The Substance Use Crisis in America

A Tragic Death

Phillip Seymour Hoffman was in so many ways exceptional.

And, like the character he played in Death of a Salesman, Willie Lowman, he was a man struggling with his own personal demons that led him to a tragic end.  While it may give some of us a sense of safety to believe this is a problem for celebrities or those struggling in the projects- the data indicate that while it is a problem in Hollywood and the projects- it is also a problem in each of our neighborhoods.

And from my standpoint the tragic nature of Phillip Seymour Hoffman’s death doesn’t have to do with the many accolades he rightly deserved.  Rather it is tragic because he was one of us, and like all of us- trying his best, and at times failing.  It seems even more tragic to me, perhaps because tragedies like this seem so preventable, if only we could better understand and address substance use disorders, if only we could agree on the goal and effectively use our resources efficiently in pursuit of the goal, instead of waste them in gridlock in service of politics. 

And in Mr. Hoffman’s case, here was someone with resources, someone who had been on the wagon for decades, had courageously publicly acknowledged substance use disorders, had been in drug treatment, and still met a tragic end.

Substance Statistics

Substance use disorders are a common problem in the United States.  I have seen estimates that approximately 9% of Americans have a substance abuse problem.  Drug and alcohol abuse contribute to 100,000 American deaths each year.  The Robert Wood Johnson Foundation in 2001 identified drug abuse as our number one health problem. 

While obesity and related diseases are certainly an incredible problem now, our drug issues haven’t improved much since 2001.  The economic costs are well over $400 billion each year.  While there are a staggering number of people using drugs, the vast majority never seek treatment.  Some estimates indicate that approximately 6% of alcoholics, 16% of drug users, and 22% of those abusing drugs and alcohol seek treatment- most never get professional drug treatment. 

What are the reasons for such small numbers of those struggling with substance use to utilize services?  I am sure the answer lies both with the individual and with how services are provided.  Can any society be satisfied with utilization rates that low, when the problem is so costly in terms of lives and financial costs?  This is a serious and widespread problem in our country that is costing us talent, dollars, and loved ones. 

Do we as Americans, who put people on the moon, really believe we can’t leverage the same ambition, passion, intellect, and national determination to improve our current system and the behaviors of our citizens? 

Do our attitudes about personal and societal responsibility for drug abuse support our moral goals or create barriers to progress?

Philip Seymour Hoffman

I was somewhat surprised by the discourse in the media, even the main stream media regarding Mr. Hoffman- I probably shouldn’t have been.  I read and heard so many comments along the lines of,  “How could Philip Seymour Hoffman do this to his children and partner?” 

I believe that question is a good one.  

How we answer that question is crucial in developing a more effective response to our drug problem.  Yes, how could one unless there was a level of pain so loud it could drown out the rational, responsible voices.  Or, “He must have been a selfish sociopath, without feelings for his own children. “

Unfortunately, the intention with which I inferred that kind of question may have often times been asked, was more along the lines of other comments that said things like he was prioritizing recreation over responsibility.  It was not a question in need of an accurate answer based on evidence, e.g., “Did he typically display affection and careful attention to the needs of his children, or was he more likely aloof and cold in response to their needs?”  

The conclusion was reached before the question was asked.  Or perhaps, fortunately for the person asking, he/she could not imagine a scenario by which a father could make those kinds of choices- and it was a sincere search for understanding of what to all of us seems a terrible decision and outcome that must have involved awful psychological pain.

What do we know about substance use?

Professionally and personally I have come across a few people where a particular choice to use may have been about recreation on a particular day or night over a specific responsibility.  But, in my experience, that is rarely the case of anyone who is really struggling with an opioid use disorder. 

Rather, the person is significantly suffering physical, emotional, and psychological pain and chooses to use drugs to temporarily escape, only to face the same or worse conditions again.  They aren’t turning up the volume on a stereo to make the party more fun, even if it wakes up their young children.  Rather the most ingrained way they have to escape suffering in the moment (turning down the volume on the pain), also happens to put them and their loved ones at risk for greater suffering over the long run.  Certainly the better choice in the long-term is to endure the pain (hopefully with support and coping skills) and to refrain from using, but I do not envy their situation.

I believe each adult is responsible for his or her choices.  By that I mean, he/she will have to face the consequences that follow each choice and therefore he/she is the biggest stakeholder.  I also believe that physiological and environmental experiences and consequences influence our decisions. 

Politely passing on a second helping of food is much more difficult if you are starving (physiology).  And yet, one might say, “No thank you,” if he/she expects to be beaten (environment) by a parent for rudely asking for more.   This is an extreme example, but so is heroin use.  Emotional pain and the physiological withdrawal symptoms can be excruciating and the potential consequences of use are incredibly hazardous. 

