IT’S DIFFICULT ENOUGH for a broad range of people interested in and affected by drug policy and health services to agree on the “right” way to reach an end goal. It’s even harder when people disagree on the end goals to begin with. After more than 120 in-depth interviews with people in recovery, physicians, counselors, judges, other criminal justice administrators, and policy makers, it is clear to me that these groups often have different pictures of how addiction health services should look. Based on hundreds of hours of interview data and a review of published scholarly studies of addiction health services, I have created a list of the top ten goals I want to see in addiction health services, specifically with respect to opioid addiction treatment and medication-assisted treatment. The United States is already making progress toward some of these goals, in part due to state and federal pressure. Other goals may take decades to achieve.
Substance use disorder treatment, including MAT, becomes mainstream medicine
If you are reading this book, like me you probably agree that addiction treatment access must increase nationally. But where should people seek treatment? A combination of physicians, counselors, and other providers are needed, working in an integrated team (see chapter 5), but few physicians are currently participating on these teams. Importantly, primary care physicians are left out, or are leaving themselves out, entirely. I have met more than a handful of addiction specialists who argue that primary care physicians are not well positioned to treat addiction, but the argument is flawed because it presumes that (1) medical school and residency programs will never change, (2) practicing physicians cannot learn, and (3) primary care physicians cannot collaborate with other behavioral health professionals to fill in knowledge and service gaps.
Obviously, increasing primary care participation in the addiction treatment workforce will not come easily. It will depend on funding, political buy-in, physician interest, destigmatization of addiction, insurance incentives, simplification of privacy laws, and other complex factors. But if primary care physicians are educated and trained to treat addiction with the support of other behavioral health professionals, there are plenty of reasons for them to become the first point of care and even the coordinators of the treatment team. Then when cases are particularly complex, such as when severe co-occurring disorders exist or a patient is pregnant, primary care physicians could send patients to specialists until the patient is stabilized; after which, the patient could return to working with the primary care physician.
Benefits to the patient would include the relatively low stigma associated with seeing a primary care physician relative to other specialists, greater accessibility in most areas to primary care physicians than to specialists, and the holistic view that primary care physicians can provide care by treating co-occurring conditions such as hepatitis C and HIV/AIDS. Specialists, such as psychiatrists, would likewise benefit from this arrangement, which would allow them to focus their time and energy on the most complex patients. Opioid addiction is a relapsing, chronic disease, so the relationship between the primary care physician and specialist would need to be continuous, with the possibility of patients traveling between the providers over time. France and the United Kingdom have already demonstrated the feasibility of this goal.
Criminal justice administrators stop making health care–related decisions
The criminal justice system is a key provider of health services in the United States (see chapter 6). Ideally, the United States would move toward decriminalization of drug possession and use, much as Portugal has done. Decriminalization would decrease the stigma associated with addiction and push people toward treatment rather than ineffective incarceration. But this is the United States, and I doubt decriminalization would be accepted in many jurisdictions. Therefore, at a minimum we should divert more people convicted of addiction-related crimes into drug courts and similar programs.
There is little doubt that drug courts are more effective at preventing re-incarceration relative to stints in jail or prison. In other words, diversion works; but is it working well enough? I have argued that drug courts can do better, largely by focusing on what they are best at: monitoring treatment participation and providing access to resources. At the same time, drug court personnel should stop making treatment-related decisions, including whether particular forms of MAT are permissible and how long an individual can stay on MAT. If, however, drug courts insist on continuing to make treatment-related decisions, then they should at least include physicians, nurse practitioners, and physician assistants on their treatment teams. These medical professionals are more likely to accurately assess the risks and benefits of MAT relative to other team members lacking medical education.
