Treatment for Substance Use Disorders

"Access to medications for OUD remains inequitable across different treatment settings as well. In the United States, methadone can only be administered through specialty facilities known as opioid treatment programs (OTPs), even though the available evidence shows that delivering it through an office-based medical practice setting is also effective. Moreover, most residential treatment facilities do not offer medications, and if they do, they rarely offer all three medications.

"Despite the large and increasing numbers of people with OUD entering the criminal justice system in the United States, evidence-based medications are often withheld or are only provided on a limited basis for medically supervised withdrawal. As a result, few people with OUD receive medication while incarcerated or under the supervision of drug courts. In addition, justice-involved people who do receive medication for OUD are often not linked with care upon release, leading to treatment discontinuation and the concomitant risks of overdose and death. Given that these medications are known to save lives, it is arguable that withholding them from persons with OUD is unethical, as withholding insulin or blood pressure medications would be.

"Pharmacies, mobile medication units, community health centers, emergency departments, and other care settings provide opportunities to engage people with OUD and link them to evidence-based care. Expanding medications for OUD into a broader range of care settings would save lives and build the capacity to make real progress against the epidemic."

"Residential treatment is often considered the highest intensity of treatment for individuals with OUD [40], and may by particularly important for those with unstable housing, co-morbid mental health conditions, or high medical need [41]. However, evidence supporting this assumption is mixed and has primarily focused on treatment completion, retention, and abstinence outcomes [9, 13]. Few studies have directly compared residential treatment with outpatient treatment for clinical outcomes such as overdose [20,21,22]. In this analysis, we used a linked Medicaid dataset to compare outcomes for individuals with OUD who received residential or outpatient treatment. After adjustment for a variety of physical, mental, and addiction-related comorbidities, we found that rates of overdose, opioid-related, and all-cause ED or hospitalizations were not reduced for individuals receiving residential treatment compared to those treated as an outpatient. While residential treatment was associated with higher retention at 6-months, this difference was not significant at 12-months. In stratified analyses, the benefits of residential treatment on retention appeared to be confined to those not receiving MOUD.

"Historically, public perception has assumed residential treatment to be the gold standard, a view often endorsed by the addiction treatment community despite its greater cost and limited evidence [8, 13]. Efforts to further refine selection of patients most likely to benefit from residential treatment are likely to be eclipsed by increasing the use of MOUD in, and following, residential treatment. Opioid agonist treatment for OUD improves a variety of addiction-related outcomes and markedly reduces the risk of overdose and all-cause mortality [7, 42]. In our study, MOUD was associated with a 55% reduction in the risk of opioid overdose independent of treatment setting. About one-third of individuals receiving treatment were prescribed MOUD which is comparable to other reports and suggests missed opportunities for improving OUD treatment outcomes [1, 24].

"This study adds to a mixed literature demonstrating the potential benefits of residential treatment for individuals with OUD with respect to treatment retention [13, 21, 22, 43]. Studies using SAMHSA TEDS data exclusively have generally shown that individuals entering residential facilities have higher treatment completion rates [43, 44]. Consistent with this literature, we found that residential treatment was associated with enhanced retention. While treatment completion is associated with improved some clinical and social outcomes, it is a surrogate indicator of improved addiction-related health outcomes. Moreover, OUD is now universally recognized as a chronic condition requiring long-term outpatient management. Although residential care was associated with improved retention in our study, it was not associated with improvements in overdose or other opioid-related outcomes. This largely comports with recent claims-based analyses that suggest outpatient treatment may be clinically superior to inpatient or residential treatment, especially when coupled with MOUD [21, 22].

"Our subgroup analyses found that among individuals receiving MOUD, outpatient treatment was associated with improved opioid-related ED or hospitalizations compared to residential treatment. Using a similar retrospective cohort design, Morgan et al. found outpatient-based MOUD to be associated with improved rates of opioid overdose and all-cause admissions compared to inpatient treatment initiation [21]. Additional research is required to identify whether other subgroups of patients might benefit from residential treatment in the fentanyl era, such as those with a history of previous unsuccessful attempts at outpatient treatment, housing instability, and adolescents."

"In a national cohort of 40,885 insured individuals between 2015 and 2017, MOUD [Medication for Opioid Use Disorder] treatment with buprenorphine or methadone was associated with a 76% reduction in overdose at 3 months and a 59% reduction in overdose at 12 months. To our knowledge, this was the largest cohort of commercially insured or MA individuals with OUD [Opioid Use Disorder] studied in a real-world environment with complete medical, pharmacy, and behavioral health administrative claims.

"Treatment with buprenorphine or methadone was associated with a 32% relative rate of reduction in serious opioid-related acute care use at 3 months and a 26% relative rate of reduction at 12 months compared with no treatment. In contrast, detoxification, intensive behavioral health, and naltrexone treatment were not associated with reduced overdose or serious opioid-related acute care use at 3 or 12 months.

"Despite the known benefit of MOUD treatment with buprenorphine or methadone, only 12.5% initiated these evidence-based treatments. Most individuals in this cohort initiated treatment with psychosocial services alone or inpatient detoxification, both of which are less effective than MOUD. It is possible that individuals accessed public sector treatments that were not captured in our data, particularly for methadone, which was not covered by Medicare and may not have been covered without co-payment for all commercial plans during this time. Low rates of MOUD use among an insured population highlight the need for strategies to improve access to and coverage for MOUD treatment."

"Our results demonstrate the importance of treatment retention with MOUD [Medication for Opioid Use Disorder]. Individuals who received methadone or buprenorphine for longer than 6 months experienced fewer overdose events and serious opioid-related acute care use compared with those who received shorter durations of treatment or no treatment. These findings are consistent with prior research^11,15,27-29 demonstrating high rates of recurrent opioid use if MOUD treatment is discontinued prematurely. Despite the benefit of MOUD in our study, treatment duration was relatively short. Given the chronic nature of OUD and the evidence that longer treatment duration may be associated with improved outcomes, patient-centered MOUD treatment models explicitly focused on engagement and retention are needed. Low-threshold treatment, which aims to reduce barriers to entry and is tailored to the needs of high-risk populations,³⁰ may be a strategy to improve retention; however, to our knowledge, no rigorous studies have evaluated these models to date.^31,32 In addition, patient-centered MOUD care, which allows participants to determine the services they need rather than requirements, such as mandatory counseling, are noninferior to traditional treatment.³²

"Numerous barriers limit sustained engagement in MOUD, including a lack of access to waivered practitioners, high co-payments, prior authorization requirements, and other restrictions on use. Previous studies^33,34 have demonstrated that restrictions on use for MOUD are associated with limited access and harm. Addiction treatment programs in states that require Medicaid prior authorizations for buprenorphine are less likely to offer buprenorphine, and the more restrictions on use in state Medicaid programs, the fewer treatment programs that offer buprenorphine.³³ Requiring prior authorization for higher doses of buprenorphine may also result in increased recurrence rates among patients.³⁴ Our finding that MOUD treatment with buprenorphine or methadone was associated with lower overdose and serious opioid-related acute care use supports expanded coverage of these medications without restrictions on use.

"Our findings are also consistent with analyses showing that MOUD treatment with buprenorphine or methadone is significantly associated with reduced overdose and recurrence of opioid use compared with no treatment or non-MOUD treatment. A previous cohort study¹⁵ of individuals in Massachusetts demonstrated a reduction in overdose-related mortality associated with treatment with buprenorphine (AHR, 0.62; 95% CI, 0.41-0.92) or methadone (AHR, 0.41; 95% CI, 0.24-0.70), results that are similar to our finding of an AHR of 0.41 (95% CI, 0.31-0.55) for overdose at 12 months for methadone or buprenorphine. A large meta-analysis¹¹ examining mortality when individuals were in or out of treatment with buprenorphine or methadone similarly showed decreased overdose mortality during treatment. A study¹² examining proxies for recurrent OUD among Massachusetts Medicaid enrollees found that treatment with buprenorphine or methadone was associated with lower recurrence rates and costs. No studies, to our knowledge, have examined the effect of different OUD treatment pathways on overdose and serious opioid-related acute care use among a national sample of commercially insured and MA enrollees."

"Our finding that MOUD [Medication for Opioid Use Disorder] treatment with naltrexone was not protective against overdose or serious opioid-related acute care use is consistent with other studies^15,35 that found naltrexone to be less effective than MOUD treatment with buprenorphine. The mean (SD) treatment duration for naltrexone in this cohort was longer than prior observational studies at 74.41 (70.15) days. 

"The findings that nonintensive behavioral health treatment was associated with a reduced risk of overdose at 12 months but not 3 months and a reduced risk of opioid-related acute care use was surprising. Although we attempted to control for differences among various treatment groups, individuals referred to nonintensive behavioral health may represent a less complex patient population than those who receive MOUD treatment or are referred to intensive behavioral health or inpatient treatment."

"Growing evidence suggests that outpatient treatment, when coupled with MOUD, may be superior to other treatment settings. Studies among commercial or Medicare Advantage enrolled patients demonstrate that outpatient treatment involving MOUD is associated with fewer overdoses, readmissions, or subsequent inpatient detoxification stays compared to inpatient detoxification or residential treatment [21, 22]."

"A number of barriers, both social and systemic, prevent people with OUD from accessing the life-saving medications they need. Making headway against the opioid crisis will require addressing barriers related to stigma and discrimination, inadequate professional education, overly stringent regulatory and legal policies, and the fragmented systems of care delivery and financing for OUD.

"The stigmatization of people with OUD is a major barrier to treatment seeking and retention. Social stigma from the general public is largely rooted in the misconception that addiction is simply the result of moral failing or a lack of self-discipline that is worthy of blame, rather than a chronic brain disease that requires medical treatment. Evidence demonstrates that social stigma contributes to public acceptance of discriminatory measures against people with OUD and to the public’s willingness to accept more punitive and less evidence-based policies for confronting the epidemic. Patients with OUD also report stigmatizing attitudes from some professionals within and beyond the health sector, further undercutting access to evidence-based treatment. The medications, particularly the agonist medications, used to treat OUD are also stigmatized. This can manifest in providers’ unwillingness to prescribe medications due to concerns about misuse and diversion and in the public’s mistaken belief that taking medication is “just substituting one drug for another.” Importantly, the rate of diversion is lower than for other prescribed medications, and it declines as the availability of medications to treat OUD increases.

"Despite the mounting crisis, the health care workforce in the United States does not receive adequate, standardized education about OUD and the evidence base for medication-based treatment. This has created a shortage of providers who are knowledgeable, confident, and willing to provide medications to patients. Many rural areas are being overwhelmed by the opioid epidemic and have very few, if any, trained and licensed providers who can prescribe the medications. Misinformation and a lack of knowledge about OUD and its medications are also prevalent across the law enforcement and criminal justice systems."

"Stringent laws and regulatory policies pose substantial barriers to methadone and buprenorphine access. Laws and regulatory requirements restrict outpatient methadone treatment to state- and federally certified OTPs, which is detrimental to long-term treatment adherence for many patients. Unlike methadone, buprenorphine is approved to be prescribed in officebased settings, but only by providers who undergo specialized training and obtain a waiver from the Drug Enforcement Administration. Few providers in the United States have such waivers (estimated at less than 3 percent), and additional regulations limit the number of patients that each provider can treat with medication. To compound the problem, most waivered providers prescribe buprenorphine at well below the capacity they are allowed. These policies are not supported by evidence, nor are such strict regulations imposed on access to life-saving medications for other chronic diseases.

"The system of care delivery for OUD is fragmented and poorly integrated into the broader health system in the United States. Treatment settings and financing streams for SUDs are generally detached from primary care, further obstructing access to medications for OUD, especially among people with other co-occurring conditions. Many providers are reluctant to treat people with OUD because they do not receive timely and sufficient reimbursement by public and private insurance coverage, which often limits or excludes evidence-based medication treatment services for OUD. These barriers are compounded by other restrictions, such as prior authorization policies, dose limitations or forced dose tapers, counseling requirements, and annual or lifetime limits on the amount of OUD medication a person can receive. Almost half of nonelderly adults with OUD are covered by Medicaid, which has been shown to help connect people with medicationbased treatment for OUD and to improve treatment retention. However, Medicaid coverage for OUD medications varies widely by state, with some states excluding methadone and buprenorphine entirely."

"Among people aged 12 or older, the percentage with a past year SUD (i.e., alcohol use disorder, illicit drug use disorder, or both) remained stable between 2015 and 2019 (Figure 45 and 2019 DT 7.46). In 2019, 20.4 million people aged 12 or older (or 7.4 percent of this population) had an SUD in the past year, including 14.5 million who had an alcohol use disorder and 8.3 million who had an illicit drug use disorder (Figure 46). Among the 8.3 million people with a past year illicit drug use disorder, 4.8 million people had a marijuana use disorder, and 1.4 million people had a prescription pain reliever use disorder.

"Among the 20.4 million people aged 12 or older with a past year SUD in 2019, 71.1 percent (or 14.5 million people) had a past year alcohol use disorder (Figure 47), and 40.7 percent (or 8.3 million people) had a past year illicit drug use disorder. Among the 14.5 million people with a past year alcohol use disorder, 12.1 million had an alcohol use disorder but not an illicit drug use disorder. Among the 8.3 million people with a past year illicit drug use disorder, 5.9 million had an illicit drug use disorder but not an alcohol use disorder. Among people with a past year SUD, 11.8 percent (or 2.4 million people) had both an alcohol use disorder and an illicit drug use disorder in the past year.21

"Aged 12 to 17
"Among adolescents aged 12 to 17 in 2019, 4.5 percent (or 1.1 million people) had a past year SUD (Figure 45 and 2019 DT 7.47). These estimates in 2019 were higher than the estimates in 2018, but they were similar to the estimates in 2015 to 2017.

"Aged 18 to 25
"Among young adults aged 18 to 25, the percentage with a past year SUD declined from 15.3 percent (or 5.3 million people) in 2015 to 14.1 percent (or 4.8 million people) in 2019 (Figure 45 and 2019 DT 7.49). The percentage in 2019 was lower than the percentages in 2015 and 2016, but it was similar to the percentages in 2017 and 2018.

"Aged 26 or Older
"Among adults aged 26 or older, the percentage with a past year SUD remained stable between 2015 and 2019 (Figure 45 and 2019 DT 7.50). In 2019, 6.7 percent of adults aged 26 or older (or 14.5 million people) had an SUD in the past year."

