Lifting the burden of addiction: Mythbuster edition

Substance use has been making headlines lately as heroin use skyrockets, but in the coverage of this “quiet epidemic,” there’s been little information about how philanthropy can help. In our upcoming guidance, Lifting the Burden of Addiction: Philanthropic opportunities to address substance use disorders in the United States, we’ll be presenting concrete ways for philanthropists to  make a difference—right now or in the future, with $5 or $500,000. To set the stage, today we’re highlighting four myths that we’ve heard about substance use disorders, along with what the evidence really shows.

MYTH 1: Addiction is just another name for bad choices.

Substance use disorders (SUDs) result from behaviors that can appear to be simply a matter of choice, and it can be difficult to understand why someone can’t just stop. Most people try drugs or alcohol at some point in their lives, and most of those people will not develop a disorder. For some fraction of the population, however, their use will take them down a slippery slope to physiological and psychological dependence: their brains will physically alter to reinforce the cycle of craving and use, and their behavior will follow. So while the initial decision to use may be a personal choice, once a person has developed a disorder, stopping use often requires more than willpower alone.

We can’t predict with certainty who will progress from use to disorder.  Any number of genetic and environmental factors can interact to make someone more vulnerable— or to protect them despite risky personal choices. What we do know is that bringing evidence-based care to SUD patients gets results: more people get better more quickly, and the pain the disorder can cause to patients and families is reduced.

MYTH 2: Clean syringe exchanges increase drug use.

With the recent HIV outbreak among injection drug users in Indiana, syringe exchanges have been hotly debated in the news and in political settings. What you may not know is that when it comes to the evidence, there’s no debate: clean syringe programs save lives, and they don’t increase drug use. Eight different reports commissioned on behalf of U.S. government agencies and the World Health Organization found that clean syringe programs reduced the spread of HIV.  Researchers have found a positive correlation between clean syringe programs and reduced drug use, greater treatment entry, and improved treatment outcomes. There’s even evidence that these programs can lead to cleaner neighborhoods as discarded syringes are returned to exchanges. For all of these reasons, clean syringe programs are used widely in Europe and other parts of the world. But the politics surrounding them in the United States remain divisive, and a ban on federal funding for syringe exchanges is still in place.

As an Indiana public health nurse told the New York Times, “If you would have asked me last year if I was for a needle exchange program, I would have said you’re nuts. I thought, just like a lot of people do, that it’s enabling — that you’re just giving needles out and assisting them in their drug habit. But then I did the research on it, and there’s 28 years of research to prove that it actually works.”

MYTH 3: There’s no progress without recovery.

In emergency situations, the first priority is to save lives, treat injuries, and meet basic needs (food, water, and shelter). Only then can other issues be addressed. For people with the most severe SUDs, the same logic applies: these individuals are in dire circumstances, and measures to protect their lives, alleviate their most immediate physical pain and isolation, and stabilize their surroundings often need to be taken before recovery from the disorder can be realistically targeted. Unfortunately, many social service programs exclude people with the disorder. The logic makes intuitive sense: tying clearly valuable services, like housing, to sobriety should help give people the extra motivation they need to get better. Here’s where it gets complicated: for some people, that’s true. But for many others, the help and support has to come first, in order to give them the foundation they need for recovery.

To that end, there are tools that have been shown again and again to save lives and reduce the harm and immediate risk caused by SUDs right now, as well as save money and open the door to treatment. These include overdose prevention medications, clean syringe programs, supportive housing, and legal aid to help ensure that patients’ basic needs are met, even if recovery remains elusive. Many of these approaches offer a double benefit: they are compassionate, recognizing that those with the most severe SUDs need help; and they save taxpayers money by reducing use of costly emergency services. The evidence shows that these tools work, but they aren’t commonly put into practice. Philanthropic support can help change that.

MYTH 4: If the 12 steps didn’t work for you or your loved one, you’re out of luck.

If you ask the average person on the street what to do for a loved one who has a drinking problem, they might well suggest Alcoholics Anonymous (AA). That might be one good option, but here’s what many don’t know: 12-step programs are just one of many effective tools available to help people recover. If they don’t work for someone, it doesn’t necessarily mean that that person isn’t ready, or that they need to hit “rock bottom” before they can make a meaningful change for the better. The right treatment can be very different from one person to another, and good treatment isn’t limited to any single therapy. Instead, good treatment is about drawing upon the full spectrum of what we know works. Evidence-based tools include different types of talk therapy, medications to reduce cravings, versions of 12-step therapy, and many more. In addition, many of these can be combined for a more tailored fit. Case managers, for instance, can help patients access and balance the treatments that are right for them. Ironically, while evidence on the effectiveness of (for example) medication-assisted treatment is much stronger than that on the effectiveness of 12 step programs, the latter is much more widely available.

And a question: what works to prevent the disease?

As with many public health issues, prevention is an appealing target for many donors—what better way to reduce suffering and save money than by stopping the disorder before it starts? When it comes to SUDs, the same holds true: prevention is an important and high-impact target for funders. What sets SUDs apart from something like measles, however, is that we don’t yet have proven tools to prevent the disorder from developing. That means that the opportunity for philanthropy to make a difference in prevention is greatest in research and innovation. There are some existing programs that have demonstrated promise within specific populations, but more piloting and research is needed before we can confidently recommend replicating them in schools and communities across the country. Conversely, there are programs that are widely implemented without strong evidence that they work. A better understanding of how these programs may or may not impact substance use will allow for more efficient spending of both public and private dollars. Finally, there are new tools—things like mobile health, genotyping, or even vaccines—that might eventually hold the key to successful prevention efforts. Innovation and information together will move the sector towards more effective prevention, and philanthropy can help make that happen.

In our upcoming guidance, we’ll build on all of the above findings to present specific, concrete strategies for helping those who suffer from substance use disorders. As always, we hope this work helps donors move from good intentions to action, and ultimately to a meaningful impact.

To be notified of the public release of our upcoming guidance – Lifting the Burden of Addiction: Philanthropic opportunities to address substance use disorders in the United States – please email Rebecca Hobble at with subject line “SUD guide request.”