via an extensive intake process and enter a highly structured, abstinence-oriented program.  These procedures may not be effective or tolerable for a client who is not severely dependent, a person who is not yet ready to become abstinent, or someone in recovery seeking support during a particularly stressful time.  As we encounter clients with less severe drug use, we must have the capacity to deliver appropriate interventions—including Screening, Brief Intervention, and Referral to Treatment (SBIRT)—both on our own and through our medical partners.

In addition to developing the workforce to treat new clients and expanding our range of services, agencies will need an administrative staff that can process Medicaid and private insurance reimbursements for all treatment modalities.  Currently, the majority of agencies do not bill Medicaid or private insurance. Smaller providers and those who do not have capacity to bill insurance may have to expand or partner with others who can perform this function.

These are just a few of the many adjustments we’ll need to make in order to maximize our potential in this era of change. But, while change isn’t easy, I have never been more optimistic about the future of our field.  The Parity Act and healthcare reform bill reflect an understanding that addiction is a disease and that those struggling with this chronic condition deserve effective treatment as part of their regular healthcare. With greater access to the services we provide, we may eventually close the gap between the many men, women, and adolescents who need our help—and the few who receive it.

For too long, the 1986 legislation on cocaine sentencing has perpetuated a distortion that crack cocaine is more addictive and harmful than its powder form. And therefore, many alleged, those involved with crack are more likely to act compulsively and commit violent crimes. We now know this to be a myth. True, crack cocaine and powder cocaine are administered differently—and the way they’re prepared impacts the speed of effect—but in essence, they are the same drug. Five grams of crack, approximately one-fifth of an ounce, is in no way equal to 500 grams of powder, which is over a pound.

What has been the ugly reality of this misguided law? For more than two decades, drug users have been arrested with many times more than five grams of powder cocaine and received a less Draconian sentence than those in possession of five grams of crack. This inequity has had a profound impact on inner-city African American communities where crack is more prevalent. As a New York Times blog points out, eight out of 10 crack cocaine defendants are African American, while almost two-thirds of powder cocaine defendants are white.

I can’t argue that some bad people with major criminal intent and affiliation have been apprehended since the law took effect. But the vast majority of those who have been sentenced were not involved with serious criminal activity; in fact, most were using low-level street dealers, not major traffickers. And, in addition to crack defendants themselves, far too many mothers, wives, and friends—who may have had the drug user’s crack stored in their homes—have been charged with conspiracy and brought under this drastic, unfair sentencing net.

As lawmakers in Washington have acknowledged, the new bill is far from perfect. It reduces the discrepancy by raising the amount for minimum mandatory sentencing from five grams of crack cocaine to 28 grams—versus 500 grams of powder cocaine. This is still an inequity of gross proportions. If three friends decided to binge over the weekend, they could consume 28 grams of cocaine—even if it were crack—by Sunday night. Five hundred grams, on the other hand, is enough to keep them high for more than a month—if they didn’t first become paranoid, act out of control, or pass out.

However, while it’s far from appropriate legislation, it will offer some relief to those facing charges in the future. But the bottom line is that prison doesn’t stem the tide of substance abuse. It may de-incentivize minor dealers, but for the average drug user, we as treatment professionals know that it doesn’t change addictive behavior. The more we spread the word that those struggling with the chronic disease of addiction deserve treatment and not jail, the closer we may get to real progress.

A recent study by CASA, Columbia University’s National Center on Addiction and Substance Abuse, found federal and state spending on health care for drug, alcohol and tobacco abusers totaled more than $200 billion a year. A fraction of this money goes to treating addiction and promoting recovery, while the lion’s share is swallowed up by treatment of the many acute and life-threatening conditions caused by the disease. A federal study found 1 out of 14 hospitals stays each year — which account for 2.3 million admissions — are directly related to drug or alcohol abuse alone. 

Not only are substance abusers costly health care consumers, so are their children. One study found children of cocaine users incurred three times the health care costs as children of non-using parents. Another study, examining neonatal health care costs in one hospital, found that costs for newborns of women who had used cocaine during their pregnancies averaged $5,200 more than costs for infants who had not been exposed to the drug.

 Suppose we addressed the cause rather than the effect and invested in appropriate addiction treatment for the estimated 23.3 million substance abusers who need treatment but don’t receive it – and whose addiction will ultimately cost us more?  We now have a wealth of proven, evidence-based programs and practices that deal with substance abuse as the chronic condition it is. Can they bring down the cost of health care? 

They can and they have.

 A California study found that the total medical costs for men who received substance abuse treatment dropped 26 percent, while their in-patient hospital costs and emergency room bills came down by 35 and 40 percent, respectively.   

With substance abusers making up about one eighth of the nation’s Medicaid population, it seems logical to increase what we spent treating the disease, and, in so doing, reduce the enormous economic burden of treating the symptoms.