"This study found that the savings of supply-control programs are smaller than the control costs (an estimated 15 cents on the dollar for source-country control, 32 cents on the dollar for interdiction, and 52 cents on the dollar for domestic enforcement). In contrast, the savings of treatment programs are larger than the control costs; we estimate that the costs of crime and lost productivity are reduced by $7.46 for every dollar spend on treatment."

"The safety and efficacy of nurse prescribing of MOUD is well established, and its expansion can provide a range of advantages to people who are dependent on opiates. This includes increasing access to treatment, but nurse prescribing of MOUD can increase the numbers of people in treatment from ‘hard-to-reach’ cohorts such as those in rural settings, or those with less financial means [19, 34]. This in itself holds a significant potential to reduce a wide range of harms and costs associated with high-risk opiate use [35, 36]. Developing NP of MOUD can also help to create new and innovative treatments which can allow services such as detoxification for complex clients, normally only considered appropriate for in-patient settings, to be delivered in a person’s own home [37]. Where MOUD treatment is already available, it is likely that developing NP will also provide opportunities for enhanced key working and more responsive services [38]. Within England and Scotland, it has been found that the number of non-medical prescribers has grown considerably in the recent past and this has provided an opportunity for nurses particularly in England to work at an advanced level [39].

"The studies included in this review, although mostly from the USA, are reflective of the European context, in that the development of nurse prescribing of MOUD is subject to the efforts made within each jurisdiction to progress it. There are significant variations across regions in terms of levels of training, autonomy and scope of practice and indeed whether nurse prescribing of MOUD happens at all [40]. For example, in the UK, nurses can prescribe MOUD independently, but ‘nurse practitioner’ is not a legally protected title as it is in other regions [41]. In this respect, the already established potential and recognition of the role of NP of MOUD has yet to be realized globally. Recent initiatives such as the ‘safer supply’ policy in British Columbia in Canada provide good examples of how the nursing workforce can provide service users access to range of MOUD treatments including injectable medications [42]. Given the increasing international policy focus placed on expanding access to harm reduction interventions such as methadone, which reduce drug-related deaths [43], it is imperative that initiatives such as NP of MOUD be fully recognised and developed by legislators, policymakers and planners. In this context, there is some guidance available that clarifies the NP role and illustrates the advantages of NP to non-experts [44]. Developing greater international consensus on this, bolstered by more research, and better ‘marketing’ of the NP model would enhance awareness of the advantages of NP of MOUD even further [40].

"To build on current success, the expansion of NP of MOUD also requires ‘whole-systems’ support. In the first instance, this should start with passing the necessary legislation to allow nurse prescribing to take place [16]. Secondly, in order to ensure maximum uptake and to optimise positive impacts on service users, this legislation should allow NPs to prescribe autonomously [12, 23]. Both third-level institutions and healthcare providers also need to collaborate on how to provide the most appropriate institutional training and support, and this should incorporate ongoing education and ‘in-practice’ supervision [45, 46]. Where relevant, this education and supervision should aim to address negative attitudes of non-specialist prescribing nurses towards people who use drugs [47]. More broadly, this should involve delivering addiction education and ‘pro-social’ messaging into the nursing ‘water supply’ at the undergraduate and postgraduate levels [48]. Assurances should also be provided to potential practitioners by properly resourcing ‘joined-up’ services with adequate clinical governance and appropriate input from multi-disciplinary teams which can support practitioners in caring holistically for people with complex needs [49]. These measures should, in turn, increase the uptake of non-specialist nurse prescribers to MOUD treatment and increase the desire for more nurses to specialise in this area."

"Illicit drug use disorder is defined as meeting DSM-IV criteria for either dependence or abuse for one or more of the following illicit drugs: marijuana, cocaine, heroin, hallucinogens, inhalants, methamphetamine, or prescription psychotherapeutic drugs that were misused (i.e., pain relievers, tranquilizers, stimulants, and sedatives). There are seven possible dependence criteria for specific illicit drugs:

"1. spent a lot of time engaging in activities related to use of the drug,
"2. used the drug in greater quantities or for a longer time than intended,
"3. developed tolerance to the drug,
"4. made unsuccessful attempts to cut down on use of the drug,
"5. continued to use the drug despite physical health or emotional problems associated with use,
"6. reduced or eliminated participation in other activities because of use of the drug, and
"7. experienced withdrawal symptoms when respondents cut back or stopped using the drug.

"For most illicit drugs, dependence is defined as meeting three or more of these seven criteria. However, experiencing withdrawal symptoms is not included as a criterion for some illicit drugs based on DSM-IV criteria. For these substances, dependence is defined as meeting three or more of the first six criteria.

"Respondents who used (or misused) a specific illicit drug in the past 12 months and did not meet the dependence criteria for that drug were defined as having abuse were defined as meeting the abuse criteria for that drug if they reported one or more of the following:

"1. problems at work, home, and school because of use of the drug;
"2. regularly using the drug and then doing something physically dangerous;
"3. repeated trouble with the law because of use of the drug; and
"4. continued use of the drug despite problems with family or friends.

"Application of these criteria is discussed briefly in the respective SUD sections for specific illicit drugs. Detailed definitions for SUDs for specific illicit drugs also can be found in a glossary of key definitions for the 2016 NSDUH.⁹"

"Facility Operation
"Table 2.2 and Figure 2. The operational structure of the substance abuse treatment system (i.e., the types of entities responsible for operating facilities) had some notable changes between 2010 and 2020.

"● Private non-profit organizations operated 58 percent of all facilities in 2010, decreasing to 50 percent in 2020 [Table 2.2 and Figure 2].

"● Private for-profit organizations operated 30 percent of facilities in 2010, increasing to 41 percent of facilities in 2020 [Table 2.2 and Figure 2].

"● Local, county, or community governments operated 6 percent of facilities in 2010, decreasing to 4 percent in 2020 [Table 2.2 and Figure 2].

"● State governments operated 3 percent of facilities in 2010, decreasing to 2 percent in 2020 [Table 2.2 and Figure 2].

"● The federal government operated 2 to 3 percent of facilities each year between 2010 and 2020 [Table 2.2 and Figure 2].5

"● Tribal governments operated 1 to 2 percent of facilities each year between 2010 and 2020 [Table 2.2 and Figure 2].

"Type of Care Offered6
"Table 2.3 and Figure 3. The proportions of facilities that offered outpatient, residential (non-hospital), and hospital inpatient care were stable between 2010 and 2020. OTPs, certified by SAMHSA, provide MAT with methadone, buprenorphine, and naltrexone. Facilities with OTPs can be associated with any type of care. Facilities with OTPs made up 8 to 11 percent of all facilities between 2010 and 2020 [Table 2.4].

"● Outpatient treatment was provided by 81 to 83 percent of facilities during this period [Table 2.3].

"● Residential (non-hospital) treatment was provided by 24 to 26 percent of facilities in this period [Table 2.3].

"● Hospital inpatient treatment was provided by 5 to 6 percent of facilities during this time period [Table 2.3].

"● Outpatient treatment was provided by 90 to 95 percent of facilities with OTPs between 2010 and 2020 [Table 2.3].

"● Residential (non-hospital) treatment was provided by 7 to 9 percent of facilities with OTPs between 2010 and 2020 [Table 2.3].

"● Hospital inpatient treatment was provided by 7 to 10 percent of facilities with OTPs between 2010 and 2020 [Table 2.3].

"Facilities That Use MAT
"Table 2.4. MAT includes the use of methadone or buprenorphine for the treatment of opioid use disorder (OUD) and the use of naltrexone for relapse prevention in OUD. Methadone for OUD is available only at the OTPs that are certified by SAMHSA’s Center for Substance Abuse Treatment.7 Buprenorphine may be prescribed by physicians or other authorized medical practitioners (physicians, physician assistants, and nurse practitioners) who have received Drug Addiction Treatment Act of 2000 (DATA 2000) specific training and received a waiver to prescribe the medication for treatment of OUD; some of these authorized medical practitioners are affiliated with facilities (either OTPs or other). All medical practitioners with prescribing privileges can prescribe injectable naltrexone.

"● The proportion of OTPs that provided methadone-only treatment decreased from 52 percent of all facilities with OTPs in 2010 to 17 percent of all facilities with OTPs in 2020 [Table 2.4].

"● The proportion of OTPs that provided only methadone and buprenorphine treatment decreased from 47 percent of all facilities with OTPs in 2010 to 42 percent in 2020. Between 2012 and 2020, the proportion of facilities with OTPs that offered methadone, buprenorphine, and injectable naltrexone increased from 12 percent in 2012 to 31 percent in 2020; over the same period, the proportion of facilities that offered only buprenorphine and injectable naltrexone increased from less than 1 percent to 6 percent [Table 2.4].8

"● The proportion of facilities (either OTP or non-OTP) that provided any buprenorphine services increased from 18 percent of all facilities in 2010 to 44 percent of all facilities in 2020 [Table 2.4].

"● The percentage of all facilities that provided any extended-release injectable naltrexone treatment increased from 10 percent in 2012 to 37 percent in 2020 [Table 2.4]."

"● The number of substance abuse treatment facilities increased between 2010 and 2020. The number of surveyed facilities eligible for inclusion in the 2020 N-SSATS report was 20 percent larger in 2020 (16,066) than in 2010 (13,339) [Table 2.1]. The number of clients in treatment on the survey reference date increased from 1,224,127 in 2011 to 1,460,706 in 2019, but fell to 1,090,357 in 2020 [Table 3.1].

"● The types of entities responsible for operating facilities—private non-profit organizations, private for-profit organizations, or governments—had some notable changes between 2010 and 2020.2 Facilities operated by private non-profit organizations decreased from 58 percent of all facilities in 2010 to 50 percent of facilities in 2020. Facilities operated by private for-profit organizations increased from 30 percent in 2010 to 41 percent in 2020 [Table 2.2 and Figure 2].

"● The proportions of facilities that offered outpatient, residential [non-hospital], and hospital inpatient care were stable between 2010 and 2020, with the exception of facilities that offered outpatient methadone/buprenorphine maintenance or naltrexone treatment, the proportion of which increased from 9 percent of facilities in 2010 to 36 percent of facilities in 2020 [Table 2.3].

"● The proportion of facilities with opioid treatment programs (OTPs) certified by SAMHSA for the provision of medication-assisted treatment (MAT) with methadone and/or buprenorphine increased from 9 percent in 2010 to 11 percent in 2020 [Table 2.4].

"● Between 2011 and 2020, the proportions of clients in treatment for the major types of care— outpatient, residential (non-hospital), and hospital inpatient— shifted. Clients in outpatient treatment increased from 90 to 94 percent while clients in residential (non-hospital) treatment declined from 9 to 5 percent. The proportion of clients in inpatient hospital treatment ranged between 1 percent and 2 percent from 2011 to 2020 [Table 3.2 and Figure 5].

"● The proportion of all clients who were receiving methadone increased from 25 percent in 2011 to 29 percent in 2020 [Table 3.2].

"● The proportion of all clients who were receiving buprenorphine increased from 3 percent in 2011 to 16 percent 2020 [Table 3.2].

"● The proportions of clients in treatment for the three broad categories of substance abuse problems—both alcohol and drug abuse, drug abuse only, and alcohol abuse only—changed between 2011 and 2020. The proportion of clients in treatment for both drug and alcohol abuse decreased from 44 to 31 percent of all clients. Clients in treatment for drug abuse only increased from 38 to 52 percent, and clients in treatment for alcohol abuse only decreased from 18 to 13 percent [Table 3.3].

"● The number of clients under the age of 18 years declined from 82,532 in 2011 to 39,271 in 2020. The proportion of clients under the age of 18 years in treatment in each type of care (outpatient, residential [non-hospital], or hospital inpatient) differed slightly from the proportion overall. The proportion of clients under the age of 18 years in outpatient treatment increased from 87 percent in 2011 to 91 percent in 2020; the proportion of clients under the age of 18 years in residential (non-hospital) treatment decreased from 12 percent in 2011 to 8 percent in 2020; the proportion of clients under the age of 18 years in hospital inpatient treatment remained steady at 1 percent over this time [Tables 3.4 and 3.2]."

"The proportion of clients in treatment for the three broad categories of substance abuse problems—both alcohol and drug abuse, drug abuse alone, and alcohol abuse alone—demonstrated some changes between 2011 and 2020.

"● The percentage of clients in treatment for both drug and alcohol abuse decreased from 44 percent in 2011 to 31 percent in 2020. (The number of clients in treatment for both drug and alcohol abuse decreased from 535,258 in 2011 to 333,526 in 2020 [Table 3.3].)

"● The percentage of clients in treatment for drug abuse alone increased from 38 percent in 2011 to 52 percent in 2020. (The number of clients in treatment for drug abuse alone increased from 464,406 in 2011 to 743,828 in 2019 and then decreased to 569,522 in 2020 [Table 3.3].)

"● The percentage of all clients in treatment for alcohol abuse alone decreased from 18 percent in 2009 to 13 percent in 2020. (The number of clients in treatment for alcohol abuse alone decreased from 221,632 in 2011 to 146,710 in 2020 [Table 3.3].)

"● The percentage of clients in treatment for diagnosed co-occurring mental and substance use disorders increased from 41 percent in 2011 to 49 percent in 2020. (The number of clients in treatment for diagnosed co-occurring mental and substance use disorders increased from 506,162 in 2011 to 702,914 in 2019, before falling to 531,105 in 2020 [Table 3.3].)"

"In this randomized clinical trial of psilocybin-assisted psychotherapy treatment for AUD [Alcohol Use Disorder], psilocybin treatment was associated with improved drinking outcomes during 32 weeks of double-blind observation. PHDD [Percentage of Heavy Drinking Days] among participants treated with psilocybin was 41% of that observed in the diphenhydramine-treated group. Exploratory analyses confirmed a between-group effect across a range of secondary drinking measures. Although this was, to our knowledge, the first controlled trial of psilocybin for AUD, these findings are consistent with a meta-analysis³⁹ of trials conducted in the 1960s evaluating LSD as a treatment for AUD.

"Adverse events associated with psilocybin administration were mostly mild and self-limiting, consistent with other recent trials evaluating the effects of psilocybin in various conditions.^1-8 However, it must be emphasized that these safety findings cannot be generalized to other contexts. The study implemented measures to ensure safety, including careful medical and psychiatric screening, therapy and monitoring provided by 2 well-trained therapists including a licensed psychiatrist, and the availability of medications to treat acute psychiatric reactions."

