Loris Mattox, Executive Director of the HIV Education and Prevention Project of Alameda County, runs harm reduction trainings for law enforcement.

“There were certainly officers who began by telling me, ‘Harm reduction is enabling and it makes my job harder,’" says Loris. “But some changed their perspective over the course of the training. We did an exercise around the ‘whys’ of harm reduction and ultimately got down to this: to keep people alive. As one officer said, every day that they are alive, they can make a change.

“One officer came up to me after and said, ‘I was trained to believe that abstinence was the light at the end of the tunnel. But what if the end of the tunnel is too far away? Now I see it as a circle, a cycle.’”

Addiction can be successfully treated. Years of work to better understand addiction have led to numerous evidence-based treatments that help people overcome both the physical and psychological pull of addiction. Yet far too many people aren’t able to get treatment they want and need. In 2014, only 11% of people needing treatment for illicit drug use in the United States actually received treatment.

Source: SAMHSA, National Survey on Drug Use and Health

Why can’t people access effective treatment? Simply put, there’s not enough treatment available – and what does exist is not always evidence-based. There are limited spots for treatment especially in rural communities. Even in urban areas, federal and state restrictions often inhibit treatment offerings, including provision of methadone and buprenorphine, two widely-accepted opioid treatments. Almost no state or federal prisons offer methadone or buprenorphine to inmates, requiring people to discontinue treatment if they become incarcerated – though this practice may stop due to a recent ruling in Boston.

The federal government is investing in treatment, with $4.5 billion allocated for this in the President’s budget for FY2020. A massive proportion of these funds are going to the opioid epidemic, which does leave behind people who use other drugs, like methamphetamine. Concerning is that a large part of the treatment dollars are reserved for abstinence-only programs, leaving far less for evidence-based, harm-reduction and medication-assisted treatment options. Plus, the money allocated to treatment is still dwarfed by that spent on enforcement. All this means that people who want to seek treatment for their substance use face many barriers to access– especially in states without Medicaid expansion.

“If people are criminalized and feel stigmatized, you can have the best services on earth and many will not access them.”

Kasia Malinowska-Sempruch
open society foundations global drug program

Why don’t people access treatment? In a word: stigma. Illicit drug use is criminalized, and many people fear that if they seek treatment they could face criminal charges – especially those who are Black, Latinx, or poor. Even if they are not worried about that, often people who want treatment don’t want anyone to know they need it – and with good reason: people are significantly more likely to have negative attitudes toward someone dealing with drug addiction than someone with mental illness, and they generally don't support insurance, housing, and employment policies that benefit those dependent on drugs. When people do seek treatment, they often experience poor treatment from the health professionals who are supposed to be helping them.

Our Approach

People who use substances must be able to make a self-directed choice about a treatment option that is best for them. All of the treatment options we look to support are voluntary and backed by evidence.

In addition to simply more treatment, we also need better integration of treatment into our healthcare and criminal justice systems. There are some great models for this, including the CA-BRIDGE program at Highland Hospital in Oakland, where people can receive opioid treatment on demand from the emergency room; and a program to continue medication-assisted treatment for opioids when people enter jails or prisons throughout Rhode Island, which resulted in a 60% drop in overdose deaths post-release. Since 2/3 of people in jail have substance use disorders, taking action in these settings is especially critical.

Source: Meta-analysis of drug-related deaths soon after release from prison. Addiction. 2010.

Medication-assisted treatment. For opioids, there are a number of medicines that can help people fight their physical addiction. Medication-assisted treatment (MAT, also known as Medications for Addiction Treatment) involves medications that combat drug cravings and block the effects of opioids on the brain. The three most common therapies are methadone, buprenorphine, and naltrexone. Methadone can only be dispensed in highly-regulated settings, while providers must undergo training and obtain an FDA waiver to prescribe buprenorphine. More opportunities are needed for people to start MAT in low-threshold settings, without long intake procedures or cumbersome appointments in intimidating clinics.

Unfortunately, there are not yet any FDA-approved medication-assisted treatments for methamphetamine, although some specialized physicians have found success in treating people with severe meth-related toxicity using anti-psychotics and anti-anxiety medications.

Behavioral therapies. In addition to medication, there are a wide variety of other therapies that have been shown to be useful in treating substance use disorders. One is cognitive behavioral therapy, which helps people recognize harmful thinking and change their patterns of behavior that contribute to their addiction. Another is motivational enhancement therapy, counseling that is designed to help people become motivated to stop (or reduce) their drug use. A third, most commonly used with methamphetamine, is contingency management, where people get incentives (usually money) every time they produce a drug-negative urine or breath test, proving they have abstained from drugs.

Abstinence-based models. While “abstinence-only” models of treatment are being phased out in favor of more evidence-based harm reduction strategies, harm reduction models include abstinence-based options for people who want them. Abstinence-based rehab centers and 12-step programs work for some people, and should also be available – as long as people who re-initiate use aren’t kicked out of the program. A number of 12-step programs have moved beyond the most well-known model of Alcoholics Anonymous, including those that are non-religious and/or women-focused.