Editorial Comment:  Susceptible populations

Two of the articles discussed relate directly to the US incarcerated population.  This invites commentary on how we may best serve them. Citizens and former citizens in our prisons exceed 2.3 million in 2019, with 11 million spending some time in jails over the year. Of these, a reliable estimate of those with substance use disorders still wants determining but certainly exceeds 50%. As Richard Rawson has separately noted, we don’t actually know the true number other than it is bound to be greater. This is in any case a point prevalence rather than a lifetime one.  An enormous opportunity is missed, or inadequately exploited, as this huge population transits the criminal justice system. Images of World War Z are conjured.  For the moment, we are still at a stage of considering how best to use – and pay for - the available medications for management of substance use disorders, focusing mainly on those suitable for opioid diagnoses. And even this sidesteps the treatment needs of the other addiction sub-populations: those with alcohol use disorder are a focus of attention only on admission, when they require withdrawal management; evidence-based treatment is normally not considered after that phase, though involvement of Alcoholics Anonymous H&I Committees may be invited. Just so, those with sedative-hypnotic disorders, stimulant use disorders involving cocaine or methamphetamine, inhalant use disorders, etc., are perceived as having no treatment need as long as they are isolated from the drug of choice.

I suspect that this readership knows all of the above, already, but it is an important preface to this contention: I ask that we give greatest attention to the susceptible populations who are most visible, and for whom easy access would seem to favor easy interventions:  Native Americans living on native homelands and reservations; military personnel and veterans (whose likelihood is enhanced by higher rates of patrilineal substance misuse); and as already noted, prison inmates.  This is neither a novel observation nor a novel intervention; many who are dedicated and deeply knowledgeable, lay and professional, have given themselves to this need. But what may be needed is a matter of scale: a big intervention, and one not limited to a single drug class, nor relying on a one-trick pony to resolve.  

If a public health model requires attention to all orders of prevention, from prevention to interdiction to control, then we can do much of what is needed by limiting the pass-through of these illnesses.  We know, in a very real sense, that these are contagious illnesses.  Using the same public health overview, we can diminish the damage by 1) reduction of infection by the agents of the illness (the substances), 2) reduction in susceptibility (primarily educational interventions but especially genetic susceptibility counseling and refusal skills training), 3) reduction in the prevalence of the illness by prompt treatment. This last one has more impact than one might imagine; because the humans are the intermediate hosts, most substance use disorders arise out of induction, whether by family or friends. Until the child or young adult is introduced of the substance, they would have no particular reason to imagine, seek, and  use a substance.

What is the foundation for such a focused effort? All the recent discussion of immunization and herd immunity demands that similar attention be given to such a concept: that by reducing the total number of those with substance use disorders you improve the general health of the surrounding population; who are thereby neither induced to use substances, nor whose use is reinforced by those with addictions.  Were I Master of the Universe (maybe with abbreviated powers), those three populations are where I would start; and if the only one of them in whom large-scale recovery could be achieved was the prison inmates, what wonderful consequences in social order, health, and happiness would follow.

- William Haning, MD, DFAPA, DFASAM

(For more on the Humane Health Care act, see:  https://www.asam.org/docs/default-source/advocacy/letters-and-comments/final-support-letter-for-humane-correctional-health-care-act.pdf?sfvrsn=6d314dc2_2 .

For more on the Inmate Medicaid/Medicare Exclusion, see:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5296706/  - WFH)