"Several limitations of the study warrant discussion. First, diphenhydramine was ineffective in maintaining the blind after drug administration, so biased expectancies could have influenced results. Control medications such as methylphenidate,⁴² niacin,² and low-dose psilocybin¹ likewise did not adequately maintain blinding in past psilocybin trials, so this issue remains a challenge for clinical research on psychedelics. Second, EtG samples, used to validate self-reported drinking outcomes, were available for only 53.8% of treated participants. Third, the study did not have adequate power to evaluate effects in subgroups, such as women, ethnic and racial minority groups, and individuals with psychiatric comorbidity, nor was it designed to identify causal mechanisms, optimal dosing, or predictors of treatment response. Fourth, the study population was lower in drinking intensity at screening than in most AUD medication trials, and results cannot be assumed to generalize to populations with more severe AUD. Fifth, the 2-group design does not permit evaluation of the effects of psychotherapy or the interaction between psychotherapy and medication. Sixth, the study does not provide information on the duration of the effects of psilocybin beyond the 32-week double-blind observation period, which is important given the often chronic, relapsing course of AUD. Further studies will be necessary to address these questions and many others concerning the use of psilocybin in the treatment of AUD."

"A review of 11 studies (McCollister and French 2003) found that the benefit–cost ratios associated with substance abuse treatment ranged from 1.33 to 23.33 and that benefits were overwhelmingly because of reductions in criminal activity, with smaller contributions of earnings, and averted health care. Our conclusion is similar, especially when inflating the arrest data. Our benefit–cost ratio is also similar to the CalDATA estimate, despite differences in study design and methodology. However, our estimates of substance abuse treatment costs tend to be lower than those in previous studies. An earlier literature review by Roebuck, French, and McLellan (2003) suggested that the average cost per treatment episode was $7,358 for MM [Methadone Maintenance], $1,944 for standard outpatient, and $9,426 for residential. Our estimates were $2,737, $838, and $2,791, respectively, based on weighted per diem estimates. The lower episode costs in CalTOP were because of shorter lengths of treatment for MM and residential, as the weekly cost of treatment was actually higher ($99 and $235, respectively, in CalTOP, compared with $91 and $194 in Roebuck et al.). For outpatient, lower episode costs were also attributable to lower weekly costs, around $48 versus $121 in Roebuck et al. These discrepancies might reflect geographic differences in the intensity and duration of treatment."

"In this study, there was no indication that needle-exchange use was associated with increasing drug use. Indeed, IDUs who were former users of the exchange were more likely than never-users to report substantial reductions in drug use or stopping injection altogether. Our analysis also suggested that among heroin injectors, needle-exchange participation was wholly compatible with the goals of drug treatment. Compared to those who had never used an exchange, new exchange users were five times more likely to enter methadone treatment and ex-exchangers were 60% more likely to remain in methadone treatment over the 1-year study period.

"Many factors may influence drug injection frequency in a population, including cost and availability of different drugs and access to drug treatment (Frykholm & Gunne 1980, Nurco et al. 1981, Robins 1980). The natural history of drug injection is also characterized by a progression toward daily use (Robins 1980). The ability of an exchange program to override these underlying factors is not well-understood, however, there is a well-recognized motivation to reduce or cease drug use exhibited by some users (Koester et al. 1999). It is conceivable that exposure to needle exchange could accelerate or facilitate this process by offering encouragement and support for risk reduction and improved self-care, and as a conduit to drug treatment services.

"In this study, baseline rate of injection was an important determinant of subsequent change in injection frequency. In all subject categories, most subjects who initially reported fewer than one injection per day progressed to daily injection by the end of the follow-up period. In contrast, reduction in drug use was more common among those who were daily injectors at the baseline visit. Since it was a potential confounder, we examined the association between needle exchange and reduction in injection, adjusted for baseline injection frequency and within separate strata of daily and nondaily injectors. This method of analysis would tend to reduce the influence of regression to the mean on our results. Further, we found that the group with the highest proportion of subjects reporting reduction in injection frequency (ex-exchangers) reported a relatively lower mean number of injections at study enrollment. Thus, it was unlikely that regression to the mean was responsible for the observed association."

"Using the Substance Abuse and Mental Health Services Administration’s treatment locator and search engine advertising data, we identified 160 residential addiction treatment facilities that treated adolescents with opioid use disorder as of December 2022. We called facilities while role-playing as the aunt or uncle of a sixteen-year-old child with a recent nonfatal overdose, to inquire about policies and costs. Eighty-seven facilities (54.4 percent) had a bed immediately available. Among sites with a waitlist, the mean wait time for a bed was 28.4 days. Of facilities providing cost information, the mean cost of treatment per day was $878. Daily costs among for-profit facilities were triple those of nonprofit facilities. Half of facilities required up-front payment by self-pay patients. The mean up-front cost was $28,731. We were unable to identify any facilities for adolescents in ten states or Washington, D.C. Access to adolescent residential addiction treatment centers in the United States is limited and costly."

"A study in Canada found that personal beliefs of NPs often pose a barrier to providing treatment, for example, views such as patients with OUD deserve less care than other patients [12], this was also reported as a barrier in the study by Spetz and colleagues [31]. Participants on the study acknowledged that some prescribers would avoid prescribing methadone for personal reasons [12]. NPs also discussed that public stigma remains a significant barrier, one stating that “there’s stigma of just going every day to the pharmacy and being there, exposed, people staring at you…” Another NP reflected that stigma may be addressed by educating prescribers and increasing their experience of working with people with OUD. It was also reported that patient’s willingness and lack of education regarding MOUD presented as a barrier to practice [33]. Elliot and colleagues [27] conducted a quasi-experimental study in which five NP doctoral students attended lectures and 16 h of direct clinical experience with OUD patients. Students reported positive attitude changes and personal reflections which suggest that such educational experiences can be beneficial for developing more confident, skilled and compassionate NPs to address the opioid crisis."

"Cannabinoid agonist treatment is unlikely to be an approach relevant to all cannabis users seeking treatment, as evidenced by the large numbers of individuals who did not complete the study screening process, and the modest 12-week treatment retention rates. Whereas nicotine-agonist and opioid-agonist treatments are considered front-line therapies, our findings suggest a more cautious approach for cannabinoid agonist treatment at this time. The control group demonstrated some benefits from treatment, confirming previous research that psychosocial interventions (CBT and case management) without medication can be effective for some patients. Although further research is required to replicate our findings and to refine how cannabinoid agonist treatment is delivered, our study suggests cannabinoid agonist treatment to be a promising approach for treating patients with cannabis dependence, particularly for those who cannot sustain reductions in illicit cannabis use with counseling-only interventions, in a stepped care approach."

"By and large, women with substance use disorders must find a way to support themselves and their children, often with little experience or education and few job skills. They frequently have to overcome feelings of guilt and shame for how they treated their children while abusing substances. When a woman becomes pregnant, her motivation to seek treatment may rise greatly. However, pregnancy itself can be a barrier to treatment because substance abuse treatment programs are not always able to admit pregnant women or to provide the services required, such as medically indicated bed rest, transportation to prenatal care, and nutritious meals (Jessup et al. 2003). Some women fear the negative consequences that will result if their substance abuse becomes known. In many States, pregnant and parenting women can be reported to child protective services, lose custody of their children, or be prosecuted for using drugs. On top of additional healthcare needs, substance use during pregnancy confers stigma and shame, which may create another challenge in treatment.

"A high proportion of women with substance use disorders have histories of trauma, often perpetrated by persons they both knew and trusted. A woman might have experienced sexual or physical abuse or witnessed violence as a child. She may be experiencing domestic violence such as battering by a partner or rape as an adult (Finkelstein 1994; Young and Gardner 1997). These traumas contribute to the treatment needs for women.

"The societal stigma toward women who abuse substances tends to be greater than that toward men, and this stigma can prevent women from seeking or admitting they need help. Women who use alcohol and illicit drugs often have great feelings of shame and guilt, have low levels of self-esteem and self-efficacy, and often are devalued or disliked by other women. These feelings make it difficult for women to seek help or feel that they deserve to be helped— creating yet more treatment needs that must be addressed. Gender role expectations in many cultures result in further stigmatization of substance use; additional challenges face women who are of color, disabled, lesbians, older, and poor."

"Our best estimate is that on average, substance abuse treatment costs $1,583 and is associated with a societal benefit of $11,487, representing a 7:1 ratio of benefits to costs (9:1 when arrest data are “inflated” to proxy for actual crimes committed). This ratio is based on weighted average treatment costs, which reflect expected costs of treatment; 9-month follow-up of clients in all modalities with follow-up survey data, so that as many sources of benefit as possible could be included in the analysis; and benefit measures that demonstrate significant change, so that the estimates are robust to rare events. Sixty-five percent of the total benefit was attributable to reductions in crime costs, including incarceration. Twenty-nine percent was because of increased employment earnings, with the remaining 6 percent because of reduced medical and behavioral health care costs."

"Foremost, cultural competence provides clients with more opportunities to access services that reflect a cultural perspective on and alternative, culturally congruent approaches to their presenting problems. Culturally responsive services will likely provide a greater sense of safety from the client’s perspective, supporting the belief that culture is essential to healing. Even though not all clients identify with or desire to connect with their cultures, culturally responsive services offer clients a chance to explore the impact of culture (including historical and generational events), acculturation, discrimination, and bias, and such services also allow them to examine how these impacts relate to or affect their mental and physical health. Culturally responsive practice recognizes the fundamental importance of language and the right to language accessibility, including translation and interpreter services. For clients, culturally responsive services honor the beliefs that culture is embedded in the clients’ language and their implicit and explicit communication styles and that languageaccommodating services can have a positive effect on clients’ responses to treatment and subsequent engagement in recovery services."

"At midyear 2019, the highest percentage of confined persons receiving MAT was reported in jails in the Northeast (3%), followed by jails in the Midwest and West (1% each) and jails in the South (0.4%) (table 7). Jails in the South accounted for more than half (53%) of the confined jail population at midyear 2019 but nearly a quarter (24%) of jail inmates receiving MAT (not shown in tables). In comparison, jails in the Northeast accounted for 10% of confined persons but 32% of those receiving MAT (not shown in tables). 

"Jail jurisdictions holding fewer than 50 inmates reported the highest percentage of confined persons at midyear 2019 receiving MAT (2%), while jail jurisdictions in each group holding 50 or more inmates reported fewer than 1%. Fewer than 1% of persons confined in urban and rural jails were receiving MAT at midyear 2019.

"Jails located in states with the highest rates of opioid overdose deaths (24.0 or more per 100,000 U.S. residents ages 15 to 74) reported the highest percentage of confined persons receiving MAT (1.4%). In comparison, jails located in states with the lowest rates of opioid overdose deaths (fewer than 10.0 per 100,000) reported the lowest percentage of confined persons receiving MAT (0.3%). 

"About 5% of persons confined in jails in New Mexico, 4% in New Jersey and Washington, and 3% in New York were receiving MAT for OUD (map 6; appendix table 5). A total of 31 states reported that fewer than 1% of their midyear 2019 confined jail population were receiving MAT, of which 20 states reported fewer than 0.5%."

"There is increasing interest in the use of ketamine as an adjunct to treatment of AUD and management of AWS. There were three studies that showed the benefit of using ketamine as an adjunctive treatment to conventional first-line therapies in patients with severe AWS. Ketamine was added to the medication regimen when AWS was refractory to BZD or after clinical signs of delirium tremens (DT). IV ketamine was administered in variable doses ranging from 0.15 to 0.75 mg/kg/h. Ketamine therapy led to a decrease in BZD dose requirements, early resolution of AWS and DT, and decreased duration of ICU stay and intubation time. No AWS complications such as seizures, hallucinations, or delirium tremens were reported after initiation of ketamine (13). The administration of ketamine in AWS was generally safe without any serious adverse effects except oversedation noted in two participants among all the three studies (13, 14). Oversedation was managed by ketamine dose reduction and there was no reported use of any additional treatment modalities. This adverse effect could be explained by either due to the primary known effect of ketamine or due to sedation potentiation by BZD’s administration.

"Despite encouraging results after ketamine initiation in AWS, one of several potential confounders was the use of other medications such as phenobarbital and propofol. In all studies, ketamine was initiated late in AWS management depending on the BZD refractory status of AWS or development of DT. It is possible that the efficacy of ketamine may be greater if it were used as a first line or adjunct to BZD before large doses of BZD or other GABA agonists are used. These limitations make it difficult to determine the true efficacy and situation in which ketamine may be used in AWS.

"We also found seven studies that assessed the efficacy and safety of ketamine for AUD. While the study design, rigor, and target population varied across studies, all studies that examined alcohol outcomes showed greater alcohol abstinence rates in both short-term (21 days) and long-term (1 year) intervals compared to control conditions (43, 44, 46). Ketamine was administered in subanesthetic doses in variable frequency and routes. The highest dose administered was a single dose ketamine 2.5 mg/kg IM (43). Subsequent studies used lower doses – single ketamine 0.35 mg/kg IV infusion, ketamine 0.5 mg/kg IV once weekly for 4 weeks, single ketamine 0.71 mg/kg, three weekly ketamine 0.8 mg/kg IV infusions. Severe adverse effects like euphoria, tachycardia, hypertension, and low mood were reported in 6.3% (3/96) of participants in the Grabski et al. study and affected their normal activities of daily living. Two out of the three participants with severe adverse effects withdrew from the study due to medication intolerability. In addition to ketamine, most studies included adjunctive psychotherapy which may have contributed to outcomes, raising important questions about the frequency, timing, and type of psychotherapy that might help to optimally improve AUD-related outcomes.

"While ketamine did show an improvement in abstinence rates, the longevity of this effect was variable as there was return to alcohol consumption. However, all studies showed ketamine administration produced longer periods of abstinence and reduction in alcohol consumption and cravings, which suggests that ketamine impacts drinking outcomes beyond the direct pharmacologic effects. Furthermore, due to its anti-depressant properties, ketamine may be useful for managing depression that may arise during the abstinence periods."

