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

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

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