American Society of Addiciton Medicine

Guest Editorial: The Future of Addiction Treatment Lies in Narrowing the Treatment Gap

by Dr. Brian Hurley, MD, MBA, FAPA, DFASAM

President, American Society of Addiction Medicine

In the time of the worst overdose crisis in American history, those of us who work in the field of addiction medicine have the responsibility of bringing treatment to where patients with addiction are. The addiction treatment gap refers to the approximately 94% of people with one or more DSM-5 defined substance use disorders (SUDs) who did not receive any addiction treatment (according to the SAMHSA’s National Survey on Drug Use and Health (NSDUH) conducted in 2021). ASAM is committed to establishing universal access to addiction treatment for everyone with addiction, and major opportunities to solve these access issues that remain ahead of us. We also have additional opportunities to engage people with SUD who are not currently receiving treatment, as approximately 97% of NSDUH survey respondents who had SUDs but did not seek treatment did not feel that they needed treatment. 

Those of us who have worked in addiction treatment for several decades will recognize labels, such as denial, that we apply to patients with addiction who may not be ready to pursue full sustained abstinence from all intoxicants. Some abstinence approaches also insist upon waiting for our patients to achieve their own recognition of the need for treatment before initiating any engagement. Affixing labels to our patients and delaying initiation of effective treatments cannot be justified in an era where the treatment gap is fueling the overdose crisis – no one can recover if they have died.  

There are promising models for enhancing access to addiction treatment, collectively referred to as low-threshold treatment, that do not predicate initiation of care upon the patient’s commitment to ongoing full sustained abstinence. Motivational interviewing approaches teach us to accept the patient’s readiness, or lack thereof, to make positive changes in their life, and promote an emphasis on engagement for ongoing identification of areas of ambivalence where the patient may be ready to make any positive changes. Medication-first approaches, which can be delivered through a variety of modalities, prioritize initiation of addiction pharmacotherapy when a patient is ready to accept these treatments as a foundation for clinician-patient relationship building that can connect the patient with necessary counseling and support. Medication-first approaches are not equivalent to medication-only approaches – all patients with addiction benefit from the combination of medications, counseling, and support – but the medication-first approach is distinguished by eliminating a requirement that patients must participate in psychosocial treatments as a condition of starting addiction medications. Contingency management, which is best offered alongside a full range of complementary psychotherapies, benefits patients even when patients are not immediately ready to accept other counseling and support. However, contingency management oftentimes serves as the bridge connecting patients to other treatments, as patients who receive incentives voluntarily choose to participate in addiction recovery activities. 

ASAM has a vast array of curricula to prepare the addiction treatment workforce on all of these topics. For those who haven’t yet taken ASAM’s Motivational Interviewing coursework, I’d encourage you to check out the myriad learning opportunities posted on the ASAM website. We have similar offerings on a variety of pharmacotherapies, contingency management treatments, and a course on the Fundamentals of Addiction Medicine. For anyone unfamiliar with any of these treatments and approaches, I’d welcome your joining the growing cohort of addiction medicine professionals working on lowering the threshold for initiating addiction treatment and integrating access to addiction treatment throughout all healthcare settings. Our patients need our leadership to advance the delivery of patient-centered care.