"Methamphetamine is a highly addictive psychostimulant with evidence of neurotoxic properties (1–3) and is consistently ranked as one of the most harmful illicit substances—both to the person using and to society (4, 5). Methamphetamine use disorder is a chronic relapsing condition increasingly associated with harms that include mental and physical illness, intimate partner violence, family disruption, health care system pressures, homelessness, crime, and mortality (6–10). At present, there are no approved medications to treat methamphetamine use disorder, despite a large body of research investigating potential pharmacological interventions (10–12). The most effective non-pharmacological evidence-based intervention for the management of methamphetamine use disorder is contingency management, a non-psychotherapy behavioral approach that most often involves monetary-based reinforcement for drug-negative urine specimens (13, 14). In practice, psychotherapy is often the standard of care given resource limitations in real world settings, including cognitive behavioral therapy and motivational interviewing. Multiple barriers to treatment exist, such as stigmatizing experiences within the health care system and existing treatment options not meeting patient needs (15). Moreover, people who use methamphetamine consistently demonstrate more challenges in treatment and recovery compared to those using other substances (16, 17). A recent systematic review estimated methamphetamine treatment drop-out rates to be 53.5% (95% CI: 16.5, 87.0), the highest compared to other substances, including the psychostimulant cocaine, with the average drop-out across all substances being 30.4% (95% CI: 27.2-33.8) (18)."

"Among residents of a COVID-19 isolation hotel shelter for people experiencing homelessness, we found that an emergency, provisional safe supply program (i.e., prescribing pharmaceutical-grade medications and beverage-grade alcohol) was associated with low rates of adverse events and high rates of successful completion of the 14-day isolation period. No shelter residents experienced an overdose during their stay. We identified medication dosage ranges that generally fell within those recommended in “risk mitigation” prescribing guidelines, which were urgently produced in response to evolving risks of COVID-19."

"At midyear 2019, fewer than two-thirds (63%) of local jail jurisdictions conducted opioid use disorder (OUD) screenings at intake and more than half (54%) of jail jurisdictions provided inmates medications to treat opioid withdrawal (figure 1). Nearly a quarter (24%) of jail jurisdictions continued medication-assisted treatment (MAT) for OUD for persons admitted with a current prescription or for those who were getting services from a methadone clinic prior to admission. Nearly a fifth (19%) of jail jurisdictions initiated MAT. A quarter (25%) of jail jurisdictions provided overdose reversal medications upon release to persons with OUD."

"The potential use of ketamine for AUD was first suggested in 1972 (32, 33). Possible hypotheses for ketamine use in AUD include balancing cortical glutamate homeostasis and enhancing neuroplasticity which may facilitate learning and acquiring new skills, especially those that help individuals cope with drinking (29, 34). Acute alcohol exposure stimulates the GABA receptors and inhibits the NMDA-glutamate receptors. Chronic alcohol use decreases the concentration of GABA receptors and upregulates NMDA-glutamate receptors. This new balance of inhibitory and excitatory neurotransmitters requires continued regulation with alcohol. Abrupt cessation of alcohol use causes enhanced signaling of the glutamatergic system manifesting as fear, anxiety, and restlessness resulting in a syndrome of alcohol withdrawal. Additionally, the dysregulation of glutaminergic tone results in individuals experiencing alcohol craving. Ketamine mimics some of the mechanisms of action of alcohol through antagonism of the NMDA receptor which may reduce alcohol cravings. Ketamine additionally upregulates the mu and kappa-opioid receptor. The downstream effects are to enhance dopamine secretion which has been described as a mechanism to address depression. For individuals who have AUD, depression is a common comorbidity and may explain some of the potential effects of ketamine on alcohol use (35, 36). Like any substance use, alcohol use can change the neuronal plasticity and lead to formation of maladaptive memories that contribute to increased drug craving and seeking behavior. This neuronal plasticity is partly modulated by the NMDA-glutamate receptor (glutamatergic system) which can be potentially reversed by the inhibitory action on this receptor by ketamine (37, 38). Ketamine can also serve as a potential adjunct in the management of AWS. Ketamine may serve as an adjunct to benzodiazepines in AWS because it acts as an NMDA antagonist and may help to balance cortical glutamate homeostasis faster with decreased sedation time than with benzodiazepines alone (39)."

"Cultural competence is the ability to recognize the importance of race, ethnicity, and culture in the provision of behavioral health services. Specifically, it is awareness and acknowledgment that people from other cultural groups do not necessarily share the same beliefs and practices or perceive, interpret, or encounter similar experiences in the same way. Thus, cultural competence is more than speaking another language or being able to recognize the basic features of a cultural group. Cultural competence means recognizing that each of us, by virtue of our culture, has at least some ethnocentric views that are provided by that culture and shaped by our individual interpretation of it. Cultural competence is rooted in respect, validation, and openness toward someone whose social and cultural background is different from one’s own (Center for Substance Abuse Treatment [CSAT] 1999b).

"Nonetheless, cultural competence literature highlights how difficult it is to appreciate cultural differences and to address these differences effectively, because many people tend to see things solely from their own culture-bound perspectives. For counselors, specific cognitions, attitudes, and behaviors characterize the path to culturally competent counseling and culturally responsive services. Exhibit 1-2 depicts the continuum of thoughts and behaviors that lead to cultural competence in the provision of treatment. The “stages” are not necessarily linear, and not all people begin with a negative impression of other cultural groups—they may simply fail to recognize differences and diverse ways of being. For most people, the process of becoming culturally competent is complex, with movement back and forth along the continuum and with feelings and thoughts from more than one stage sometimes existing concurrently."

"Using national data, we found that blacks and Hispanics were 3.5–8.1 percentage points less likely than whites to complete treatment for alcohol and drugs, and Native Americans were 4.7 percentage points less likely to complete alcohol treatment. Only Asian Americans fared better than whites for both types of treatment. Completion disparities for blacks and Hispanics were largely explained by differences in socioeconomic status and, in particular, greater unemployment and housing instability. However, the alcohol treatment disparity for Native Americans was not explained by socioeconomic or treatment variables, a finding that warrants further investigation."

"The prescribing practices described in this evaluation – safe supply medications and managed alcohol, for unwitnessed consumption – are a recent development. While the relative safety of medications and alcohol dispensed for unwitnessed consumption has not been previously well-described in the literature, the practice is an extension of the evidence from witnessed consumption settings (Bonn et al., 2021; Brothers et al., 2022; Tyndall, 2020; Hales et al., 2020; Bonn et al., 2021). Witnessed injectable OAT (iOAT) with liquid hydromorphone or diacetylmorphine (Heroin) has a robust evidence-based and has been incorporated into Canadian clinical practice guidelines for opioid use disorder (Oviedo-Joekes et al., 2016; Fairbairn et al., 2019). Qualitative studies have evaluated the benefits of witnessed hydromorphone tablet consumption, which is more flexible and less resource-intensive than witnessed iOAT (Ivsins et al., 2021; Ivsins et al., 2020). A recent study from Ottawa, Canada, describes positive outcomes for people with severe opioid use disorder who are provided hydromorphone iOAT along with supported housing (Harris et al., 2021). Benefits of managed alcohol programs are also clearly established for people with severe alcohol use disorder, and particularly people who drink non-beverage alcohol (Stockwell et al., 2021; Stockwell et al., 2018; Crabtree et al., 2018). Some existing managed alcohol programs include once-daily alcohol dispensing and/or unwitnessed ingestion (Pauly et al., 2018)."

"Between June 1 and June 30, 2019, an estimated 894,030 persons were admitted to local jails (table 3). During that period, jails in the Northeast admitted 53,340 persons and screened 80% of those admissions for OUD. More than a quarter (26%) of OUD screenings in the Northeast were positive. Jails in the West (197,570 admissions) and Midwest (208,880) had about four times as many admissions as those in the Northeast and screened a smaller percentage for OUD (68% of admissions in the West and 61% in the Midwest). Jails in the South (434,230 admissions), with more than eight times as many admissions as jails in the Northeast, screened 62% of admissions for OUD. Fifteen percent of OUD screenings in the South, 13% in the Midwest, and 11% in the West were positive. 

"Larger jail jurisdictions (those holding 1,000 or more inmates) reported that 79% of persons admitted in June 2019 were screened for OUD. Forty-eight percent of persons admitted in smaller jail jurisdictions (those holding fewer than 250 inmates) were screened for OUD. While the percentage of admissions screened generally increased with jail jurisdiction size, the percentage of screenings that were positive fluctuated. The percent of positive OUD screenings (22%) was highest in jail jurisdictions holding 100 to 249 inmates.

"Urban jails (69%) screened a larger percentage of admissions for OUD than rural jails (53%). However, a greater percentage of screenings in rural jails (19%) than in urban jails (13%) were positive. In states with the highest opioid overdose death rates (24.0 or more per 100,000 U.S. residents ages 15 to 74), local jails conducted OUD screenings on 68% of June 2019 admissions. For states with the lowest opioid overdose death rates (fewer than 10.0 per 100,000), 58% of admissions were screened. Twenty-two percent of OUD screenings in states with the highest opioid overdose death rates were positive, compared to 6% in states with the lowest rates."

"Forty-one percent of local jail jurisdictions initiated behavioral or psychological treatment for OUD, 24% continued MAT for persons admitted with a current prescription or getting services from a methadone clinic prior to admission, and 19% initiated MAT for inmates with OUD at midyear 2019. Regardless of region, jail jurisdiction size, locality, or opioid overdose death rate, larger percentages of jail jurisdictions initiated behavioral or psychological treatment for OUD than initiated or continued MAT. 

"In states with 24.0 or more opioid overdose deaths per 100,000 U.S. residents ages 15 to 74, 28% of jail jurisdictions continued MAT, while 25% initiated MAT. In states with fewer than 10.0 opioid overdose deaths per 100,000, 19% of jail jurisdictions continued MAT and 13% initiated MAT for OUD."

"Counselors who are aware of their own cultural backgrounds are more likely to acknowledge and explore how culture affects their client– counselor relationships. Without cultural awareness, counselors may provide counseling that ignores or does not address obvious issues that specifically relate to race, ethnic heritage, and culture. Lack of awareness can discount the importance of how counselors’ cultural backgrounds—including beliefs, values, and attitudes—influence their initial and diagnostic impressions of clients. Without cultural awareness, counselors can unwittingly use their own cultural experiences as a template to prejudge and assess client experiences and clinical presentations. They may struggle to see the cultural uniqueness of each client, assuming that they understand the client’s life experiences and background better than they really do. With cultural awareness, counselors examine how their own beliefs, experiences, and biases affect their definitions of normal and abnormal behavior. By valuing this awareness, counselors are more likely to take the time to understand the client’s cultural groups and their role in the therapeutic process, the client’s relationships, and his or her substance-related and other presenting clinical problems. Cultural awareness is the first step toward becoming a culturally competent counselor."

"Our analysis points to factors that may help explain disparities and guide policy. In particular, when we adjusted for both individual need and provider setting, we found that alcohol treatment disparities widened between whites and blacks and between whites and Native Americans. Blacks and Native Americans also were more likely to be treated in residential settings than were whites, suggesting that higher placement rates in residential treatment for these groups may actually help limit disparities and could compensate for other forms of disadvantage.

"Further adjustment for socioeconomic status narrowed the completion gap between whites and blacks and between whites and Hispanics for both alcohol and drug treatment. This change suggests that housing instability and lower employment are important barriers to treatment completion for blacks and Hispanics. Adjusting for socioeconomic status modestly increased the relative Asian American advantage, probably because if Asian Americans had the same educational attainment as whites, they would fare even better in treatment.

"Our findings linking lower socioeconomic status to worse treatment completion are important. Low socioeconomic status is a known risk factor for poor access to and quality of mental health treatment.³⁰ Nonethless, some studies suggest that low socioeconomic status may, paradoxically, promote greater access to substance abuse treatment for minorities.³¹ Adjusting for socioeconomic status narrowed white-minority disparities for all groups except Native Americans in alcohol treatment. This finding warrants further investigation, since Native Americans in alcohol treatment were more likely than whites to be unemployed and to have less education."

"Findings from our study illustrate that many substance use programs do not fit directly into a binary of “harm reduction” or “treatment.” Most of the participating programs in this study reported offering a spectrum of harm reduction and treatment services. Still, SSPs [Syringe Service Programs] were most likely to offer harm reduction services, MOUD [Medications for Opioid Use Disorder] programs were most likely to offer treatment services, and those characterized as offering both MOUD & SSPs were most likely to offer the broadest services. Program clients also did not fit into the supposed binary of “active drug use” vs. “abstinence.” In fact, of the clients who attended MOUD only programs, nearly three quarters reported using non-prescribed drugs in the past week, and more than half reported injecting drugs in the past week; these rates were similar to those reported by clients who attended combined MOUD & SSP programs. Meanwhile, more than 40% of those who attended SSP only programs reported attending some type of drug treatment service in the past month.

"Our results reveal some important incongruencies between services being offered by substance use programs and characteristics and behaviors reported by clients who attend such programs. For example, while three-quarters of MOUD program clients reported using non-prescribed drugs (one-quarter reported using opioids), only two-thirds of these programs offered overdose education or naloxone distribution and one-third offered fentanyl testing or test strips. This is highly concerning given the high prevalence of fentanyl in both the opioid and non-opioid illicit drug supplies [21] and may partly reflect the presence of policies that criminalize possession of fentanyl test strips in some of the sampled states [22]. Moreover, half of clients who attended MOUD programs without SSP or wound care actively injected drugs. While it is possible that these clients seek safe injection supplies elsewhere, a minority (14%) reported visiting an SSP in the past month.

"There were also discrepancies in services offered by SSPs relative to client-reported service utilization. Of clients recruited from SSPs without MOUD, 22% indicated receiving methadone and 8% reported receiving buprenorphine in the past month. This implies clients are either seeking these medications via other service providers or acquiring them on the street, which has been reported to often be easier than enrolling in formal treatment [9, 23, 24]. Roughly half of MOUD programs offered same-day treatment initiation. Additionally, SSP programs were reaching the highest risk population that with the greatest rates of active drug use. Yet, on average, these programs reported having the smallest number of staff and the least available treatment or social services relative to the other programs types. The limited workforce and services offered may reflect the limited budgets often used to operate these programs. Many harm reduction services operate independently from the medical system and are not eligible for insurance reimbursement. Additionally, programs have been historically banned from accessing federal and local funds for SSPs; programs have had to depend on scarce funds acquired a combination of small grants, individual donations, and charitable foundations [4, 25]. The Biden Administration’s 2021 American Rescue Act was the first federal action to allocate targeted funding toward harm reduction services and SSPs [25, 26]. While this was an important step to potentially help scale up these services, local and national resistance and stigma to these programs remains persistent (highlighted by the recent resistance to federal funding sterile pipes [27]). Continued efforts to combat ongoing stigma and political resistance to these programs are needed [25]."