Methadone treatment becomes available through general practitioners after stabilization at opioid treatment programs
This is likely my most controversial goal. Yet if we examine the experience of the UK and France, there is little reason for the controversy. In the UK, general practitioners can initiate methadone treatment for any patient who would benefit without special certification requirements or patient limits. In France, specialists initiate methadone treatment but then transfer patients to general practitioners once the patient is stabilized. In both nations, methadone is dispensed in community pharmacies with pharmacists playing an important role on the treatment team. The French example is likely to seem less extreme to many Americans than the UK example. Therefore, I posit that the French model is more achievable in the United States than the UK model, given our historical biases against expanding methadone treatment access—ironic since methadone treatment for opioid addiction began in the United States.
The benefits of permitting practitioners outside of OTPs to prescribe methadone to stabilized patients include the following: greater methadone treatment access for patients, particularly given the few OTP clinics in each state; integration of methadone treatment with other health services; and creating the perception of methadone treatment as part of mainstream medicine. Additionally, while many patients benefit from stepwise take-home limits where they “earn” take-home doses as stability increases, specific decisions regarding take-home allowances should be made by the physician and his or her team, with broad flexibility unimpeded by strict regulations. One of the most surprising results of my research is that many methadone treatment patients appreciate the accountability and responsibility associated with earning take-homes and the regular health service interaction afforded by daily dispensing (see chapter 4). But other patients are seriously inconvenienced by daily attendance requirements, especially when trying to maintain a job or take care of a family. Only flexibility in physician decision-making can address the variance in patient needs.
Support groups for people undergoing MAT become accessible everywhere
There is no doubt that support groups, particularly twelve-step support groups, have helped millions of people in recovery around the world—so much so that some people become deeply offended if twelve-step groups are criticized at all. Nevertheless, one criticism has been repeated by many scholars, including me, yet largely ignored by local support groups: people undergoing MAT feel stigmatized when they discuss their treatment in twelve-step meetings.
Despite the stigmatization, many people undergoing MAT express a deep desire for concurrent twelve-step group participation and gratitude for the life skills that group membership has taught them. At the same time, they feel like hypocrites when compelled to hide one of the most effective tools they have used—medication—while being told during meetings that honesty is critical to recovery. Sometimes MAT stigmatization in twelve-step groups is so extreme that people are encouraged to stop MAT or to quit early, to their detriment. Ideally, twelve-step groups would be openly supportive of MAT, explicitly stating at meetings that MAT is an acceptable form of recovery and that it can be used in conjunction with twelve-step support. But numerous interviewees say that day is a long way off, especially for Narcotics Anonymous, in which stigma seems more salient than in Alcoholics Anonymous. Therefore, to meet the needs of people in recovery who desire the benefits of twelve-step peer support, new groups should be formed.
One such group, Medication-Assisted Recovery Anonymous (MARA), is a twelve-step group explicitly open to MAT. It is springing up in some cities around the nation but is still largely inaccessible to most Americans. Online versions may make it available in rural areas and small cities. Significantly more research is needed into the efficacy of groups like MARA, including online versions. Treatment centers can also initiate support groups that are peer-led and held on-site but that openly support MAT. The idea is not to displace existing support groups but to provide more peer support options to the many people who are tired of the pointless battle between twelve-step recovery approaches and MAT.
Addiction treatment centers, whether inpatient, residential, or outpatient, offer a menu of treatment methods, including MAT
The Institute of Medicine and the Picker/Commonwealth Program for Patient-Centered Care have identified eight dimensions to person-centered care.314,315 The first and possibly most important dimension is respect for patient preferences and values. Unfortunately, many SUD treatment centers today appear far from supportive of patient preferences and values. They typically offer one abstinence-only treatment track consisting entirely of detoxification, group counseling, and AA or NA, with little respect for individuals’ unique recovery goals. Clients are given a preset program that they must follow or be asked to leave.
Theoretically, such one-track treatment centers would not be problematic if other multi-track treatment centers existed in the same area, allowing people to choose among a range of treatment centers. Yet small cities and rural areas rarely have treatment center variety. Even people living in urban areas may learn that what looks like a sea of treatment centers is a small puddle after eliminating those that do not take insurance or have months-long wait lists.
