Intervention and Treatment
Recovery
Prevention
Summary: Treatment must be expanded to meet the individualized needs of Americans with substance use disorder, a treatable condition with identifiable criteria in DSM-5. These treatment models—spanning the continuum from the earliest interventions to detoxification, then treatment and re-entry—must be developmentally personalized and grounded in evidence and acknowledge that all pathways to recovery are different. Likewise, interventions along a continuum of care must be tailored to the unique needs of each patient, addressing the physical, psychological, social, and spiritual aspects of recovery. To help the greatest number of individuals, treatment must also be affordable and within reach of those who would benefit from it. Increasing connections to treatment is a vital step for helping people who use drugs overcome their conditions and regain control of their lives.
- The percentage of Americans with a drug use disorder is reduced by 20% by 2030, from 9.6% in 2023
to 7.7% in 2030. - The number of treatment admissions is increased by 25% by 2030, from 1,482,543 in 2021 to
1,853,179 in 2030. - The percentage of admissions that did not need to wait 1 or more days to enter treatment is increased
by 15% by 2030, from 70.9% in 2021 to 81.5% in 2030.
Treatment options can vary and may include medical detoxification, inpatient or outpatient rehabilitation programs, counseling, therapy, support groups including 12-step programs, and medications for opioid use disorder. While opioid use disorder can be treated with medications such as methadone and buprenorphine, comparable interventions do not exist for other substance use disorders (SUDs). Contingency management is an increasingly promising intervention to help those with stimulant use disorder. And policies that nudge people into treatment, including drug treatment courts, healthcare provider incentives, and testing and sanctions programs should be much more widely adopted.
According to the 2023 National Survey on Drug Use and Health, the top five reasons cited by individuals for not receiving substance use treatment were: 1) they thought they could handle their drug use on their own, 2) they were not ready to start treatment, 3) they were not ready to stop or cut back on using alcohol or drugs, 4) they were worried about what people would say or think if they got treatment, and 5) they thought it would cost too much. Additionally, many clinical treatment programs do not meet adequate standards of care and patients may face long wait times.
In 2020, Oregon became the first state to vote to decriminalize the possession of all drugs, including fentanyl, cocaine, heroin, and methamphetamine. This policy change followed millions in funding from pro-legalization groups, such as the Drug Policy Alliance. By nearly all indicators, Measure 110 has been recognized as a failed policy experiment.
Between 2020 and 2022, the number of overdose deaths in Oregon increased 75%, compared to only 18% nationally. Likewise, Oregon was one of only two states that had a rate of nonfatal overdoses more than 200% above the national average.
Oregon now has the highest rate of past-month illicit drug use, not including marijuana, and this measure increased 6.9 times faster than the national average. At the same time, Oregon now has the lowest share of residents that say there is great risk associated with trying heroin once or twice or using cocaine once a month. Measure 110 appears to have further normalized hard drugs and increased their use.
Oregon’s Department of Transportation said the passage of Measure 110 “has resulted in a predictable increase in drug-impaired driving crashes and related injuries and deaths.” While Measure 110 did increase funding for much-needed services, it is important to recognize that these changes could have been implemented without the decriminalization of all drugs. Oregon Public Broadcasting reported, “the combined result of all the legislative efforts on Measure 110 was to leave Oregon with no carrot and no stick to steer people into treatment.” The removal of criminal penalties eliminated a policy lever that was often used to guide individuals with a substance use disorder into treatment, such as through a drug court.
Between 2020 and 2022, the number of overdose deaths in Oregon
Moreover, between 2020 and 2023, the number of individuals experiencing homelessness increased by 10.8% in Oregon, while it decreased in neighboring states. The Associated Press reported that public drug use in Oregon became “rampant.” The violent crime rate increased by 17.3% in Oregon between 2020 and 2022, despite decreasing 4.5% nationally.
In turn, public support for decriminalization fell rapidly. Though Measure 110 passed with 58% of the votes in November 2020, a poll from August 2023 found that only 2% of voters think Measure 110 has been a success, compared to 61% that think it has been a failure. A separate poll found that nearly two-thirds of Oregonians—including 74% of Black Oregonians and 79% of Hispanics—wanted to repeal parts of Measure 110 and reinstate penalties for possession.
In late February and early March 2024, the Oregon legislature voted to reinstate criminal penalties for the possession of drugs, effectively undoing the central premise of Measure 110. This failed policy experiment should serve as a cautionary tale to other states that are considering decriminalization.