"While cultural and structural differences continue to divide many substance use treatment and harm reduction services, the needs and goals of people who seek these two services may have always been much less distinctive. For example, many who attend substance use treatment continue to use drugs [5]. Similarly, many who attend harm reduction programs seek to engage in treatment at some points [6]. Indeed, clients of SSPs are approximately five times more likely to engage in treatment and three times more likely to stop using drugs than persons who do not access SSPs [7]. In recent decades, harm reduction and treatment goals have become increasingly blurred with the growing uptake of medications for opioid use disorder (MOUD). In particular, methadone and buprenorphine are used by some with a goal of abstaining from opioid use; for others, MOUD are used to help mitigate withdrawal and overdose risk without abstaining from drug use [8, 9].

"Despite this reality, programs that successfully combine treatment and harm reduction services and principles are often the exception rather than the rule [8, 10, 11]. Yet, the increasing severity of the opioid overdose crisis in North America and the rise in viral and bacterial infections among PWUD [12–14] have led to a recognition of the urgent need to utilize multiple approaches toward the joint goal of reducing drug-related harms [15]. In particular, concerns about the increasingly lethal opioid supply [16] have emphasized the need to use any available evidence-based strategies known to reduce opioid-related overdose mortality. These concerns have encouraged more treatment providers to incorporate harm reduction approaches (e.g., naloxone distribution and overdose education) [17], and harm reduction providers to integrate MOUD as a direct service [18]."

"Findings from this study demonstrate that in many ways, existing programs are not adequately meeting the service needs of or catering to the realities of PWUD. Creating a substance use service system that is truly person-centered and successful at improving health and dignity will necessitate moving away from the binary mentality of harm reduction vs. treatment to one which is better tailored to individual clients. This includes offering a continuum of co-located treatment, harm reduction, and social services that can meet individuals where they are. This would help facilitate access to life-saving services and greater socioeconomic stability [28, 29]. This may be particularly important for individuals with multiple vulnerabilities, as well as during emergencies—such as the COVID-19 pandemic—when minimizing travel and co-locating access to multiple health and social services is key [30]. In our study, programs that included both MOUD & SSP offered the greatest range of treatment and harm reduction services, including naloxone distribution, overdose prevention education, same-day treatment initiation, drop-in spaces, peer services/street outreach, and counseling services. However, these programs were the rarest in our sample of providers and remain largely under-resourced and at the periphery of the substance use service system. Moreover, such integrated models have been made possible by the ability to prescribe buprenorphine in non-traditional treatment settings [31]. Methadone, which may be the most effective and desirable MOUD option for some individuals, and used by many participants in our study, is still largely restricted to the opioid treatment program system bound by regulations on staffing, zoning, and hefty requirements for patients such as frequent urine drug screening [32, 33]. While there are some successful models of lower threshold methadone in other countries[34], scaling up methadone to meet needs of PWUD in the USA will require rethinking some of the core federal and state regulations, including expanding methadone availability beyond the opioid treatment program system [35]. It is important to note that most participating clients reported using drugs other than opioids; thus, integrating interventions for stimulant and other drug use should be central to efforts to better align programs with client behaviors."

According to the Substance Abuse and Mental Health Service's Treatment Episode Data Set, in 2020 in the US there were 139,481 admissions to treatment with marijuana reported as the primary substance out of the total 1,416,357 admissions to treatment in the US for those aged 12 and older for all substances that year.

By comparison, in 2010 in the US there were 358,034 admissions to treatment with marijuana reported as the primary substance out of the total 1,928,013 admissions to treatment in the US for those aged 12 and older for all substances that year.

"• The proportion of marijuana/hashish admissions aged 12 years and older steadily declined each year from 18.6 percent in 2010 to 9.8 percent in 2020. [Table 1.1b].

"• The average age at admission was 28 years among admissions for primary use of marijuana/hashish [Table 2.1b].

"• Whites represented 50.9 percent of primary marijuana/hashish admissions aged 12 years or older, while Blacks or African Americans represented 34.2 percent [Table 2.2b].

"• Among admissions for primary marijuana/hashish use aged 12 years or older, 18.9 percent were of Hispanic or Latino origin [Table 2.2b].

"• Among admissions aged 12 year or older that were admitted for primary use of marijuana/hashish 68.4 percent were male, and 31.6 percent were female. [Table 2.1b]."

"In 2016 only 13.8 percent of substance use treatment programs accepted Medicare and offered an FDA-approved medication for opioid use disorder treatment (exhibit 1). While the percentage of programs that offered such treatment was low across all insurance types (24.8 percent among programs that accepted Medicaid and 28.6 percent among programs that accepted private insurance), access for Medicare beneficiaries was nearly twice as limited. Furthermore, just 20.8 percent of US counties—home to roughly 60 percent of the Medicare population—had at least one treatment program that accepted Medicare and offered buprenorphine or injectable naltrexone for older adults (exhibit 2). The majority of counties with at least one treatment program that accepted Medicare and offered an opioid use disorder treatment medication (65.1 percent) were in urban areas (data not shown). In 2016, 36.4 percent of treatment programs accepted Medicare, compared to 63.7 percent that accepted Medicaid and 70.3 percent that accepted private insurance. Of the treatment programs that accepted private insurance, 46.5 percent also accepted Medicare. Of those that accepted Medicaid, 52.1 percent also accepted Medicare."

"Recent trials with extended-release formulations and higher dosages of PPs, particularly prescription amphetamines, have shown promising results promoting abstinence from cocaine and reducing drug use. PPs’ potential as an “agonist-type” treatment seems to be better explored with higher dosage regimens and at clinical settings that have direct observed dosing available. The results from patients with comorbid opioid use disorders are particularly encouraging, and this may be due to the fact that high dosages of potent PPs were used, and this population is already enrolled to a healthcare facility that offers daily attendance, supervised medication intake, evidencebased psychosocial interventions, and a wide-range of ancillary services. A widely used and successful model of treating opioid use disorder or incorporating mobile technology solutions to monitor and enhance medication adherence may now be assessed for treatment of individuals with psychostimulant use disorder and incorporate prescription amphetamines as an agonist intervention. Considering the major public health impact of untreated PSUD, and the absence of the widely accepted pharmacological intervention, there is an urgent need to conduct implementation studies of this treatment approach."

"In this trial, patients assigned to receive injectable diacetylmorphine were more likely to stay in treatment and to reduce their use of illegal drugs and other illegal activities than patients assigned to receive oral methadone. These findings are consistent with the results of European studies that suggest greater effectiveness of diacetylmorphine than methadone as maintenance treatment for long-term, treatment-refractory opioid use.^10,12,13 Two of these trials showed no differences between groups in the rate of retention in treatment for addiction. However, the fact that control patients were eligible to receive diacetylmorphine at the end of the study period may have introduced a bias in the observed retention rates. In addition, patients currently enrolled in methadone maintenance treatment were eligible for the European trials but not for the present study. Although the definitions of clinical response varied among the trials, all of them considered the same variables (drug use, illegal activities, health, and social adjustment) and showed greater effectiveness of diacetylmorphine than of methadone for maintenance treatment.

"Secondary analyses showed that both groups had significant improvement in many of the variables that were evaluated. The diacetylmorphine group had greater improvements with respect to medical and psychiatric status, economic status, employment situation, and family and social relations. These results are particularly noteworthy in view of the nature of the population and the time frame. The fact that patients who received diacetylmorphine had significant improvement in these areas suggests a positive treatment effect beyond a reduction in illicit-drug use or other illegal activities."

"In this trial, both diacetylmorphine treatment and optimized methadone maintenance treatment resulted in high retention and response rates. Methadone, provided according to best-practice guidelines, should remain the treatment of choice for the majority of patients. However, there will continue to be a subgroup of patients who will not benefit even from optimized methadone maintenance. Prescribed, supervised use of diacetylmorphine appears to be a safe and effective adjunctive treatment for this severely affected population of patients who would otherwise remain outside the health care system."

"VIVITROL was approved in 2006 by the FDA as an extended-release formulation of naltrexone for the treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment. VIVITROL is administered by intramuscular (IM) injection once per month."

"A few key conclusions and discussion points regarding the state and future of HAT (heroin-assisted treatment) can be offered based on the above review of completed or ongoing studies.

"First, although the basic goal of the different HAT studies is similar, each of the studies is distinct in key aspects, thus limiting direct comparisons and meta-analyses.⁴⁰ Although this might be a desirable goal for science, it should be noted that heroin addiction and its consequences occur in distinct real-life environments (including unique cultural and system factors), and interventions need to be devised, measured, and evaluated within these to have authentic relevance for policy and practice.^33,41

"Second, the discussed studies above have demonstrated in several different contexts that the implementation of HAT is feasible, effective, and safe as a therapeutic intervention.^21,24,26,30 This should not be seen as a conclusion that could be taken for granted because many observers expected disastrous consequences from the provision of medical heroin prescription.

"Third, even within the contexts of relevant methodological constraints, e.g., the Swiss study relying purely on prospective observational data, and most of the other RCTs comparing HAT outcomes against a control intervention (MMT), which participants have previously either rejected by choice or proven to be ineffective, ^32,42 the reviewed HAT studies have demonstrated rather robust and consistently positive therapeutic outcomes on the various indicators chosen for a population of high-risk heroin addicts for whom currently no effective alternative therapies are available. Clearly, this demonstrated effectiveness is at this point limited to short-term outcomes, and long-term examinations ought to follow (albeit Swiss follow-up data present initial positive evidence in this regard).⁴³ It may very well emerge that HAT's main long-term benefit does not materialize through life-long maintenance, but by stabilizing and readying many of its patients for other simpler therapeutic interventions or even abstinence.

"Fourth, also given the current expansion and diversification of alternative oral opioid maintenance therapies (e.g., buprenorphine and morphine) and considering the complex logistics (on both providers and patients_ ends), high costs, and sociopolitical controversy around (especially injection) HAT, the most sensible role of HAT is likely that of an exceptional 'last resort' option for heroin addicts who cannot be effectively attracted into or treated in other available therapeutic interventions.^44,45 Granted the above, the primary emerging challenge for science—rather than conducting new and more HAT effectiveness studies—is to provide evidence-based guidelines on how to effectively match existing heroin addict profiles and needs with existing treatment options. This challenge has recently been complicated—in at least some jurisdictions—with the increasing diversification of heroin into poly-opioid (e.g., prescription) use profiles.⁴⁶

"Finally, after extensive HAT research efforts over the past decade, the principal onus of action has shifted from the scientific to the political arena in the jurisdictions under study.^12,18 Despite the overall positive results of completed HAT trials undoubtedly justifying some role of HAT in the addiction treatment landscape, authorities in only two countries, Switzerland and the Netherlands, have decisively acted on this issue.³⁴"

"NSDUH includes questions that are used to identify people who needed substance use treatment (i.e., treatment for problems related to the use of alcohol or illicit drugs) in the past year. For NSDUH, people are defined as needing substance use treatment if they had an SUD in the past year or if they received substance use treatment at a specialty facility³² in the past year.^33,34
"In 2016, an estimated 21.0 million people aged 12 or older needed substance use treatment. Stated another way, about 1 in 13 people aged 12 or older (7.8 percent) needed substance use treatment (Figure 45).34 About 1.1 million adolescents aged 12 to 17 needed treatment for a substance use problem in the past year, representing 4.4 percent of adolescents. About 5.3 million young adults aged 18 to 25 needed treatment for a substance use problem in the past year, representing 15.5 percent of young adults. Stated another way, about 1 in 7 young adults needed substance use treatment. About 14.5 million adults aged 26 or older needed substance use treatment in the past year, which represents 6.9 percent of adults in this age group."

"Some 4.3 percent of Americans have been dependent on marijuana, as defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision(DSM-IV-TR; American Psychiatric Association,2000), at some time in their lives. Marijuana produces dependence less readily than most other illicit drugs. Some 9 percent of those who try marijuana develop dependence compared to, for example, 15 percent of people who try cocaine and 24 percent of those who try heroin. However, because so many people use marijuana,cannabis dependence is twice as prevalent as dependence on any other illicit psychoactive substance (cocaine, 1.8 percent; heroin, 0.7 percent; Anthony and Helzer,1991; Anthony, Warner, and Kessler, 1994)."

"Expressed in monetary terms, some US$ 200 billion-250 billion (0.3-0.4 per cent of global GDP) would be needed to cover all costs related to drug treatment worldwide. In reality, the actual amounts spent on treatment for drug abuse are far lower — and less than one in five persons who needs such treatment actually receives it."

"Globally, the extent to which people in need of drug treatment actually receive it remains limited. In 2016, as in previous years, an estimated one in six people who had drug use disorders received treatment. Despite limitations, information about people in treatment for drug use can provide useful insight into trends and geographical variations with respect to drug use disorders. However, this information should be interpreted with caution because treatment numbers reflect not only demand for treatment (the number of people seeking help) but also the extent of the provision of treatment (depending on government willingness to finance treatment services).

"Most people in drug treatment in Africa, the Americas and Oceania are being treated for cannabis use. In all regions except Africa, an increasing proportion of the drug treatment provided is related to cannabis use. Although cannabis has consistently been the most common drug of use among those receiving drug treatment in Africa, treatment for opioid use disorders is increasing in the region. This trend may be an indication that ongoing trafficking of heroin and pharmaceutical opioids in transit through Africa to other destinations has produced a worrying spillover effect on drug use within Africa. Opioids remain a major concern in Europe and Asia, especially in Eastern and South-Eastern Europe, where two of every three people in drug treatment are there for opioid use disorders.

"Cocaine continues to be a drug of concern among those receiving treatment in Latin America and the Caribbean, in particular, where one third of those in treatment for drug use disorders are being treated for cocaine use, although that proportion has been declining. Cocaine use disorders are reported as the primary reason for drug treatment, albeit to a lesser extent, in North America and Western and Central Europe as well. In North America, treatment primarily for cocaine use disorders has been declining in relative importance, while the proportion of those in treatment for opioid use disorders has increased. In the United States, between 2004 and 2014, the number of admissions related primarily to the use of cocaine declined by 65 per cent, from 248,000 to 88,000 individuals, and treatment for the use of opiates increased by 51 per cent, from 323,000 to 490,000 individuals. There is a higher proportion of treatment for the use of ATS in Asia and Oceania than in other regions."

