By Paul M. Roman, University of Georgia
As usual, my colleagues have provided a rich offering of ideas and experience about advancing the use of pharmacotherapy in SUD treatment. These essays include some of the first empirical data on the overall subject, and we are grateful to the additional authors who shared their work for publication in The Bridge. All of this signifies progress on the path to better understanding and hopefully interventions toward increased consumer education.
My response to the concern about consumer's knowledge about pharmacotherapies is that it is part of a much larger problem of public ignorance about the treatment of substance use disorders generally, and that this ignorance stems from a lack of coordinated effort to inform the public, the allocation of essentially all of our prevention resources into a one-sided emphasis, and the near-total absence of field leadership.
Among the many "sound bites" commonly featured in the plenary sessions of conferences is the statement that only a tiny proportion of those who (through epidemiological surveys) we estimate are in need of treatment for substance use and alcohol use disorders actually seek or receive treatment. This can be a feel-good statement for service providers...we cannot even imagine the horizon of opportunity, we must demand more resources, we have charge of the nation's biggest social problem, etc., etc.
However, if the speaker then segues to the next piece of data that derives from this one, a whole different mood can take over: only a tiny proportion of those who we (the professionals) estimate through these surveys to be in need of treatment believe that they (members of the public) need treatment. This switches the feel-good into a disconnect. Are our estimates wrong? Is denial that great? (there is likely substantial acceptance of that belief!) Is the stigma of accepting the label of "needing treatment" that potent?
Or, do these responses reflect public beliefs that yes, there are a lot of people who need to do something about their use of alcohol or drugs, but it isn't "treatment" that they need.
I would assert that everyone working in some subset of the drugs and alcohol research and interventions specialties has had some version of the following experiences that I have had repeatedly: When we find ourselves in conversations with those who are not in our specialty, i.e. members of the public, they have only the vaguest and most muddled understanding of what it is that we do or that we try to do. I find that this lack of accurate or adequate information prevails regardless of social class, ethnicity, and level of education.
How can this be explained? The easiest answer is, again, "denial," namely that people don't want to know because of their own problems, or problems among their significant others that they do not want to face. A second easy answer is "stigma," namely that who wants to know about this ugly, dirty, and smelly stuff anyway, and we experts can take it and the horse we rode in on and head elsewhere. These answers can effectively close the issue to discussion, and let us hope for a better day.
On perhaps a positive side that suggests attitudes are not set in stone; it can be argued that we have no mechanism for educating the public about the treatment of substance use and alcohol use disorders. After at least 50 years of fairly steady exposure, the public has caught on to many aspects of 12-step concepts and likely in their personal lives has been exposed to someone whose attempted, ongoing, or completed recovery was facilitated by a 12-step experience. To many, 12 step approaches equal treatment. This knowledge level reflects well-established "cultural lag," where the natural diffusion of new and unusual ideas takes time. With this knowledge and associated expectations established in the general population, we can project certainly a consumer acceptance and perhaps even a consumer demand for treatment that is basically 12-step in its design, although there is a proneness to harangue the providers for their backwardness.
Other than what the mass media may decide to include in its dramatic or "informational" programming about addiction and dependence, the public receives almost no treatment education. There can be little argument with the observation that the US mass media have fully succeeded in institutionalizing the notion that no one "wants" to go to treatment, and that treatment entry is only the product of successful precipitation of a crisis. I find it difficult to argue for the effectiveness of this kind of treatment education. It clearly illustrates that "rock bottom" substance use must precede considerations of treatment, that treatment will always be resisted and dreaded, and that if a family member has a problem, prepare for war.
But where are the alternative messages? Nowhere that I know of. There is a substantial platform of funding that could support such messages, but it is used exclusively for something called prevention, and such prevention is reserved for public school students or that segment of young adults fortunate enough to go to college. Treatment is not discussed in prevention programming, and by implication, those who fail to adhere to the prevention messages and end up in need of treatment are "losers," finding themselves in the same regrettable social status of those who are the targets of "interventions" by self-anointed TV geniuses in addiction and human relations. So it seems to be of little surprise that the public is not informed about pharmacological interventions available in SUD treatment. In the contexts offered by prevention programs and by the mass media, there is little reason to expect anything good from these medications, and indeed there would be substantial reason to believe that they are in some way part of the coercive struggle.
Other diseases have advocacy organizations that advance public education. Many of these have strong bases in their respective treatment communities, and find much of their leadership from charismatic treatment professionals, usually physicians. Where is ours? While we all include in our august histories of our specialty the National Council on Alcoholism and Marty Mann's heroic efforts in its growth, we easily miss the hugely diminished status of its descendent, the broadened National Council on Alcoholism and Drug Dependence. This failure cannot be placed at the doorstep of those who have led this organization, but by the process of default whereby this specialty has been in fact led for the last 40 years by the US government. Rather than generating treatment education through grassroots interest and private organizations, perhaps funded by our treatment industry, we are dependent on someone, somewhere deciding to write a grant application to NIDA or NIAAA that someone, somewhere might like.
These observations are rooted in study of what has happened over time with the diseases of cancer and of polio, and there are a vast number of other examples of vigorous support from private sources for disease conditions affecting far fewer than those impacted by SUDs and AUDs. Perhaps the hoped-for integration of SUD treatment under the Affordable Care Act will change the constituencies of interest in the treatment of SUDs and AUDs. Unfortunately, a quick solution is not available as to how to create not only awareness of new treatments but readiness to use them.