Steven Kassels, M.D.


This is the fourth in a series of articles discussing the ten reasons for the current heroin epidemic, so if you have missed the prior editions of The Sober World Magazine, you can easily review them by going to www.thesoberworld.com This article will focus on the topics of Supply and Demand (“War on Drugs”) and Physician Training and Biases. Next month the series will close out with the final two reasons: Mental Health Treatment and the role of Public Officials. As the final four reasons for the heroin epidemic are reviewed, solutions within reach will also be emphasized. The issue of Supply and Demand directly relates to both the problem and the solution.

Heroin production and distribution seems to be an unending saga; and unfortunately it has been compounded by the War in Afghanistan. No matter how many drug lords and kingpins we kill or arrest, there is always someone willing to fill the void. Money and power is the “addiction” that attracts people to the illicit drug world. Interdiction and attempting to close our borders to drugs is a losing battle; and increasing tax payers’ burden by growing law enforcement and judicial budgets has been unsuccessful. Yes, we can arrest and incarcerate all the current drug pushers, big and small, and we can continue to burn the fields of the countries that produce opium; but the profits of this organized industry of drug production and distribution is so great that there is a continuously replenishable supply of people who want to be the next kingpin or the next local drug pusher.

Let’s look at this from a different perspective, using an economic analysis. If we cannot limit the supply, then we must look at the demand side of the equation. If there is decreasing demand, there will be decreasing profits and therefore decreasing production. I am not saying that we should abandon attempts to bring to justice those who are poisoning our communities with a constant flow of illicit drugs. What I am saying is we should attack the demand side of this problem with greater vigor. We spend $400 Billion Dollars annually dealing with the consequences of addiction in terms of crime, health care and lost worker productivity. This should be incentive enough to advocate for more preventive programs and more treatment centers to decrease demand.

As I stated earlier in this series of articles, there is plenty of blame to go around. We must focus on the solutions. Last month’s article dealt with NIMBY (“Not in My Back Yard”) which is interconnected with the Supply and Demand. If our community leaders and citizens do not support local treatment centers in
greater numbers, then curbing demand will remain an uphill battle.

As you may recall from the article in the November edition, I casted some blame on doctors. I am further implicating the medical profession as a contributing factor, but now from the perspective of the educational process. To state it bluntly, sufficient addiction medicine training and emphasis on the complexity and interrelationship of addiction and underlying associated illnesses is lacking in our medical schools and residency programs. This not only leads to a lack of appreciation of the importance of screening patients for predisposition to and/or ongoing addiction, but also creates biases. In general, misconstruing or minimizing the complex societal and psychological issues reinforces preconceptions that are not based in fact. When this hypothesis is applied to physicians who are asked to treat the difficult and multifactorial aspects of addictive disease, bias can prevail. There are certain diseases that are more time consuming to manage than others, especially when the patient is either in denial and/or non-compliant. Examples may include diabetes, cardiac disease and lung disease. But physicians in general receive the appropriate training to deal with the demands of patients with these illnesses. That is not the case with addictive illnesses and bias is compounded by other societal factors that influence perceptions, such as jailing patients. Dr. Saul Tolson, in my novel Addiction on Trial, addresses this very issue:

Pausing while attempting to make eye contact with each and every individual in the audience before proceeding, Dr. Tolson delivered his next few lines in a compassionate tone. “With no disrespect, but as a way to reinforce the point I am trying to make, I’d like to ask you to please tell me the difference between a nicotine or alcohol addict, who in some cases may even receive a heart or liver transplant, and someone addicted to heroin or cocaine? Why are those afflicted with the disease of addiction to certain drugs treated so differently than patients who suffer from nicotine or alcohol addiction or other chronic diseases like diabetes? Are they really any different?”

Dr. Tolson never relinquished the podium without one last attempt to convert the naysayers. “Now for those of you who fail to agree with me, and I know you’re out there, let me appeal to your wallets. To incarcerate one addicted patient—that’s right, jailing patients—costs between $40,000 and $50,000 per year. A one-year stay for a patient in a halfway house costs society about $20,000 per year and this does not include any medical care. But to treat one heroin addict as an outpatient with regular individual and/or group counseling sessions, ongoing urine drug testing to monitor for illicit drug use, a complete admission physical exam including laboratory tests that screen for contagious diseases such as Hepatitis C and HIV, and the daily monitoring of medication administration costs approximately $5,000 per year! That’s right—only $5,000 per year or about one-tenth the cost of putting this patient in jail!

Like they say in the Midas commercial, ‘you can pay now or you can pay later, but you’re gonna pay.’

However, inroads are being made to correct the deficiency in medical education. The organization, Coalition on Physician Education in Substance Use Disorders is making great inroads within the medical educational process, and I feel honored to have been chosen as a speaker at a recent event. I presented some facts such as:

  • The changing face of addiction now includes aging baby boomers;
  • Heroin addiction is no longer just an inner city problem, as it has migrated to college campuses and to white suburban men and women in their late 20’s;
  • Physicians can make a tremendous difference by having a brief discussion and/or implementing a form to rapidly identify patients at risk. The tool is called SBIRT (Screening, Brief Intervention and Referral for Treatment – http://www.integration.samhsa. gov/clinical-practice/SBIRT ; and most importantly
  • “Drug addiction is a brain disease that can be treated” (Nora D. Volkow, M.D., Director, National Institute on Drug Abuse)

Physician bias is another roadblock to solving the heroin epidemic; biased doctors are less likely to treat patients with addiction. It is essential to attack this scourge to society by decreasing demand through treatment and education. We need more doctors willing to treat patients and also to be more involved in educating our citizens and public officials that treatment works. Our medical schools and residency programs need to do more. I hope my participation will further encourage these goals. I appreciate the opportunity to contribute to such an important advocacy magazine.

Dr. Kassels has been Board Certified in both Addiction Medicine and Emergency Medicine. He serves as the Medical Director of Community Substance Abuse Centers. He is the author of “Addiction on Trial”, written as a murder mystery/legal thriller to reach and educate a wide range of readers. The book has recently been entered into medical school curriculum to help decrease physician bias. The book is available at: Amazon (www.amazon. com/Addiction-Trial-Tragedy-Downeast-Maine/dp/1491825316) and free author book club presentations and educational meetings (in person or using Skype) can be arranged at: www.addictionontrial.com/author-events/