"It is estimated that 20 per cent of problem drug users in 2010 received treatment for their drug dependence. Opioids (largely heroin) continue to be the dominant drug type accounting for treatment demand in Asia and Europe (particularly in Eastern Europe and South-Eastern Europe, where they account for almost four out of every five drug users in treatment). Opioids also contribute considerably to demand for treatment in Africa, North America and Oceania. Only in South America is demand for treatment for opioid use negligible (accounting for 1 per cent of all demand for treatment for drug dependence in the region).
"Cannabis, the most widely consumed illicit drug world-wide, is considered to be the least harmful of the illicit drugs. Yet it is the dominant drug accounting for treatment demand in Africa, North America and Oceania, a major contributor to treatment demand in South America and the second most important contributor to such treatment in Europe.
"Treatment for cocaine use is largely associated with the Americas, particularly South America, where it accounts for nearly half of all treatment for illicit drug use, whereas in Asia, Eastern Europe, South-Eastern Europe and Oceania, the share of demand for treatment for drug use accounted for by cocaine use is negligible (less than 1 per cent).
"Demand for treatment for the use of ATS (mostly methamphetamine), is most noticeable in Asia where such drugs are the second major contributor to treatment demand, and to a lesser extent in Oceania, Western and Central Europe and North America."

"More than 60 per cent of drug treatment demand in Asia and Europe relate to opiates that are, especially heroin, the most deadly drugs. Deaths due to overdose are, in any single year, as high as 5,000-8,000 in Europe, and several times this amount in the Russian Federation alone."

"• In 2013, 2.5 million persons (0.9 percent of persons aged 12 or older and 10.9 percent of those who needed treatment) received treatment at a specialty facility for an illicit drug or alcohol problem. The number in 2013 was similar to the numbers in 2002 (2.3 million) and in 2004 through 2012 (ranging from 2.3 million to 2.6 million), and it was higher than the number in 2003 (1.9 million). The rate in 2013 was not different from the rates in 2002 to 2012 (ranging from 0.8 to 1.0 percent).
"• In 2013, 20.2 million persons (7.7 percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive treatment at a specialty facility in the past year. The number in 2013 was similar to the numbers in 2002 to 2012 (ranging from 19.3 million to 21.1 million). The rate in 2013 was similar to the rates in 2010 to 2012 (ranging from 7.5 to 8.1 percent), but it was lower than the rates in 2002 to 2009 (ranging from 8.3 to 8.8 percent).
"• Of the 2.5 million persons aged 12 or older who received specialty substance use treatment in 2013, 875,000 received treatment for alcohol use only, 936,000 received treatment for illicit drug use only, and 547,000 received treatment for both alcohol and illicit drug use. These estimates in 2013 were similar to the estimates in 2012 and 2002."

"In 2007, the criminal justice system was the largest single source of referrals to the substance abuse treatment system, comprising 37 percent of all admissions in the Treatment Episode Data Set (TEDS) (approximately 670,500 of the 1.8 million admissions). Moreover, the majority of these referrals were from parole and probation offices (44 percent of criminal justice admissions where detailed criminal justice source information is known)."

"Five primary substances of abuse accounted for 96 percent of all substance abuse treatment admissions in 2007: alcohol, opiates (including heroin and prescription painkillers), marijuana, cocaine, and methamphetamine. Criminal justice system referral admissions were more likely than all other referral admissions to report primary alcohol abuse, primary marijuana abuse, and primary methamphetamine abuse and less likely to report primary opiate abuse. The high rate of criminal justice system referral admissions younger than 18 years old may have contributed significantly to the high rate of admissions with marijuana as a primary substance of abuse."

"An admission [to treatment] was considered marijuana-involved if marijuana was reported as a primary, secondary, or tertiary substance. In 1999, 43 percent of all adolescent admissions were marijuana-involved admissions referred to treatment by the criminal justice system, and 39 percent were marijuana involved but referred by other sources. Between 1999 and 2002, the proportion referred by the criminal justice system increased to 45 percent while the proportion referred by other sources decreased to 37 percent. The proportions started to converge in 2007.
"Adolescent admissions not involving marijuana that were referred by the criminal justice system fell from 8 percent in 1999 to 5 percent in 2009. Admissions not involving marijuana that were referred from other sources were fairly stable, at between 9 and 11 percent of adolescent admissions."

Heroin
"• Heroin was reported as the primary substance of abuse for 26 percent of TEDS admissions aged 12 and older in 2015 [Table 1.1b].

"• Sixty-seven percent of primary heroin admissions were non-Hispanic White (41 percent were males and 26 percent were females). Non-Hispanic Blacks made up 14 percent (9 percent were males and 5 percent were females). Admissions of Puerto Rican origin made up 7 percent of primary heroin admissions (6 percent were males and 1 percent were females) [Table 2.3b]. See Chapter 3 for additional data on heroin admissions.

"• Injection was reported as the usual route of administration by 68 percent of primary heroin admissions; inhalation was reported by 25 percent. Daily heroin use was reported by 63 percent of primary heroin admissions [Table 2.4b].

"• Twenty-two percent of primary heroin admissions had no prior treatment episode, and 25 percent had been in treatment five or more times previously [Table 2.5b].

"• Primary heroin admissions were less likely than all admissions combined to be referred to treatment by the court/criminal justice system (14 vs. 30 percent) and more likely to be self or individually referred (61 vs. 41 percent) [Table 2.6b].

"• Medication-assisted opioid therapy was planned for 37 percent of heroin admissions [Table 2.7b].

"• Only 17 percent of primary heroin admissions aged 16 and older were employed (vs. 25 percent of all admissions that age); 45 percent were not in labor force (vs. 39 percent of all admissions that age) [Table 2.8b].

"• Sixty-one percent of primary heroin admissions reported abuse of additional substances. Marijuana/hashish was reported by 18 percent, alcohol by 14 percent, and non-smoked cocaine by 13 percent [Table 3.8].

Opiates Other than Heroin
"• Opiates other than heroin were reported as the primary substance of abuse for 8 percent of TEDS admissions aged 12 and older in 2015 [Table 1.1b]. These drugs include methadone, buprenorphine, codeine, hydrocodone, hydromorphone, meperidine, morphine, opium, oxycodone, pentazocine, propoxyphene, tramadol, and any other drug with morphine-like effects.

"• Admissions for primary opiates other than heroin were more likely than all admissions combined to be aged 20 to 39 (74 vs. 58 percent) [Table 2.1b].

"• Non-Hispanic Whites made up approximately 82 percent of admissions for primary opiates other than heroin (43 percent were males and 39 percent were females) [Table 2.3b].

"• The usual route of administration most frequently reported by admissions of primary opiates other than heroin was oral (61 percent); next were inhalation (18 percent) and injection (16 percent) [Table 2.4b].

"• Admissions for primary opiates other than heroin were more likely than all admissions combined to report first use after age 18 (66 vs. 39 percent) [Table 2.5b].

"• Medication-assisted opioid therapy was planned for 31 percent of admissions for primary opiates other than heroin [Table 2.7b].

"• Fifty-eight percent of admissions for primary opiates other than heroin reported abuse of other substances. The most commonly reported secondary substances of abuse were marijuana/hashish (22 percent), alcohol (16 percent), and tranquilizers (12 percent) [Table 3.8]."

"While it is generally assumed that polydrug use is a hard-to-treat condition, results from large treatment outcome studies in Europe show significant reductions in multiple drug use among highly problematic users. Nevertheless, managing the care of problem polydrug users requires long-term treatment planning with attention to individual needs and multidisciplinary teams working together with flexible and sometimes innovative treatment options."

"• Admissions for primary abuse of alcohol with secondary abuse of drugs represented 18 percent of TEDS admissions aged 12 and older in 2012 [Table 1.1b].
"• The average age at admission for primary alcohol with secondary drug abuse was lower, at 37 years, than for abuse of alcohol alone (41 years) [Table 2.1a].
"• Non-Hispanic Whites accounted for 58 percent of admissions for primary alcohol with secondary drug abuse (41 percent were males and 17 percent were females). Non-Hispanic Blacks made up 23 percent of admissions (18 percent were males and 6 percent were females) [Table 2.3a].
"• Almost half (45 percent) of admissions for primary alcohol with secondary drug abuse first became intoxicated by age 14, and 93 percent first became intoxicated before age 21 (the legal drinking age) [Table 2.5].
"• Admissions for primary alcohol with secondary drug abuse were less likely to be in treatment for the first time than alcohol-only admissions (35 vs. 46 percent) [Table 2.5].
"• Among admissions referred to treatment by the criminal justice/DUI source, admissions for alcohol with secondary drug abuse were more likely than alcohol-only admissions to have been referred to treatment as a condition of probation/parole (30 vs. 17 percent) [Table 2.6].
"• Among admissions for alcohol with secondary drug abuse, marijuana and smoked cocaine were the most frequently reported secondary substances (25 percent and 8 percent, respectively) [Table 3.8]."

"• Admissions for abuse of alcohol alone, with no secondary drug abuse, represented 21 percent of TEDS admissions aged 12 and older in 2012 [Table 1.1b].
"• The average age at admission among admissions for alcohol only was 41 years. The average age at admission for alcohol with secondary drug was 37 years [Table 2.1a]. Admission for alcohol only or with secondary drug was the most likely reason for admissions aged 30 and older [Table 2.1b].
"• Non-Hispanic Whites made up 66 percent of all alcohol-only admissions (approximately 46 percent were males and 21 percent were females) [Table 2.3a].
"• Eighty-seven percent of alcohol-only admissions reported that they first became intoxicated before age 21, the legal drinking age. Almost one-third (30 percent) first became intoxicated by age 14 [Table 2.5].
"• Among admissions referred to treatment by the criminal justice/DUI source, alcohol-only admissions were more likely than admissions for alcohol with secondary drug abuse to have been referred as a result of a DUI/DWI offense (28 vs. 16 percent) [Table 2.6].
"• Some 34 percent of alcohol-only admissions aged 16 and older were employed compared with 22 percent of all admissions that age [Table 2.8]."

"Facilities were asked to estimate the proportion of clients in treatment with diagnosed co-occurring mental and substance abuse disorders.
"• On March 30, 2012, 46 percent of clients who were in treatment had a diagnosed co-occurring mental and substance abuse disorder.
"• The highest proportions of clients with co-occurring mental and substance abuse disorders were in federal government-operated facilities (61 percent) and in facilities with a primary focus of mental health services (74 percent)."

"In 2004, about 642,000 State prisoners were drug dependent or abusing in the year before their admission to prison. An estimated 258,900 of these inmates (or 40%) had taken part in some type of drug abuse program (table 10). These inmates were more than twice as likely to report participation in selfhelp or peer counseling groups and education programs (35%) than to receive drug treatment from a trained professional (15%).
"In Federal prison, a higher percentage of drug dependent or abusing inmates (49%) reported taking part in some type of drug abuse programs. Nearly 1 in 3 took part in drug abuse education classes, and 1 in 5 had participated in self-help or peer counseling groups. Overall, 17% took part in drug treatment programs with a trained professional, and 41% had participated in other drug abuse programs."

" A recent issue of The DASIS Report² examined marijuana treatment admissions between 1992 and 2002 and found that between these years [1992 and 2002] the rate of substance abuse treatment admissions reporting marijuana as their primary substance of abuse³ per 100,000 population increased 162 percent. Similarly, the proportion of marijuana admissions increased from 6 percent of all admissions in 1992 to 15 percent of all admissions reported to the Treatment Episode Data Set (TEDS) in 2002.
"During this time period, the percentage of marijuana treatment admissions that were referred from the criminal justice system increased from 48 percent of all marijuana admissions in 1992 to 58 percent of all marijuana admissions in 2002."

"Nationally, in 2012, the rate of opioid abuse or dependence was 891.8 per 100,000 people aged 12 years or older compared with national rates of maximum potential buprenorphine treatment capacity and patients receiving methadone in OTPs of, respectively, 420.3 and 119.9. Among states and the District of Columbia, 96% had opioid abuse or dependence rates higher than their buprenorphine treatment capacity rates; 37% had a gap of at least 5 per 1000 people. Thirty-eight states (77.6%) reported at least 75% of their OTPs were operating at 80% capacity or more."

Available Treatment Capacity and Services Offered

"Facilities were asked to report the number of residential (non-hospital) and hospital inpatient beds designated for substance abuse treatment. Utilization rates were calculated by dividing the number of residential (non-hospital) or hospital inpatient clients by the number of residential (non-hospital) or hospital inpatient designated beds. Because substance abuse treatment clients may also occupy non-designated beds, utilization rates could be more than 100 percent.
"• Table 4.6. Some 2,401 facilities (23 percent) reported outpatient operational capacity under 80 percent, 3,628 facilities (34 percent) reported outpatient operational capacity between 80 and 94 percent, 3,818 facilities (36 percent) reported outpatient operational capacity between 95 and 105 percent and 727 facilities (7 percent) reported operational capacity above 105 percent.
"• Table 4.7. Some 3,281 facilities reported having 107,888 residential (non-hospital) beds designated for substance abuse treatment on March 30, 2012. The utilization rate11 was 96 percent, and ranged from 86 percent in facilities operated by local governments to 112 percent in facilities operated by tribal governments.
"• Table 4.8. Some 731 facilities reported having 11,280 hospital inpatient beds designated for substance abuse treatment on March 30, 2012. The utilization rate12 was 111 percent, and ranged from 79 percent in facilities operated by the state government to 2,000 percent in facilities operated by tribal governments. By facility focus, utilization rates ranged from 88 percent in facilities primarily focused on general health care to 165 percent in facilities focused on mental health services.
"• Tables 4.7 and 4.8 and Figure 7 show the distribution of facility-level utilization rates for residential (non-hospital) beds and for hospital inpatient beds. Facilities with residential (non-hospital) beds had generally higher utilization rates than facilities with hospital inpatient beds. Forty-eight percent of facilities with residential (non-hospital) beds had utilization rates of 91 to 100 percent and 10 percent had utilization rates above 100 percent. Twenty-nine percent of facilities with hospital inpatient beds had utilization rates of 91 to 100 percent while 16 percent had utilization rates above 100 percent."

"Facilities were asked about the provision of treatment programs or groups specially designed for specific client types. Overall, 82 percent of facilities offered at least one special program or group to serve a specific client type."