Therefore, the best health service approach is for every treatment center to offer a menu of treatment options, including all forms of MAT, individual counseling utilizing a variety of evidence-based methods, group counseling in which clients are matched to appropriate rather than arbitrary groups, and both spiritual and nonspiritual peer support. Furthermore, treatment centers should respect and support a wide range of goals, including complete abstinence, reduced drug use, and controlled drug use. It is not uncommon for people to fluctuate between different goals at different times. Obviously, each of these goals requires different outcome evaluation metrics, yet treatment centers primarily rely on the absence of drugs on a urine drug screen.
Low-barrier buprenorphine treatment becomes widely available
Buprenorphine treatment is often “high barrier” in the United States, meaning that patients must meet a set of restrictive criteria to both begin and continue treatment (see chapter 3). To begin treatment, for example, they must demonstrate abstinence from all nonopioids, including marijuana, cocaine, alcohol, and benzodiazepines. To continue treatment, they must have negative urine drug screens for all drugs and opioids other than buprenorphine. If they miss more than a few doses, they are kicked out of treatment. Some treatment centers even require counseling or peer support group participation for buprenorphine access, even though the latest research suggests that not every person undergoing buprenorphine treatment benefits from additional psychosocial services.23,316,317
A low-barrier treatment approach largely eliminates these requirements, accepting patients under the theory that it is better to do some treatment than no treatment, even if the patient’s participation is not ideal. It is a type of harm reduction. Relatedly, low-barrier treatment approaches often use a hub-and-spoke model, wherein the individual becomes a new patient immediately at the hub. After induction and stabilization, the individual is transferred to a spoke. The spoke is sometimes a higher-barrier treatment provider who would be uncomfortable treating someone who has not been stabilized.
The low-barrier buprenorphine treatment approach especially benefits people in vulnerable social situations, such as those experiencing homelessness or those who are uncertain about full recovery but want to start somewhere. It allows for treatment services to be established in resource-poor areas, including church basements and syringe exchange programs. Low-barrier treatment can also be combined with emergency department services for those who have recently overdosed. For example, following overdose reversal, the emergency department could provide up to three days’ worth of buprenorphine, a legally permissive exception to the DATA-waiver requirement, after which the patient would immediately begin buprenorphine treatment in a low-barrier clinic. If only high-barrier clinics exist in the area, then the individual would likely wait weeks before beginning buprenorphine treatment—weeks during which another overdose is likely.
People feel safe discussing their opioid problems, enabling them to seek treatment
I have arthritis. It is a chronic condition for which I take medication and watch my diet since some foods are linked to an inflammatory response. When I started exhibiting symptoms, I was confused about the symptoms’ cause, but I felt no shame, even though at one point I was on crutches and pain prevented my participation in certain social events. I knew that I should seek treatment and immediately visited my primary care physician who then connected me to an orthopedic physician and ultimately to a rheumatologist. I had no trouble telling my family or friends. I was able to take some time off work to navigate the health services required to get me back on my feet.
If only people with opioid addiction felt the same level of comfort discussing their chronic health condition with others, enabling them to comfortably seek treatment resources without the fear of stigma or social backlash. Yet most instinctively hide their problem from family, friends, employers, and even health care providers. They fear being labeled as immoral or criminal. When the substance in question is itself illicit, such as heroin, then the stigma is heightened.
Destigmatization of any population is notoriously difficult, because stigma often builds on decades, if not centuries, of implicit and explicit derogatory beliefs about others, sometimes to the point that these beliefs become unconscious. Regular interaction with the stigmatized population can help decrease negative beliefs, as demonstrated by pharmacists in the UK and France who over time have come to see people with addiction less and less negatively. Courageous people in recovery sharing their stories with the public could slowly lead to a decrease in addiction-related stigma. But therein lies the rub: who wants to risk private and public backlash?
