“Even if you’re thirty years sober, the condition doesn’t go away.”
I first met Terrance in a secured state prison. He was nearing the end of his sentence, and I was meeting with him and his case manager before he would be released the following week.
Terrance had originally been arrested on a drug-related charge, and although he had been sober for the duration of his prison sentence, the call of his addiction was never far. Terrance’s care coordinator in the prison had reached out to us to help ensure that—once Terrance left the system—he would still remain supported.
The high cost of the War on Drugs
The War on Drugs, officially declared in the seventies, has led to the mass incarceration of individuals like Terrance. For over five decades this war has played out—always with politically charged directives but with rarely with the required focus on the individual stories of substance abuse, addiction, and the consequences of both.
Some argue that providing appropriate SUD care is too costly—a close look at the data indicates that nothing could be further from the truth.
The cost of a comprehensive approach to SUD programs that includes acute and outpatient care, Medication Assisted Treatment (MAT), and longer-term support groups is miniscule in comparison to the cost of incarceration. Data shows that the U.S. government spends an estimated $9.2 million per day on incarceration of drug offenders. In addition, the National Drug Intelligence Center estimates that drug use causes society as a whole $193 billion a year—$113 billion of which is associated with drug-related crime.
And how do we put a cost on the loss of human lives? More Americans died in 2017 of drug overdoses than the total number of casualties from the Vietnam War. Of these overdoses, 68 percent were caused by opioid abuse.
Never truly free: the chains of addiction
Roughly 65 percent of individuals in jails or prisons across the U.S. struggle with some form of addiction. Yet research conducted in 2010 by the National Center on Addiction and Substance Abuse at Columbia University suggests that only 11 percent of individuals in our criminal justice system receive any treatment for their SUD. And the trend is actually worsening— a 2019 study by the National Academy of Sciences showed that only 5 percent of inmates with opioid use disorder received specific opioid-related treatment.
This lack of treatment could be a result of the common misconception that sobriety means we’ve won the batter over addiction. In reality, the early recovery stage of addiction can last up to a year, and post-acute withdrawal symptoms (PAWS) can last even longer.
After a sober prison sentence, individuals may experience drug cravings for months or longer. This is a critical period—arguably THE critical period—in which support can translate into long-term success.
Typically, the immediate post-incarceration period results in gaps in SUD support just at the moment individuals need this support most to have any chance for a successful transition into community life. Without appropriate SUD support during this period, individuals may be momentarily free from the penal system, but they remain prisoners to their addictions—never truly being free of either the cycles of incarceration or addition.
Appropriate SUD support upon release from incarceration is critical to breaking the cycles of addiction and incarceration that permeate our society. We CAN win this war, but only by understanding and addressing these dynamics through the funding of programs that effectively provide this support.
Widening access to Medication Assisted Treatment and other SUD supports
Until the Affordable Care Act, costs associated with SUD (and behavioral health) were not supported by Medicare or Medicaid. Since then, great efforts are being made to expand the substance use disorder support available—including the decision by CMS earlier this year to reimburse the cost of approved opioid treatment programs. Still, there’s room for improvement.
Federal, state, and local governments spend a combined $74 billion annually on SUD-related court hearings, incarcerations, and paroles. Only $632 million of that money is spent on actual SUD prevention and treatment. THAT’S LESS THAN 1 PERCENT!!!
If an appropriate portion of that funding were reallocated to the actual treatment of SUD—rather than its criminalization and punishment—we could improve the care addicted individuals receive AND dramatically reduce the financial and human costs of SUD on society.
Data from the National Institute on Drug Abuse shows that every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. When healthcare-related savings such as reduced acute and ED care are also factored in, savings jump up further to $12 for every $1 spent! And—most importantly—individuals are finally getting the support they need to leave behind addiction for good.
What we can do as payers and providers?
Ideal post-incarceration SUD care involves coordinated community-wide participation. Appropriate resources for housing and post-incarceration job support yield significant dividends, and dramatically increase the success rates of SUD program efforts. Coordination with local law enforcement and corrections efforts all point to long-term community success, as do dedicated coordination between local hospitals, clinics and Emergency Medical Services.
When communities offer such a coordinated approach, care teams can assure former inmates have access to the medical care they need from day one of their new life. Indeed, when working with care coordinators in the prison system to meet with individuals like Terrance, significant work can be accomplished prior to release from incarceration. Case managers can establish a primary care provider, enroll the individual in Medicaid, and arrange transportation to and from medical appointments. In addition, we can collaborate with prison system coordinators, outside case managers, primary care providers, and MAT facilities to establish a seamless plan for recovery to support.
A collective responsibility
Providing the resources necessary to better support individuals with SUD post-incarceration is critical to breaking the cycle off addiction and incarceration—and ending this fifty-year War on Drugs. This is a shared responsibility. By placing the patient at the center of the “wheel-of-care”, we can better understand how each of us contributes in our own way as an additional spoke to support that center and keep the wheel moving forward.
Patients move forward when we bring all key parties to the table—supporting patients with our time, attention, and financial resources. As primary care providers, payers, and MAT facilities, we bring our individual spokes together to support those of behavioral health organizations, local law enforcement, and community resources offering transportation, housing, and food security. Non-profits, support groups, and employment specialists can be brought in to further support patient progress.
Together, the efforts and resources of all members work to propel patient progress and keep the wheel moving on the path to recovery.
We have to move beyond dialogues on political ideologies and improve our focus and support for patients like Terrance as they leave our prison systems. By providing him with sufficient resources– the right spokes – his wheel begins to turn. And only as Terrance’s wheel turns do we all move closer to victory in the war on addiction.
Related Reading: Eliminating Medical Bias Starts with Studying Patterns
Dr. Enrique Enguidanos has over 20 years of clinical experience in Emergency Medicine—much of which has been spent also serving in organizational and systems management roles. As CEO of Community Based Coordination Solutions and a practicing ED physician, he has spent over a decade developing and fine-tuning systems of care and community management systems that have proven very effective for frequent utilizers. He has organized these systems in a manner that allows CBCS to continuously reproduce care results across varying communities and health care systems.
This article is provided through a collaborative effort with Collective Medical.