^{1: Facilities treating incarcerated persons only were excluded from this report.
2: Persons who have experienced trauma, active duty military, and the military families categories appeared for the first time in the 2012 questionnaire.}

"Facilities were asked to indicate whether or not they accepted specified types of payment or insurance for substance abuse treatment. They were also asked about the use of a sliding fee scale and if they offered treatment at no charge to clients who could not pay.
"• The proportions of all facilities reporting acceptance of specific payment options were:
"  • Cash or self-payment  90 percent
"  • Private health insurance  65 percent
"  • Medicaid  58 percent
"  • State-financed health insurance  40 percent
"  • Medicare  33 percent
"  • Federal military insurance  33 percent
"• Facilities operated by federal and tribal governments were least likely to accept cash or self-payment (41 and 42 percent, respectively). Private for-profit and federal government-operated facilities were less likely to accept Medicare, Medicaid, or state-financed health insurance than were facilities operated by private non-profits and state, local, or tribal governments.
"• Acceptance of Access to Recovery vouchers was reported in 35 states or jurisdictions. The proportion of facilities accepting Access to Recovery vouchers ranged from 2 percent in Utah to 74 percent in Idaho [Table 6.19b].16
"• Use of a sliding fee scale was reported by 62 percent of all facilities, ranging from 18 percent of facilities operated by the federal government to 82 percent of facilities operated by local governments.
"• Facilities operated by tribal governments were the most likely to accept IHS/63817 contract care funds (70 percent).
"• Treatment at no charge for persons who cannot afford to pay was offered by 50 percent of all facilities, ranging from 21 percent of private for-profit facilities to 84 percent of facilities operated by tribal governments."

"One or more of the 17 specified ancillary services were provided by 99 percent of all facilities (Table 1). Ancillary services provided by more than half of all facilities included substance abuse education (94 percent); case management services (76 percent); social skills development (66 percent); HIV or AIDS education, counseling, or support (56 percent); mental health services (54 percent); and assistance with obtaining social services (52 percent)."

Barriers to Treatment Access

"Increasing evidence suggests that distance, which can impact travel times to outpatient treatment settings, can have a significant effect on OSAT service utilization. Fortney et al. [22] studied 106 clients receiving treatment for depression and found that increased travel time from providers was significantly associated with making fewer visits and a greater likelihood of receiving less effective care [22]. Similarly, Beardsley et al. [21] focused on the distance traveled by 1,735 clients to various outpatient treatment programs in an urban setting. They found that distance is strongly correlated with treatment completion and higher retention rates; specifically, clients who traveled less than one mile (less than 1.6 kilometers) were more likely to complete treatment than those who traveled farther [21]."

"Using a multi-method approach, we identified specific areas with limited availability of OSAT [Outpatient Substance Abuse Treatment] services in Spanish in the county with the largest population of Spanish-speaking Latinos in the United States. While most communities have access to services in Spanish, the northeast area of the county – representing SPA 3 with cities such as Rowland-Hacienda Heights, West Covina, La Puente, Alhambra, El Monte, and Rosemead – reported the greatest linear distance to treatment facilities offering services in Spanish. Maps of these Latino communities, which surround cold spots E and G, show the significant scarcity of general and Spanish-speaking providers. This is a geographic region that is home to almost one fifth (18%) of the county’s Latino residents, and where 70% of Latino residents report speaking primarily Spanish in the home [39].
"It is highly likely that the disparity between the need for Spanish-language substance abuse treatment and
geographical accessibility to Spanish OSAT services in certain regions of the County (e.g., SPA 3) is greater than what is presented in this study. U.S. Census data from 2000 yield conservative Latino population estimates in L.A. County, and although final 2010 Census estimates are not yet fully available, it is evident that the Latino population has grown rapidly in the last decade. Possibly the most interesting finding extracted from these maps is that the areas traditionally known to have high Latino populations (the three highlighted SPAs–4, 6, and 7–in Figure 1) may be relatively well served. It is the more fragmented, but expanding, communities that may not be accurately depicted in data from 2000 (i.e., SPA 3) wherein the greatest need for language capacity building exists. Considering that Latinos are the fastest-growing ethnic minority group [6], the unmet service need found in this study is likely to be more pronounced in population data from 2010, as preliminary information indicates significant growth in SPA 3.
When combined with the oversimplification of linear distance and considering that the most recent data are
the facility locations, our findings suggest that an inaccessibility problem exists for neighborhoods in these areas. It is expected that there will always be neighborhoods that are poorly served due to isolation. However, these results, especially if overlaid with other socioeconomic measures, will make for an interesting comparison between 2000 and 2010 census population distributions in future studies."

"The relationship between access to responsive services and treatment completion rates among Latinos points to a serious need for greater geographic proximity to Spanish-language services for this population. Although testing treatment outcomes is not the focus of this paper, it should be noted that studies suggest that linguistic preferences significantly impact the treatment process among Latinos, indirectly contributing to treatment outcomes [5,19,25,26]. In particular, engaging clients in their native language during the intake process increases treatment retention and compliance, which are highly associated with treatment completion and improvements in posttreatment drug use. Similarly, studies have found that limited availability of bilingual treatment services is highly associated with high attrition rates from substance abuse treatment among Latinos when compared to other racial/ethnic groups [27-30].
"Highlighting potential barriers to health care access, such as distance to treatment, is of importance as past studies indicate that treatment completion rates are affected by transportation issues related to distance to outpatient treatment sources [31]. In particular, low-income individuals with significant transportation and communication challenges would be at a considerable disadvantage in terms of addressing their substance abuse issues."

"In contrast to other chronic diseases, funding for addiction treatment disproportionately comes from government sources. More than three quarters—77 percent—of treatment costs are paid by federal, state and local governments, including Medicaid and Medicare.
"Private insurance covers only 10 percent of addiction treatment costs, with out-of-pocket expenditures and other private funding making up the remaining percentage. In contrast, private insurance pays for approximately 37 percent of general medical costs. The passage of federal parity and health care reform legislation should help address this imbalance in the future.
"On an individual level, nearly half of those receiving treatment reported using their own money to pay for their care, and 34.8 percent report using private health insurance."

"To be equally represented in treatment, the ratio of males to females in treatment should be similar to the ratio of males to females in problem drug use. Using past-month prevalence as a proxy for problematic use,²⁴ gender-disaggregated data from EMCDDA on past-month prevalence and outpatient clients in treatment suggest that in most countries in Europe females could be underrepresented in treatment for the problematic use of cannabis, cocaine and amphetamines (see figure 5). There are few studies that analyse gender differences in the accessibility of treatment services; however, the ratio of males and females reported in treatment in Europe was 4:1 — higher than the ratio between male and female drug users.²⁵ In many developing countries, there are limited services for the treatment and care of female drug users and the stigma associated with being a female drug user can make accessibility to treatment even more difficult. In Afghanistan, for instance, 10 per cent of all estimated drug users have access to treatment services,²⁶ whereas only 4 per cent of female drug users and their partners have access to treatment services and interventions."

Effectiveness

"The overriding finding from this study is that treatment is associated with a reduction in harmful behaviours that are associated with problem drug use. The majority of treatment seekers received care-coordinated treatment, expressed satisfaction with their care, were retained in treatment beyond three months, reported significant and substantial reductions in drug use and offending, and improvements in mental well-being and social functioning."

"Results: Compared with computer- or therapist-delivered CBT/MI [cognitive behaviour therapy and motivational interviewing], PCT [person-centred therapy] was associated with significantly less reduction in depression and alcohol consumption at 3 months. CAC [(clinician-assisted computerised] therapy was associated with improvement at least equivalent to that achieved by therapist-delivered treatment, with superior results as far as reducing alcohol consumption. Change in depression was significantly predicted by change in alcohol use (in the same direction) and an ability to determine primacy, irrespective of whether this was for drug use or depression. Change in alcohol use was significantly predicted by changes in cannabis use and depression, and change in cannabis use by change in alcohol use. In the regression model, treatment allocation did not independently predict change, but was associated with significant reduction in depression and alcohol use at 3 months.
"Conclusions: Over a 3-month period, CBT/MI was associated with a better treatment response than supportive counselling. CAC therapy was associated with greater reduction in alcohol use than therapist-delivered treatment."

"Across racial and ethnic groups, treatment completion rates were generally highest for people receiving treatment that primarily targeted alcohol abuse, followed by treatment for methamphetamines, and were lowest for treatment for heroin (Exhibit 2). Except for opiates and heroin, where the differences were not significant, Asian Americans were more likely than whites to complete treatment for all substances. Conversely, blacks and Hispanics were significantly less likely than whites to complete treatment for all substances except for opiates. Native Americans had significantly lower completion rates than whites for all substances except for cocaine and methamphetamines.
"Blacks and Hispanics were less likely than whites to complete treatment across all settings, and Asian Americans were more likely (Exhibit 3). The alcohol treatment completion rate was generally higher for people discharged from residential settings, followed by intensive outpatient settings. However, Asian Americans and Hispanics were just as likely to complete nonintensive as intensive outpatient alcohol treatment."

"During the course of treatment, many treatment seekers stopped using the drugs that they reported using at entry to the study. Lower rates of drug use were recorded at each follow-up. Furthermore, those that continued to use tended to use less. Most of the changes observed occurred by first follow-up. For most forms of drug use, no particular treatment modality was more associated with cessation than any other and the route into treatment (CJS or non-CJS) did not influence drug-use outcomes.

"The proportion using each drug reduced significantly between baseline and follow-up (Figure 5). Most of this change occurred by first follow-up; indeed use of some drug types increased marginally, and levels of abstinence from all drugs decreased between first and second follow-up.

"The proportion of treatment seekers using heroin, crack, cocaine, amphetamine or benzodiazepines decreased between baseline and follow-up by around 50 per cent; the proportion using non-prescribed methadone or other opiates such as morphine, decreased by considerably more; but the proportion using cannabis or alcohol decreased by considerably less.The proportion who reported each drug to be causing problems fell substantially for all drug types, suggesting that continued use was often, in the client’s view, non-problematic."

"Overall, lower levels of acquisitive offending and high-cost offending were recorded at follow-up. Among those who continued to offend, improvements in offending behaviour at follow-up, in terms of a decrease in its volume and/ or the costs associated with it, were observed. Crack users, injecting users, users with high SDS [Severity of Dependence Scores] scores, and those with previous treatment experience were more likely to offend than others at any point. However, neither referral source nor the type of treatment modalities received, were significantly associated with the level of acquisitive offending at any point (within the adjusted model)."

"Increases in admissions to substance abuse treatment are associated with reductions in crime rates. Admissions to drug treatment increased 37.4 percent and federal spending on drug treatment increased 14.6 percent from 1995 to 2005. During the same period, violent crime fell 31.5 percent. Maryland experienced decreases in crime when jurisdictions increased the number of people sent to drug treatment."

"Examination of all clients exiting [drug treatment] in 2005-06 revealed that 46% didn’t return to drug treatment nor had a drug related contact with the CJS [criminal justice system] in the following four years. This would suggest the majority of these individuals are managing to sustain their recovery from addiction though it is not possible to confirm this from the analysis presented in this report."

"The Drug Treatment Outcomes Research Study (DTORS) was one example of European research with encouraging results regarding employment (Jones et al., 2009). This study investigated drug use, health and psychosocial outcomes in 1 796 English drug users attending a range of different types of treatment service. Follow-up interviews were conducted between 3 and 13 months after baseline (soon after initial treatment entry). Regardless of the type of treatment received or drug use outcomes, employment levels increased from 9 % at baseline to 16 % at follow-up. This was accompanied by a corresponding increase in the amount of legitimate income earned per week. The proportion reporting being unemployed but actively looking for work decreased slightly from 27 % to 24 %, reflecting the increase in employment and a 5 percentage point increase in those reporting being unable to work (because of long-term sickness or disability). The proportion of participants classed as unemployed and not looking for work also fell from 24 % to 11 %. Treatment attendance was also associated with changes in housing status; the proportion staying in stable accommodation increased from 60 % to 77 % at follow-up. It should be noted that the findings of this study were weakened by use of a non-experimental design, failure to separate outcomes according to client type and treatment modality, and insufficient detail on the nature of the employment obtained."

"In a recent secondary analysis of a national US survey of clients conducted in the early 1990s (National Treatment Improvement Evaluation Study), researchers tried to identify which types of treatment modality (methadone-substitute prescribing, methadone-assisted detoxification, outpatient detoxification, short-term residential, long-term residential or criminal justice focused) and treatment characteristics (e.g. length of treatment) were associated with better employment outcomes (Dunlap et al., 2007). Overall, the treatment modality received and the characteristics of that treatment (such as length of stay or number of sessions completed) were not significantly associated with employment outcomes. The strongest predictor of employment was pre-treatment employments. The authors hypothesised that receipt of treatment services per se was less important than the quality of services received, although this was not tested."

Cost Effectiveness of Substance Use Treatment

The RAND Corporation found that the additional spending needed to achieve a 1% reduction in the number of cocaine users varies according to the sort of program used, and that treatment is the most cost-effective:

Table comparing cost effectiveness of spending on treatment versus law enforcement for reducing substance use

"Substance abuse treatment is more cost-effective than prison or other punitive measures. The Washington State Institute for Public Policy (WSIPP) found that drug treatment conducted within the community is extremely beneficial in terms of cost, especially compared to prison. Every dollar spent on drug treatment in the community is estimated to return $18.52 in benefits to society."

"The percentage of recent drug users in State prison who reported participation in a variety of drug abuse programs rose from 34% in 1997 to 39% in 2004 (table 9). This increase was the result of the growing percentage of recent drug users who reported taking part in self-help groups, peer counseling and drug abuse education programs (up from 28% to 34%). Over the same period, the percentage of recent drug users taking part in drug treatment programs with a trained professional was almost unchanged (15% in 1997, 14% in 2004).

"Participation in drug abuse programs also increased among Federal inmates who had used drugs in the month before their offense, from 39% in 1997 to 45% in 2004. While there was no change in percentage of these inmates who had undergone drug treatment with a trained professional (15% in both years), the percentage taking part in other drug abuse programs rose from 32% in 1997 to 39% in 2004."

"Government agencies and professional societies,* including the American Society of Addiction Medicine, have recommended against using AAROD in clinical settings (9). There is insufficient knowledge regarding how widely AAROD is used in the United States and the frequency of AAROD-associated adverse events in community practice settings. At least seven deaths occurred following AAROD among 2,350 procedures performed in one practice during 1995–1999.†
"The New York City clinic investigation revealed that AAROD was performed on 75 patients during January–September 2012 and was associated with two deaths and five additional adverse events requiring hospitalization, a serious adverse event rate of 9.3%. No standard protocol exists for AAROD; however, the clinic’s practice was consistent with AAROD use described elsewhere (7). All events occurred after and in close temporal proximity to AAROD. Although a common mechanism linking these events to AAROD is not evident, the events are consistent with previously proposed mechanisms of AAROD-associated adverse events, including electrolyte disturbance, catecholamine release, altered cardiopulmonary functioning, acute lung injury, and other physiologic effects associated with administration of high doses of opioid antagonists under general anesthesia (10). Given the ongoing epidemic of prescription opioid dependence, further increases in the demand for substance use disorder services are to be expected. AAROD has substantial risks, including a risk for death, and little to no evidence to support its use. Safe, evidence-based treatments of opioid dependence (e.g., MAT [Medication-Assisted Treatment]) exist and are preferred (2)."

