That's Billion (with a B)

The estimated total cost of addiction and mental health treatment in North America for 2020 is right around 330 billion dollars. That's not an insignificant amount of money.

And that doesn't include the costs associated with co-morbid health issues or indirect costs like lost wages and productivity. That number is just for the treatment of substance use and mental health issues.

So the 330 billion dollar question that we should be asking ourselves?

How do we know if our "treatment" is working?

Spoiler alert: we don't.

There are certainly pockets of practitioners and organizations, and even a few systems, that have embarked on the journey of "feedback-informed treatment" (I've been fortunate to work with several), or engaged in some meaningful outcomes and evaluation work. But as a sector, we're lagging behind every other area of medicine by a substantial margin.

Get diagnosed with diabetes? You can expect quarterly blood tests with follow ups and adjustments to your insulin depending on the results.

Cancer? Regular scans, screenings and tests, both during and after your course of treatment.

Addiction? Please go and find a 12-step group in the local church basement, they meet on Thursdays at 7pm.

Mental Health? .......(cross your fingers for a great family doctor or emergency room nurse)...

Now, before you throw your hands up in the air or throw some comments down to the effect of "it's more complex than that" and "co-morbidity" and "it's a societal thing", (all of which I won't argue with), let's spend a minute and zoom out to look at what's happening from 40,000 feet. I'm using drug use data from the United States due to ease of data access, though the Canadian story is pretty much the same over the same timeframe. We'll focus on "substance use" moving forward, but the same principles and underlying questions apply equally to "mental health".

Now, the question that needs asking with this first graph (highlighting drug overdose deaths from 1999-2017) is;

Is the background rate of addiction the same over that time frame, or are the drugs themselves deadlier? Is the 3x increase in the drug overdose rate due to more use overall, or more dangerous drugs being consumed?

Turns out the answer is yes.

Overall rates of "illicit drug" and marijuana use have increased significantly since 2007. Other drug use (cocaine, prescription drugs and hallucinogens) have remained relatively steady.

In the "illicit drug" category, the fastest rate of increase has been seen in the use of opioid pain killers such as oxycontin and fentanyl (and, of course, heroin).

In 2017, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 6 times higher than in 1999, and accounted for 68% of all overdose deaths in that year.

Increased use + deadlier drug supply. Not a great picture from 40,000 feet.

If you had to answer the question "is addiction treatment working?", you'd be hard pressed to say yes. In fact, you'd be hard pressed to say that ANY of our drug enforcement, prevention efforts, treatment and relapse prevention programs are making a significant difference. From 40,000 feet, anyway.

And this matters, aside from the obvious human toll, because with the kind of investment that society is making in trying to prevent and remediate this issue, we should expect some kind of positive return.

Which involves measuring the impact of our efforts, and adjusting investment (time, energy, resources) as a result. Here's the short list of changes we'll need to make to ensure that we're having the kind of impact that we intend to.

1. Accelerate the development of Routine Outcome Monitoring systems within our treatment settings. More on that (and a short video) here. Without tracking progress at the individual client level, we'll never truly realize "client/patient/human-centred" practice.
2. Embrace Utilization-Focused (and/or Values-Focused) Evaluation. When paired with a robust routine outcome monitoring system, gathering client feedback (and actually acting on it to improve services) is the FASTEST and CHEAPEST method for improving services. Full stop. In fact, one of our clients recently improved treatment efficacy by 60% in less than a year, with a series of practical and efficient steps to operationalize feedback and track outcomes.

That's it. That's the short list. Not to discount the concrete efforts that need to happen in tandem to these two systems of evaluation (like safe supply & harm reduction initiatives, increased accessibility to after-care supports, etc.), but without them...how do we know the difference our efforts are making?

We don't, but we need to. There's too much at stake. And I'm not talking about the billions of dollars we're spending, but the immeasurable value of lives being lost and not fully lived.

-Jeff