Specific Recommendation 4Individuals and families benefit most from treatment and care that is available, accessible, affordable, and engaging to those being served.
Summary: In order for individuals to benefit from treatment, they must first be able to find an appropriate program that is accessible, available, and affordable. Treatment programs should be tailored to meet the unique needs of patients and accommodate their preferences within reason and without compromising quality, accountability, or effectiveness. Policies should aim to overcome barriers to enrolling in treatment, including wait times and geographic distances.
Description: To best meet the needs of those with a substance use disorder, treatment must be:
- Available. Similar to the treatment of other conditions in general health care, the treatment of SUDs must be considered an essential service that should be readily available to those in need. It is important for communities, healthcare systems, and governments to invest in and support the development and availability of comprehensive SUD treatment programs, including developing the treatment workforce and addressing reimbursement rates. These programs should address the unique needs of individuals, consider co-occurring mental health disorders, provide ongoing support and aftercare to promote long-term recovery, and provide support for families trying to find care for a loved one with a SUD.
- Accessible. SUD treatment should be easily accessible to individuals who need it. Easy accessibility can help ensure that people struggling with SUDs can receive timely and appropriate care, increasing their chances of recovery and improving their overall well-being. Additionally, efforts should be made to reduce the stigma associated with substance use, as it can be a barrier to seeking treatment. Treatment should also extend to hard-to-reach populations, including those who are unhoused and those who are involved with the criminal justice system. This includes rural areas, where treatment is often limited and the workforce is scarce, highlighting the importance of providing virtual and telehealth services for SUD treatment.
- Affordable. SUD treatment can be costly, and financial barriers should be minimized. Insurance coverage, including Medicaid and private insurance plans, should adequately cover substance use treatment services. Government programs and funding should be available to individuals who are uninsured or cannot afford treatment. Integrating SUD treatment into primary care settings can also make it easier for individuals to seek help.
- Engaging. Making treatment attractive and engaging can play a crucial role in encouraging individuals to seek help and actively participate in their treatment process. Treatment programs can incorporate a person-centered, holistic approach that considers the developmental status, physical, psychological, and social aspects of recovery. Treatment should also cater to different learning styles and preferences and address practical concerns, such as providing flexible scheduling options, childcare assistance, and transportation support, or help with employment or educational needs. All pathways to treatment should be explored, whether they are mandated by the criminal justice system or pursued on a voluntary basis by the individual.
Specific Recommendation 5Evidence must support all the following outcomes for an activity to be considered as treatment: an end to drug use, which leads to symptom reduction, prevention of complications, improved functioning, and ultimately recovery.
Summary: In the area of treatment for substance use disorder, any activity to be considered a treatment must have evidence that this activity can result in 4 outcomes: 1) symptom reduction, 2) prevention of complications, 3) improved functioning, and 4) respect for human rights. This is particularly important for administrators and decision makers who often face a difficult decision whether to use public dollars to fund “a treatment.”
Description: All four criteria must be present for an activity to be considered a treatment.
- Symptom reduction: Ending compulsive drug use, the “symptom,” is a challenging but achievable goal. This typically requires a comprehensive, individualized, and multi-faceted approach, involving both professional help and personal commitment. Relapses are common along one’s recovery journey, but they don’t mean failure. Over time, with the right support and effort, positive changes can be achieved.
- Prevention of complications: Preventing complications is a crucial aspect of treating SUDs. The primary goal of SUD treatment is not only to help individuals stop substance use, but also to address the physical, psychological, psychiatric and social consequences of or pre-existing problems associated with SUD. By preventing complications, we can significantly improve an individual’s overall health and quality of life. Some of the ways in which SUD treatment can focus on preventing complications include: early intervention, comprehensive assessment, medical management, psychosocial interventions, supportive services, relapse prevention planning, and social and community support.
- Improved functioning: Improving functioning is a fundamental goal in the treatment of substance use disorders. SUDs can have a profound negative impact on various aspects of an individual’s life, including physical health, mental well-being, relationships, employment, criminality, and overall quality of life. The primary objective of SUD treatment is not only to stop drug use, but also to help individuals regain control over their lives and improve their functioning in various domains.
- Treatment must respect human rights: Treatment of SUDs must uphold and respect human rights, as individuals with SUDs are entitled to the same human rights and dignity as any other person. Approaches to treatment should be compassionate, non-discriminatory, and adhere to principles that protect and promote human rights, such as informed consent and the confidentiality of patient information. This includes trauma-informed care, and the need to define a global standard for such care to apply across demand reduction strategies.