Decriminalization of drug possession could help disassociate addiction with criminality in the public’s mind, but in most parts of the United States, we are a long way away from decriminalization. Nonprofit organizations or even the federal government could use billboards and other forms of public service announcements to share the fact that addiction is a health condition that cuts across race, income, gender, and other demographic variables rather than an indicator of morality. In the meantime, much more research evaluating the feasibility and efficacy of programs designed to destigmatize addiction is needed.
The public has accurate knowledge about a full range of addiction treatments
Few studies have explored the public’s knowledge about evidence-based treatments for opioid addiction, but existing data suggests that public knowledge is incomplete and heavily clouded by myths. In combination with low levels of education among health care providers about addiction medicine, it is no surprise that families of people in recovery feel lost in a tumultuous sea of treatment options. Family members have likely heard of AA, counseling, and rehab but may have little conception of what these recovery approaches entail. They are likely to have minimal knowledge about MAT.
Historically, any public service announcements related to drug use have primarily served a prevention aim—namely, warning the public of the danger of drugs. Public service announcements have rarely been used to educate people about treatment options. In other words, drug-related education has overwhelmingly focused on preventing people from developing addiction, leaving behind those who have already developed the condition, as if once you have addiction you are a lost cause. Researchers should seek to identify how best to educate the public about evidence-based treatment options. One such approach could include modifying existing public service announcements and education programs in schools so that people not only hear preventative messages but also learn what to do, or at least what reliable government resource to access, once an addiction has developed.
Harm reduction becomes the norm
No one recovers from opioid addiction when they are dead. So, first and foremost, let’s prevent overdose deaths by encouraging and training health care providers, emergency medical personnel, and police to distribute naloxone to people with opioid addiction and their family members. Additionally, naloxone should be available over the counter at a low cost in every pharmacy. Prisons and jails should provide naloxone upon release given the high overdose potential following incarceration.
Additionally, let’s prevent unnecessary suffering from communicable diseases, such as HIV/AIDS and hepatitis C, among people who are actively using drugs. This requires widespread availability of syringes, such as through syringe exchange programs. Currently only some US cities operate syringe exchange programs, but these programs are far from adequate due to their low accessibility, stigmatization by the public and police, and lack of reliable funding. Ideally, syringe exchange programs would be complemented by federal and state law permitting community pharmacies to openly distribute and collect syringes, like in the UK. Such a law should go hand in hand with decriminalization of drug paraphernalia possession, which is often still illegal in areas where authorized syringe exchange programs operate. Finally, let’s open supervised injection sites, especially given the growing evidence base of their benefits and minimal harms.
Dual-diagnosis treatment becomes more widely available
Not everyone with an addiction has a co-occurring mental health disorder, such as depression, anxiety, or post-traumatic stress disorder. But study after study finds a high correlation between addiction and mental health disorders. Both similarly affect the brain, and the worsening of one disorder may negatively influence the other.
Ideally, treatment centers should offer services for both addiction and mental health. At the minimum, treatment providers of addiction should work collaboratively with offsite mental health treatment providers, and vice versa. Unfortunately, dual-diagnosis treatment today is rare, hampered by many of the same barriers that exist for addiction treatment, including stigma, lack of providers, and inadequate insurance reimbursement. Furthermore, addiction and mental health treatment providers may be deterred from collaboration by misunderstanding existing privacy laws, specifically 42 CFR 2 regulations, which require written consent from the patient for one treatment provider to share health records with another provider. Ideally, these regulations should be simplified, if not abandoned, in favor of HIPAA. At the minimum, treatment providers need better education about privacy law requirements so that they do not feel unnecessarily deterred from collaboration by misconceptions.
A Fictional Story of Jane Doe, September 2025, “Ideal City” in Anywhere, U.S.A.
