Substance Use(r) Treatment and Health Disparities: Some Considerations or An Askance Look at Institutionalized Substance Use(r) Intervention Disparities

Abstract

It is necessary to consider substance user treatment and derived health disparities in terms of: historical perspectives, stereotyping and “homogenization”; mystification; institutionalized disinformation; institutional myopia; institutionally created and maintained paradoxes; organizational, systemic, and human failure; the status of facts; environmental considerations; conceptual masking and overloading; fictions and fantasies; policy models and policy perversion; resource ignorance; slogans; de facto realities; the phenomenon of “lifeless lucidity” when statistical significance is not matched by substantive significance, problem definitions, and current unresolved critical issues that merit attention. The article's central thesis is that substance user treatment failure and derived health disparities are built into this complex, chaotic, nonlinear, multidimensional, highly politicalized, arbitrary, but institutionalized and “ghettoized” field that is also faulted by human, systemic, and organizational errors and that is removed from the “normed,” mainstream of intervention and innovation.

Keywords:

• accountability
• availability
• collaboration
• complicated
• complex
• diagnosis
• disease
• ethical
• health
• health parities
• health disparities
• iatrogenic failure
• de facto reality
• information
• knowledge
• linear
• nonlinear
• “normed” disease
• “normed” treatment sites
• opportunity-driven
• relapse
• solution matrix
• substance user treatment
• “tame” problems
• treatment
• treatment availability
• treatment accessibility
• treatment beneficence
• treatment culture
• treatment malfeasance
• treatment matching
• treatment disparities
• “wicked” problems

Notes

Notes

1. Treatment can be briefly and usefully defined as a planned, goal-directed change process, which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual help–based (AA, NA, etc.) and self-help (“natural recovery”) models. These are not semantic issues. They are associated with policy, organizational, and ethical issues for and by individual and systemic stakeholders representing micro- to macro levels of program planning, implementation, and assessment. There are no unique models or techniques used with substance users—of whatever types—that are not also used with non-substance users. Drug treatment, alcohol treatment, terms that are used in abundance, do not exist in a treatment reality. They are amusing when visualized. So … I have included both at the beginning of this article—Figure 1—to amuse you, the reader and to warm you up for the trek/pilgrimage through what is being posited. This graphic interpretation of my free association was created by Ms. Shirly Levy-Aldema, who continues to “visualize” the concepts that I bring to her. Many thanks. Figure 2 is a well known illustration (see Jastrow).

2. “Health is a state of complete physical, mental and social well-being and not merely the absence of disease.” (World Health Organization: Introduction to Constitution, 1985, p. 34). The WHO defines QOL as ‘an individual's perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns’ (WHOQOL Group, 1994).

3. This article is a relatively brief summary of a long-ish PowerPoint presentation presented at this meeting and two quite long papers, each with many graphics, which the interested reader can receive by e-mailing the author: [email protected]

4. The newer artificial science and their paradigms (based upon chaos, uncertainty, and complexity theories) have posited that prediction and control have different meanings and dimensions than they do in the more traditional linear cause and effect paradigms. See “Artificial Neural Networks,” by M. Buscema, 1998, Substance Use & Misuse, 33 (1–3).

5. Horst Rittel has suggested that problems can and should be usefully categorized into two types: “tame” problems and “wicked” problems. The former are solved in a traditional known and tried “waterfall paradigm”: gather data, analyze data, formulate solution, implement solution. The latter wicked problems can only be responded to individually, each time anew, with no ultimate, repeatable solution. This distinction, regarding a taxonomy of problems, has yet to be considered in terms of its utility, demands, and implications for substance use treatment and prevention programs and processes. (The Institute of Urban and Regional Development, University of California, Berkeley, California, email: [email protected])

6. Complicated and complex are often confused and used interchangeably. They are quite different in their essence. We need to be sensitive to their distinctions particularly when we “medicalize” and “pathologize” people, their behavior, and their lifestyles. A complicated system is a combination of many units, each maintaining its identity along the way and outside of the system. Consider a screw in a 747 jumbo jet. If you modify the screw a little bit, the system will not work; complications will occur. In a complex system, each component changes, over time, losing its identity outside of the system; caterpillar ↔ cocoon ↔ butterfly ↔ egg ↔

7. With the relatively recent pathologizing and medicalizing of drug use (substance use disorder), there may also be an advantage to medicalizing this possible impairment as either being a beneficence disorder or perhaps even a malfeasance disorder, depending upon one's orientation.

