Competing Ideologies: The Quest for a Consensus on SUD Outcomes

Let’s reflect on how complicated substance use disorder (SUD) is, and even more so, the complexities of agreeing on solutions to SUD. This complexity is not just medical; it is deeply embedded in the ways our society perceives and reacts to SUDs and their treatment. The lack of consensus around definitions of success and desired outcomes in solving SUD highlights the complex, multifaceted nature of addiction.

This blog post describes the four, often conflicting, ideological categories that many of our current solutions to SUD fall into, and how each of these ideologies determines our measures for success.

Forces of Capitalism: Finance-centric Outcomes

Capitalists value monetary gain.

• Legislature: In a society leaning toward capitalism, legislators often define SUD success in terms of increasing reemployment rates and returning individuals to the workforce, with a focus on outcomes that reduce societal costs through the criminal justice and health care systems.
• Commercial and venture capitalist-owned health care organizations: For-profit hospitals, clinics and other health care facilities often prioritize outcome measures that reduce length of stays, accelerate discharge and turnaround, and minimize resource use, favoring treatments that show quick, tangible results and have lower upfront costs.
• Health insurance organizations: Payers will prioritize cost-effective and efficient solutions, focusing on strategies that reduce payouts and long-term financial liability, such as lower-cost treatments and those that reduce readmission and relapse rates or the need for long-term care.

The health care system shows a clear tension between capitalist motives and humanitarian values. This is reflected in the simultaneous implementation of value-based payment (VBP) programs — aimed at cutting health care costs and “improving” patient outcomes — with patient-centered care approaches emphasizing the importance of patient preferences in all aspects of care. Presently, even when a patient’s personal goal is substance use moderation, health care payers perceive any outcome other than abstinence as a failure to deliver value, resulting in financial penalties for the attending providers.

Forces of Humanitarianism: Person-centric Outcomes

Humanitarians value human welfare and prioritize the intrinsic importance of every human life.

• Harm reductionists: Advocates emphasize the human aspect, valuing love, acceptance and care for individuals regardless of their substance use. The harm reduction approach aims to foster positive change, empowering individuals and families to build toward healthy, self-directed lives. Outcome measures for success include assessments of wellbeing, happiness, health and purpose.

• Nonprofit advocacy organizations: Grassroots and philanthropic advocacy organizations typically measure success through quality-of-life (QOL) indicators, gauging success by enhancements in social connections, emotional wellbeing, financial stability, educational opportunities, access to clean living environments and overall life satisfaction.

Forces of Utilitarianism: Population-centric Outcomes

Utilitarians value the maximization of overall benefit or wellbeing for the greatest number of people, emphasizing the beneficial outcomes or consequences for the majority of a population.

• Medical providers: The medical community may judge success in terms of the overall effectiveness of a treatment and the wellbeing of their patient populations, valuing outcome measures of substance use rates, treatment adherence and completion, decreased drug-related crises and hospitalizations, lower relapse rates, patient satisfaction and increased access to and utilization of services.
• Criminal justice professionals: From police to prison officials, punitive approaches such as incarceration can be considered a utilitarian solution that seeks to solve SUD through national systems of deterrence and negative reinforcement. Outcome measures prioritized include the number of individuals prosecuted and removed from society (i.e., incarcerated) and overall drug-related crime rates. Underlying this solution is the assumption that negative reinforcement and deterrence tactics work at a population level. (We will refrain from discussing the harm, inequities and discrimination resulting from the pursuit of this category of outcomes.)
• Federal health agencies: Bodies such as the Centers for Disease Control and Prevention or the National Institutes of Health will prioritize population-level outcome measures such as rates of alcohol and other drug use, drug-related crime, death and disease rates, access to treatment, public awareness, levels of equity and transparency across systems of care and population-wide reductions in stigma associated with SUD.

Forces of Escapism: Avoidance-centric Outcomes

Escapists value lowering the visibility or impact of a problem to reduce its immediate burden, often avoiding genuine solutions or direct engagement with root causes or those affected.

• Escapists: Individuals or organizations can too often prioritize avoidance, embodying the sentiment “make it go away.” Success for this approach is characterized by outcome measures that aim to hide or avoid the issue, such as decreased rates of public intoxication or disorder, increased incarceration rates, reducing immediate or short-term health care costs or monitoring levels of public attention and commitment.

Straddling the Ideologies

In tackling substance use disorder, many health care entities blend ideological approaches, creating a nuanced landscape of strategies and outcomes.

For example, nonprofit health care organizations frequently operate financially lucrative specialties such as cancer, in conjunction with essential but less profitable services, such as substance use treatment. We see a similar blending of capitalist and humanitarian outcomes when pharmaceutical companies establish patient assistance programs, such as the inSupport program for Sublocade, or in corporate wellness programs that combine the motives of increasing workforce productivity and reducing health care costs with desires to improve the wellbeing and happiness of employees.

International health organizations often straddle humanitarian and utilitarian priorities with their interest in improving both QOL and population-based health outcomes. A specific example of this is the World Health Organization’s work on the “Global Strategy to Reduce the Harmful Use of Alcohol,” which reflects a blend of QOL improvements and population-based health outcomes.

On the other hand, for-profit, publicly traded jails embody a mix of capitalist and escapist ideologies with their focus on shareholder profits, typically through government contracts to house inmates. Involved in SUD treatment for inmates as mandated by law, these facilities inadvertently conceal alcohol and other drug-related issues through the act of incarceration. Their primary measures of success sit squarely between the ideologies: annual numbers of individuals detained, efficient operations and profitability.

Onward

As we venture further into 2024, the absence of a universally accepted definition of success and agreed-upon outcome measures further complicates the task of effectively tackling SUD. The quest for unified strategies must navigate complex and often competing ideologies, aiming to blend the financial pragmatism of capitalism, the compassion of humanitarianism, the broader perspective of utilitarianism and an honest confrontation of escapism. Only by intermingling these approaches and finding common ground can we appreciate that no singular approach can entirely gauge the success of treatment interventions for a condition as complex and intertwining as addiction.