Specific Recommendation 6Sufficient permanent funding, including insurance coverage, that incentivizes cost-effective and demonstrably clinically effective services along the full continuum of care is required to achieve its full impact.
Summary: Policymakers must work to reduce barriers to treatment and ensure that there is sufficient funding in place for treatment to remain accessible into the future. To achieve this goal, they should ensure that treatment programs meet standards of clinical effectiveness and are cost-efficient, which will require coverage for those with insurance and those without it. Access to treatment can also be improved by integrating treatment into primary care settings.
Description: Treatment must be:
- Cost-efficient: Substance use disorder treatment is often expensive, hindering the ability of patients to receive the help they need. Individuals should be made aware of existing low-cost or free programs with proven track records, particularly 12-step programs. To improve access, clinically effective and cost-efficient residential treatment should qualify for the Institution of Mental Disorder (IMD) exclusion that is legislated.
To ensure sufficient, permanent funding for treatment into the future, there must be coordination and collaboration between federal, state, and local governments, in addition to private insurance companies. The 2022 National Drug Control Strategy stated, “Wherever possible, inexpensive oral methadone and sublingual buprenorphine should be the backbone of our treatment system for caring for people with opioid use disorder, and selected far more often because of their relative safety, efficacy, and low cost.” - Covered by Insurance: SUD treatment can be costly, and financial barriers should be minimized. Insurance coverage, including Medicaid and private insurance plans, should adequately cover substance use treatment services. Government programs and funding should be available to individuals who are uninsured or cannot afford treatment. Policymakers must also ensure compliance with federal parity laws, allowing for behavioral health conditions to be covered the same way that physical conditions would be.
- Integrated into Primary Care: Integrating SUD treatment into primary care settings can make it easier for individuals, particularly adolescents and teenagers, to seek and receive help. This can involve training primary care providers to identify and address substance use issues, offering screening and brief interventions, and providing referrals to specialized treatment centers when needed. This is particularly important for health care for children and adolescents.
Specific Recommendation 7As part of the continuum of care, people who use drugs should have access to evidence-based harm reduction interventions, which can minimize––but not eliminate––the life-threatening risks that face them. These interventions must always come with true treatment linkage and not as standalone programs.
Summary: Evidence-based harm reduction interventions, such as the use of naloxone to reverse an opioidinduced overdose, have the potential to reduce the harms facing people who use drugs; however, more research must be done into the effectiveness of other proposed interventions. Harm reduction strategies represent one additional lever along the continuum of interventions.
Description: Harm reduction has emerged as a suite of interventions that seeks to reduce the harms facing people who use drugs. It should not be seen as incompatible with treatment. Supporters argue that these individuals must be kept alive until they are ready to enter treatment on their own accord. Former Congressman Patrick Kennedy has said we must “meet people where they are at, but not leave them there.”
The answer to the question: ‘What do we do after Naloxone works on someone?’ is one that is rarely addressed.
And this neglect is costing us dearly.– Dr. Kevin A. Sabet, CEO, Foundation for Drug Policy Solutions, former senior advisor at the White House Office of National Drug Control Policy
- Harm reduction interventions––such as naloxone and syringe services programs––have the potential to reduce harm and connect people to support services. Rather than viewing harm reduction as an approach that allows for, and perhaps even facilitates, drug use, policymakers must situate these tools within a broader framework that remains focused on connecting people to treatment and helping them achieve recovery. For example, if someone overdoses on an opioid, is given naloxone, and is then transported to a hospital, hospital staff should be ready to refer this individual to treatment and encourage them through this process—however, we recognize that this is rarely done.
- Policymakers should increase access to naloxone nationwide. Naloxone, also known as Narcan, is a medication that can reverse an opioid-induced overdose death. In March 2023, the FDA approved overthe-counter access to naloxone. Further measures must be taken to ensure that naloxone is accessible and affordable. Naloxone should be carried by all first responders, as they are often the ones first on the scene of an overdose. Additionally, families should be encouraged to have naloxone available, and it should be widely accessible for the public, as automated external defibrillators are available in the community..
- More research must be done into the effectiveness of other harm reduction interventions in leading
people to recovery. Dr. Nora Volkow, the director of NIDA, a leading funder of drug policy research, stated we must “build the evidence base to see what other harm-reduction approaches could help in the current crisis and how they can be adapted to diverse communities.” More research must be done into the potential benefits and unintended consequences of other harm reduction interventions that have been proposed—including safe injection sites, fentanyl test strips, and so-called “safer supply,” among others—before policymakers proceed with their implementation.