^{* Additional information available at http://www.nice.org.uk/. Care Med 2000;28:969–76.
† Additional information available at http://njlaw.rutgers.edu/coll….}

"Harm-reduction services for problematic drug users usually address the associated harms and risk behaviours, such as injecting, with a holistic approach that focuses on the nature and severity of the behaviours and problems experienced by the individual, rather than on a specific substance. Therefore, in response to the elevated health risks associated with problem drug use, including polydrug use, harm-reduction services are generally provided on a case-by-case basis and often according to professionals’ own work experience. Furthermore, harm-reduction interventions usually operate within a broader local prevention strategy that combines other types of services such as outreach work and opioid substitution treatment, which contribute to the reduction of risks and health problems experienced by problem polydrug users. Evidence of the effectiveness of harm-reduction interventions has been reported in other EMCDDA publications (EMCDDA, 2008a) and will be reviewed in a forthcoming monograph on harm reduction."

"In 2003, an estimated $21 billion was spent on drug and alcohol addiction treatment. This represents 1.3 percent of all health care spending for that year."

"• In 2013, among the 20.2 million persons aged 12 or older who were classified as needing substance use treatment but not receiving treatment at a specialty facility in the past year, 908,000 persons (4.5 percent) reported that they perceived a need for treatment for their illicit drug or alcohol use problem (Figure 7.10). Of these 908,000 persons who felt they needed treatment but did not receive treatment in 2013, 316,000 (34.8 percent) reported that they made an effort to get treatment, and 592,000 (65.2 percent) reported making no effort to get treatment. These estimates were stable between 2012 and 2013.

"• The rate and the number of youths aged 12 to 17 who needed treatment for an illicit drug or alcohol use problem in 2013 (5.4 percent and 1.3 million) were lower than those in 2012 (6.3 percent and 1.6 million), 2011 (7.0 percent and 1.7 million), 2010 (7.5 percent and 1.8 million), and 2002 (9.1 percent and 2.3 million). Of the 1.3 million youths who needed treatment in 2013, 122,000 received treatment at a specialty facility (about 9.1 percent of the youths who needed treatment), leaving about 1.2 million who needed treatment for a substance use problem but did not receive it at a specialty facility.

"• Based on 2010-2013 combined data, commonly reported reasons for not receiving illicit drug or alcohol use treatment among persons aged 12 or older who needed and perceived a need for treatment but did not receive treatment at a specialty facility were (a) not ready to stop using (40.3 percent), (b) no health coverage and could not afford cost (31.4 percent), (c) possible negative effect on job (10.7 percent), (d) concern that receiving treatment might cause neighbors/community to have a negative opinion (10.1 percent), (e) not knowing where to go for treatment (9.2 percent), and (f) no program having type of treatment (8.0 percent).

"• Based on 2010-2013 combined data, among persons aged 12 or older who needed but did not receive illicit drug or alcohol use treatment, felt a need for treatment, and made an effort to receive treatment, commonly reported reasons for not receiving treatment were (a) no health coverage and could not afford cost (37.3 percent), (b) not ready to stop using (24.5 percent), (c) did not know where to go for treatment (9.0 percent), (d) had health coverage but did not cover treatment or did not cover cost (8.2 percent), and (e) no transportation or inconvenient (8.0 percent) (Figure 7.11)."

"• Marijuana/hashish was reported as the primary substance of abuse by 15 percent of TEDS admissions aged 12 and older in 2014 [Table 1.1b].
"• The average age at admission for primary marijuana/hashish admissions was 26 years [Table 2.1b], although the peak age at admission for both genders in all race/ethnicities was about 16 to 17 years [Figure 12]. Thirty-two percent of marijuana/hashish admissions were under age 20 (vs. 8 percent of all admissions combined), and primary marijuana/hashish abuse accounted for 78 percent of admissions aged 12 to 14 and 76 percent of admissions aged 15 to 17 years [Table 2.1c].
"• Non-Hispanic Whites accounted for 44 percent of primary marijuana/hashish admissions (30 percent were males and 14 percent were females), and non-Hispanic Blacks accounted for 31 percent (24 percent were males and 8 percent were females) [Table 2.3b].
"• Twenty-four percent of primary marijuana/hashish admissions had first used marijuana/hashish by age 12 and another 30 percent had first used it by age 14 [Table 2.5b].
"• Primary marijuana/hashish admissions were most likely to be referred by the court/criminal justice system (52 percent). Primary marijuana/hashish admissions were less likely than all admis-sions combined to be self- or individually referred to treatment (18 vs. 37 percent) [Table 2.6b].
"• More than 4 in 5 marijuana/hashish admissions (86 percent) received ambulatory treatment; among all admissions combined, 3 in 5 (61 percent) received ambulatory treatment [Table 2.7b].
"• Sixty-three percent of primary marijuana/hashish admissions reported abuse of additional sub-stances. Alcohol was reported by 37 percent [Table 3.8]."

"Domestic enforcement costs 4 times as much as treatment for a given amount of user reduction, 7 times as much for consumption reduction, and 15 times as much for societal cost reduction."

"Despite the many factors that contribute to the gap, the Panel agrees with many in the field that inadequate funding for substance abuse treatment is a major part of the problem. Over the last decade, spending on substance abuse prevention and treatment has increased, albeit more slowly than overall health spending, to an estimated annual total of $12.6 billion in 1996 (McKusick, Mark, King, Harwood, Buck, Dilonardo, and Genuardi, 1998). Of this amount, public spending is estimated at $7.6 billion (McKusick, et al., 1998). The public spending includes dollars from Medicaid and Medicare, as well as other Federal funds from the Department of Defense, the Department of Veterans Administration, the Department of Justice, and the Substance Abuse Prevention and Treatment (SAPT) Block Grant. The SAPT Block Grant provides Federal support to addiction prevention and treatment services nationally through State and local governments. Private spending includes individual out-of-pocket payment, insurance, and other nonpublic sources, and is estimated at $4.7 billion (McKusick, et al., 1998)."

"One of the main reasons for the higher outlay in public spending is the frequently limited coverage of substance abuse treatment by private insurers. Although 70 percent of drug users are employed and most have private health insurance, 20 percent of public treatment funds were spent on people with private health insurance in 1993, due to limitations on their policy (ONDCP, 1996b). In the view of the Panel, private insurers should serve as the primary source of coverage, with public insurance serving as the safety net."

"An additional cocaine-control dollar generates societal cost savings of 15 cents if used for source-country control, 32 cents if used for interdiction, and 52 cents if used for domestic enforcement. In contrast, the savings from treatment programs are larger than control costs: an additional cocaine-control dollar generates societal cost savings of $7.48 if used for treatment."

"Increased admissions to drug treatment are associated with reduced incarceration rates. States with a higher drug treatment admission rate than the national average send, on average, 100 fewer people to prison per 100,000 in the population than states that have lower than average drug treatment admissions. Of the 20 states that admit the most people to treatment per 100,000, 19 had incarceration rates below the national average. Of the 20 states that admitted the fewest people to treatment per 100,000, eight had incarceration rates above the national average."

"Many countries believe (erroneously) that the international drug conventions prohibit the use of heroin in medical treatment. Furthermore, the International Narcotics Control Board (INCB) has exerted great pressure on countries to cease prescribing heroin for any medical purpose. Nevertheless, a few countries, including the UK, Belgium, the Netherlands, Iceland, Malta, Canada and Switzerland, continue to use heroin (diamorphine) for general medical purposes, mostly in hospital settings (usually for severe pain relief). Until recently, however, Britain was the only country that allowed doctors to prescribe heroin for the treatment of drug dependence."

"Currently, pharmaceutical treatment for substance abuse addiction in the United States is limited to two basic types: (1) replacement therapy; and (2) aversion therapy.²¹ Replacement therapy is characterized by substituting or replacing the drug that the person is addicted to with a “safer drug” under the theory that the individual can be weaned off the replacement drug over time.²² The most prominent examples of this are methadone maintenance for heroin addiction and nicotine replacement drugs for smokers.²³ Unfortunately, there are no “safer drugs” available for individuals with addictions to cocaine, crack, or methamphetamine.²⁴"

"Aversion therapy, on the other hand, involves the use of drugs that interact negatively with the drug of addiction, such as disulfiram, which is used to treat alcoholism.²⁵ This treatment choice posits that the individual will be deterred from using the drug to which they are addicted because, when combined with aversion drugs, it induces nausea, vomiting, and physical pain.²⁶ The problems associated with these treatment methods, however, are numerous. Both require long-term treatment, which greatly increases the chance that an addict will quit treatment and return to using.²⁷ Replacement therapy simply replaces one drug with another, and, as is the case with methadone, the “safer drug” is itself addictive. ... The unpleasant side effects associated with aversion therapy, however, result in many patients stopping treatment and relapsing.³¹"

"Only orally given THC and, to a lesser extent, nefazodone have shown promise [in treating marijuana dependence]. THC reduced craving and ratings of anxiety, feelings of misery, difficulty sleeping, and chills (Haney et al., 2004). In addition, participants could not distinguish active THC from placebo. These findings were replicated in an outpatient study, which found that a moderate oral dosage of THC (10 mg, three times daily) suppressed many marijuana withdrawal symptoms and that a higher dosage (30 mg, three times daily) almost completely abolished withdrawal symptoms (Budney et al., 2007)."

"Changing The Conversation initiated the first intensive exploration of the stigmas and attitudes that affect people with alcohol and drug problems. The Panel addressed stigma as a powerful, shame-based mark of disgrace and reproach that impedes treatment and recovery. Prejudicial attitudes and beliefs generate and perpetuate stigma; therefore, people suffering from alcohol and/or drug problems and those in recovery are often ostracized, discriminated against, and deprived of basic human rights. Their families, treatment providers, and even researchers may face comparable stigmas and attitudes. Ironically, stigmatized individuals often endorse the attitudes and practices that stigmatize them. They may internalize this thinking and behavior, which consequently becomes part of their identity and sense of self-worth.

"Public support and public policy are influenced by addiction stigma. Addiction stigma delays acknowledging the disease and inhibits prevention, care, treatment, and research. It diminishes the life opportunities of the stigmatized."

"Prescribing injectable opiates is one of many options in a range of treatments for opiate-dependent drug users. In showing that it attracts and retains long term resistant opiate-dependent drug users in treatment and that it is associated with significant and sustained reductions in drug use and improvements in health and social status, our findings endorse the view that it is a feasible option."

"The German model project for heroin-assisted treatment of opioid dependent patients is so far the largest randomised control group study that investigated the effects of heroin treatment. This fact alone lends particular importance to the results in the (meanwhile worldwide) discussion of effects and benefits of heroin treatment. For the group of so-called most severely dependent patients, heroin treatment proves to be superior to the goals of methadone maintenance based on pharmacological maintenance treatment. This result should not be left without consequences. In accordance with the research results from other countries, it has to be investigated to what extent heroin-assisted treatment can be integrated into the regular treatment offers for severely ill i.v. opioid addicts."

"Heroin misuse in Switzerland was characterised by a substantial decline in heroin incidence and by heroin users entering substitution treatment after a short time, but with a low cessation rate. There are different explanations for the sharp decline in incidence of problematic heroin use. According to Ditton and Frischer, such a steep decline in incidence of heroin use is caused by the quick slow down of the number of non-using friends who are prepared to become users in friendship chains. Musto's generational theory regards the decline in incidence more as a social learning effect whereby the next generation will not use heroin because they have seen the former generation go from pleasant early experiences to devastating circumstances for addicts, families, and communities later on."

"With respect to the group of those treated uninterruptedly during four years, a strong decrease in the incidence and prevalence rates of overall criminal implication for both intense and moderate offenders was found. As to the type of offense, similar diminutions were observed for all types of offenses related to the use or acquisition of drugs. Not surprisingly, the most pronounced drop was found for use/possession of heroin. In accordance with self-reported and clinical data (Blaettler, Dobler-Mikola, Steffen, & Uchtenhagen, 2002; Uchtenhagen et al., 1999), the analysis of police records suggests that program participants also tend strongly to reduce cocaine and cannabis use probably because program participants dramatically reduced their contacts with the drug scene when entering the program (Uchtenhagen et al., 1999) and were thus less exposed to opportunities to buy drugs. Consequently, their need for money is not only reduced with regard to heroin but also to other substances. Accordingly, the drop in acquisitive crime, such as drug selling or property crime, is also remarkable and related to all kinds of thefts like shoplifting, vehicle theft, burglary, etc. Detailed analyses indicated that the drop found is related to a true diminution in criminal activity rather than a more lenient recording practice of police officers towards program participants.

"On average, males had higher overall rates than females in the pretreatment period. However, no marked gender differences were found with regard to in-treatment rates. Taken as a whole, this suggests that the treatment had a somewhat more beneficial effect on men than women. This result is corroborated by self-report data (Killias et al., 2002). With respect to age and cocaine use, no relevant in-treatment differences were observed. As to program dropout, after one year, about a quarter of the patients had left the program, and after four years, about 50% had left. Considering the high-risk profile of the treated addicts, this retention rate is, at least, promising."

"Finally, the analysis of the reasons for interrupting treatment revealed that, even in the group of those treated for less than one year, the majority did not actually drop out of the program but rather changed the type of treatment, mostly either methadone maintenance or abstinence treatment. Knowing that methadone maintenance treatment – and a fortiori abstinence treatment – is able to substantially reduce acquisitive crime, the redirection of heroin maintenance patients toward alternative treatments is probably the main cause for the ongoing reduction or at least stabilization of criminal involvement of most patients after treatment interruption. Thus the principal post-treatment benefit of heroin maintenance seems to be its ability to redirect even briefly treated high-risk patients towards alternative treatments rather than back 'on the street'."

"Eighty five percent of the BPG [Berkeley Patients Group] sample reported that cannabis has much less adverse side effects than their prescription medications. Additionally, the top two reasons listed by participants as reasons for substituting cannabis for one of the substances previously mentioned were less adverse side effects from cannabis (65%) and better symptom management from cannabis (57.4%).

"Conclusion
"The substitution of one psychoactive substance for another with the goal of reducing negative outcomes can be included within the framework of harm reduction. Medical cannabis patients have been engaging in substitution by using cannabis as an alternative to alcohol, prescription and illicit drugs."