Gary Tsai, MD, FAPA, FASAM 

Director, Substance Abuse Prevention and Control Bureau, County of Los Angeles, Department of Public Health

If the data around substance use disorder (SUD) treatment-seeking teach us anything, it’s that most people with these conditions are not actually interested in the services we offer.  

A big part of the reason for this is not because the SUD field doesn’t have an amazingly dedicated workforce or offer lifechanging services. Instead, the fact that readiness for SUD treatment is often defined as synonymous with readiness for complete abstinence from substances has set a treatment bar that is too high and unrealistic for most. While the influences of stigma and the criminalization of addiction on treatment-seeking cannot be ignored, it is generally easier to shape our practices than to solve these bigger societal issues.  

In recognition of the need for fresh approaches to address addiction, ASAM recently approved a clinical considerations document focused on the Engagement and Retention of Nonabstinent Patients in Substance Use Treatment.  

Developed via an extensive literature review and expert consensus and refined through a robust public comment process, the strategies highlighted in this document serve as a roadmap for designing treatment systems, services, and processes that can better engage all populations with SUDs, particularly those who are more upstream on the readiness to change continuum. 

Rather than focusing on program-centered rules, these clinical considerations encourage programs to focus on more client-centered approaches to address the complexities of nonabstinent patients in treatment, realize lower-threshold SUD care, and reduce administrative discharges.  

This does not mean that SUD programs cannot have rules. But our experience with launching a similar effort in Los Angeles County in 2023 via the Reaching the 95% Initiative is that SUD program culture can change drastically for the better when staff are oriented to focus on widening treatment doors as opposed to rules that narrow them. As a result, opportunities for challenging but necessary conversations with both clients and staff also tend to present themselves. While this shift in approach requires thoughtful discussions with the SUD workforce and is not without controversy, SUD programs that implement these lower-threshold approaches are ultimately better positioned to achieve their mission of helping more people.  

It’s also important to note that these approaches align with how other areas of health systems approach care. When individuals present to primary care with a blood sugar level of 500, they're not told to return when it's down to 200 to prove their commitment to treatment. Nor are they discharged from care if their HbA1c goes up instead of down at their next follow-up, or if they show up at their next appointment with a doughnut in hand. 

Markets evolve their strategies depending on demand, and the addiction field is no different. While SUD clients will likely never view addiction services like we’ve come to expect from more popular activities - like Taylor Swift concerts or watching Travis Kelce in the Super Bowl - there are still strategies we can employ to modulate demand in favor of openness to needed treatment.  

The unprecedented overdose crisis and decades of low treatment penetration rates are glaring reminders that a revamp is sorely needed - as emphasized in ASAM’s clinical considerations document, Engagement and Retention of Nonabstinent Patients in Substance Use Treatment. It’s a change we should all embrace, even if “old habits die screaming,” as Taylor Swift would say.