A few months ago, Jane was prescribed oxycodone for low-back pain after all other treatments failed to give her any relief following a car accident. She never expected to become another person with opioid addiction. After a while, she took oxycodone not so much to treat back pain but rather to numb any unpleasant emotional sensations. She’d never really thought about it, but she’d probably been depressed for years. Oxycodone had become a bandage, albeit one that was causing more harm than healing.
When her boyfriend, Conor, yelled at her for not having the money to contribute to their rent after she secretly spent it all on oxycodone, and when her boss chewed her out for falling asleep during a work meeting, Jane took a hard look at her oxycodone use and decided to stop. But as soon as she tried to quit on her own, her depression worsened and she experienced flu-like symptoms, making her unable to concentrate on anything, least of all work.
“It’s happened. I’ve developed opioid addiction,” she told herself. It wasn’t a comfortable fact to admit, but she knew it could happen to anyone. She knew she was not a bad person. She knew she needed medical help.
She sat her boyfriend down and told him about her problem. Fortunately, Conor had been educated about substance use disorders in public school and through public service announcements, so he knew addiction was not a choice even if Jane’s first misuse of oxycodone was exactly that. He thanked God that Jane had not been arrested since drug possession and use had been recently decriminalized.
“I’ll go call your primary care doctor,” he said, “and get you an appointment for first thing tomorrow morning. In the meantime, contact your boss and tell her that you have a serious illness and need to take some time off work to recover. I’m sure your doctor will give you a note tomorrow.” Conor then called Jane’s primary care physician’s office and asked for an appointment for the next day. When the receptionist asked what the problem was, he said his girlfriend had opioid addiction. The receptionist did not act surprised or judgmental while scheduling Jane for the following morning.
The next day, Conor and Jane attended the primary care appointment together. Jane was forthcoming about how she started misusing oxycodone. She had expected the conversation to be embarrassing, especially given that this primary care physician was the same one who had prescribed the oxycodone to begin with for her low-back pain. But the physician seemed completely unfazed. He asked Jane if she’d thought about treatment options and whether she had any preferences. He also asked about her goals.
Jane said she’d like to quit oxycodone entirely and try buprenorphine as a recovery tool. She said she was not sure she could handle the full detoxification required for extended-release naltrexone, at least not yet, even though she would eventually like to be opioid-free. The physician responded that there was no rush to be opioid-free; what was most important was that she was starting her recovery. They also discussed methadone as an option, but Jane decided she did not want to travel to a methadone clinic daily, even though the primary care physician could eventually prescribe the methadone and have it dispensed at the local pharmacy after stabilization.
The physician asked whether Jane would like to participate in counseling and peer support groups as well, since psychosocial support could help her depression symptoms and keep her focused on her recovery. Jane agreed that the counseling would likely be beneficial, but she said she’d only be in a peer support group that is supportive of buprenorphine treatment. The physician nodded and introduced Jane to his case manager, Terry. Without needing any extra paperwork, Terry made some phone calls to local addiction counselors. A few minutes later, Terry informed Jane that a counselor in a mental health clinic would see her the following week. Terry also provided brochures for a range of local peer support groups, including spiritual and nonspiritual ones, and ones that explicitly accepted people utilizing MAT.
The physician then conducted a comprehensive physical and mental health examination, after which he explained the risks and benefits of buprenorphine treatment. Jane decided she wanted to move forward with it, so the physician administered the first dose of buprenorphine directly. A nurse kept Jane under observation for an hour to make sure no unexpected side effects occurred. None did. The physician then returned and handed Jane a prescription for a month’s medication supply, telling her to come in for a follow-up appointment in one month but to contact the office earlier if needed.
Jane and Conor drove to the local pharmacy where they picked up the buprenorphine prescription immediately as no prior insurance authorization was required and the pharmacy was fully stocked. The pharmacist was friendly and nonjudgmental, asking Jane if she had any questions or concerns about buprenorphine. Conor bought some naloxone over the counter while Jane waited for her prescription to be filled, feeling for the first time in months like everything was going to be okay.