As a society, we have choices to make about environmental consequences.  We must believe our current traditional justice system has an impact on people’s choice to use drugs, otherwise why have it?  Therefore it behooves us if we are spending money to support it, to consider if it is the most effective environment (consequence) for the financial cost.

As a scientist, specifically a behaviorist, providing a jail sentence or any harsh penalty following heroin use could be acceptable to me given my goal to prevent further use, if it is effective.  In fact, I may even consider something incredibly extreme, e.g., public canings, once all other non-corporal interventions were exhausted. 

The acceptability of the consequence should largely be based on its effectiveness.  The effectiveness of a jail sentence, corporal punishment, mandatory drug treatment, or any other consequence is what matters most. The punishment should be determined by its effectiveness at reducing the behavior from occurring again.  I see the moral choice for our community as the selection of the consequence that is most successful at helping the individual from choosing what is in his/her long-term best interest the next time (and society’s). 

Selecting an intense, severe, aversive punishment can make sense if it is the mildest effective consequence at our disposal.  This is where I believe science can help in the process of following our moral compass.

Public Policy: Morality versus Science

Our beliefs about choice, substance use, and our moral beliefs about drugs likely influence what we think public policy and the legal system should be in the case of drug use.  Is free will – completely free

Does someone in the throes of a substance use disorder have the same kind of choice, or should that matter even be considered in terms of the legal consequences?

My heading Morality vs. Science is often the starting point for an unproductive discussion.  It also seems to be a common theme when it comes to drug policy in this country.  I believe whenever possible morality should be used to inform our thinking as we establish goals, and the scientific method should be used as a tool to determine the best processes to achieve those morally, value informed goals. 

Our laws and their enforcement can flow directly from that process.  Polarized sound bites may be effective political rhetoric.  But they lead to an unwillingness to consider and test new possibilities in service of reaching the best possible outcome.  They breed contempt, indifference, and stagnant ineffective systems.

When it comes to drug use, it is unlikely there will be a convergence of everyone’s moral beliefs.  There are those who prioritize freedom for adults to have ultimate liberty regarding personal behaviors that do not directly affect others and believe the individual should face the consequences without governmental intervention, no matter how dire. 

There are those who believe that each person has a moral obligation to treat his/her body as a sacred temple, and the rest of the community has an obligation to prevent an individual from doing anything harmful to him/herself.  Without question, drug use is a complex and charged issue.  Regardless of our philosophical viewpoints and the complexities of the issue, can we accept the status quo as a viable option? 

Despite the distance between the opposing factions, don’t we have a moral obligation to be engaged- to discuss, open our minds and our hearts, negotiate, compromise, and continually test and evaluate the process and the outcomes?

There is research on our traditional system, Drug Courts, and other alternative systems, e.g., Portugal’s approach.  Sometimes I like to get a sense of my own values, morals, preferences, biases, and emotions on a topic before immersing myself in the data. 

I believe that without some level of self-awareness, I may prematurely judge the information I am reviewing or even select or ignore materials based on those biases, unless I am fully aware of what I think and feel in advance.  Below are a few questions I have been asking myself- for a long time, but more frequently recently in response to the many news stories on Philip Seymour Hoffman.

If you are interested in getting a sense of what your attitudes about drug use and what possible changes to our system you may or may not consider- you could take a look at one or two of the questions below.  In order to gain insight about your answers, it may be valuable to ask yourself what values, assumptions, and inferences were important in your reasoning to respond to the question.

If you have any constructive responses or comments and are willing to share here or with your friends and family, I would be interested to see if we can have a more constructive and open dialogue on substance use for once. It may be unclear where we go from here, but simply accepting where we are seems unworkable, given what I know of most Americans’ values, goals, and beliefs.

Let’s see if our morality and science can let us hope and experiment in order to improve our world:

  1. Should all victimless crimes be legalized, e.g., gambling, prostitution, illicit drug use?
  2. Should any current victimless behaviors such as consuming excessive calories, consuming high amounts of sugar if one is diabetic, smoking cigarettes, drinking alcohol, etc. be made illegal?
  3. If I believe any of these behaviors should be illegal, what criteria should be used to establish the appropriate consequences for a violation of the law?
  4. Are there any reasons a criminal penalty should be considered for a victimless crime?
  5. While keeping in mind the actions I believe should be illegal, the penalties for those acts, and the expected effectiveness of those penalties, what role should society have in treating or providing for someone who a) is engaging in those illegal acts, e.g., illicit drug use, overeating while it is negatively affecting his/her health, gambling, etc., and is asking for help or b) is in need of medical intervention to save his/her life when he/she does not have any resources to cover the costs?
  6. What are the pros/cons the Good Samaritan Laws?
  7. If jail sentences or corporal punishment were scientifically proven to be the most effective treatment for victimless crimes, would I support either?
  8. If decriminalizing victimless crimes, drug courts, simply providing treatment, or some other alternative to incarceration, were shown to be the most cost-effective approach, would I support any or all of them?