8. What follows is a brief summary of a lengthy chapter that explores ethical challenges to “drug user” treatment (Einstein, 2005). Einstein, S. Drug users can't be treated, people can be! The creation and maintenance of ethical travesties, or at least dilemmas in Kleinig, J. and Einstein, S. (eds.) 2006, Ethical challenges for intervening in drug use: Policy, research and treatment IssuesOICJ, Huntsville TX, (2006)

9. “Substance use disorder” is a new diagnosis created by a committee of medical experts and published in the DSM-IV in 1994 by the American Psychiatric Association (Eistein, 2006). The APA's previous psychiatric diagnostic manual was used to diagnose the heterogeneous group of substance users as manifesting a full range of psychiatric diagnoses. Now that we have SUD, we also have “dual diagnosis”. Is the treated drug user any better off? Has SUD resulted in better health and treatment parity for those who manifest it?

10. There are many disease models, not just one. These include, among others, biochemical-based models, actuarial, functional, experiential, social, political, religious-spirit-animisim, economic, and consumer-based models. Each has its own critical definitions, criteria, goals and agendas, constituencies, indicated and contra-indicated techniques and services, “healers” and change agents, preferred sites for intervention, temporal parameters and stakeholders, unique ethical associated issues, as well as normed and non-normed statuses. Substance use, and users, have generally been classified as being part of a social disease nosology along with a range of other deviant behaviors. Substance users, who represent a broad, heterogeneous population can and do manifest actuarial, functional, experiential, and self-defined diseases.

11. It is useful to remember that from a scientific perspective a “drug” is any active chemical that affects the structure and/or functioning of any living organism. Using this definition, how many non-drug users do you know?

12. Consider selecting giving up the use of a substance that is important to you, or an activity to which you are addicted for one week—beginning now. Record your thoughts, behavior, and feelings in a diary as you “abstain,” as well as the behaviors of those around you who are aware of what you are doing. Are they helpful to you or not? I have been using this exercise for 40 years with students, therapists from various disciplines whom I supervise, and policy-makers in workshops in the United States, Europe, Asia, Australia, and Israel. I can count on both hands—and not use all of my fingers—how many people have chosen to continue this exercise for a week's time as well as how many have “succeeded.” Why, indeed, should they? Just because a teacher, supervisor, etc., asked you to do so?

13. Being a substance user, of various types, is a “job” in which one generally “works” more than the hours of the salaried and employed with none of the employment benefits and that demands many skills and abilities.

14. The Buddhists remind us: “Fall down 7 times, get up 8 times, that is the road to perfection.” We all learned to walk by falling many, many times. One trial learning of complex behaviors—holding in abeyance lifestyle changes—is a rare outcome in humans.

15. The cyberneticist Heinz Von Foerster posited that there are two types of questions: illegitimate questions and legitimate questions. The former are those for which the answer is not known. An illegitimate question is one for which the answer is known (see “Doomsday; Friday, 13 November, A.D., 2026,” by H. Von Foerster, P. M. Mora, and L. W. Amiot, 1960, Science, 132, pp. 1291–1295).

16. Research welfarism is an ongoing phenomenon in which substance use(r) researchers and other intervention-treatment-change agents and agencies continue to be publicly funded can and do document important generalizable findings and report them through a range of public and professional media and forums. All too often these findings are not used as the broader intervention field continues with its institutionalized traditions while being aware of the findings or protecting itself from them. With sufficient reporting, the right connections, and a viable research design, the researchers and others can and generally are refunded. This can and does limit the burden of the welfare system for researchers if not for the object of their research.