OVERVIEW
According to the National Survey on Drug Use and Health (NSDUH), in 2018 an estimated 21.2 million Americans aged 12 and older needed treatment for a substance use disorder (SUD), but only 3.7 million received any kind of treatment and only 2.4 million received treatment at a specialty facility – a disparity known as the “treatment gap”.
Children and young adults have unique prevention and treatment considerations, and the treatment gap for youth and young adults ages 12-17 is greater than it is for the general public.
In 2018 an estimated 31.9 million Americans reported using an illicit drug in the past month. Furthermore, in 2018, an estimated 21.2 million Americans aged 12 and older needed treatment for a substance use disorder, approximately 20.3 million people aged 12 or older met the medical criteria for a substance use disorder, including 14.8 million people with an alcohol use disorder and 8.1 million with a drug use disorder. That year, an estimated 27.2 million Americans age 18 and older reported they experienced an alcohol or other drug use problem in their lifetime and approximately 20.2 million Americans over 18 described themselves as being in recovery from a drug or alcohol problem or having recovered from one.
Despite the number of people in recovery, nearly 89% of the estimated 20.2 million Americans who met the criteria for a substance use disorder (SUD) in 2018 did not receive specialized treatment for their condition.
That is, barely more than 1 in 10 Americans needing substance use disorder treatment actually received it. Of those who needed treatment at a specialty facility, 18 million (89%) did not feel they needed treatment; 2.36 million (11%) did receive treatment at a specialized facility; another 573,000 (3%) felt they needed treatment but did not make an effort to receive it; and 392,000 (2%) attempted to access treatment but, for a variety of reasons, failed to do so.
When examining only those Americans who suffer from drug use disorder and not including those with alcohol use disorder only, the numbers are only slightly better. An estimated 6.8 million (79%) of the 8.1 million Americans who suffer from drug use disorder did not feel they needed treatment; 1.4 million (16%) of them did receive specialty treatment; 251,000 (3%) felt they needed treatment but did not make an effort to receive it; and 218,000 (2%) felt they needed treatment and attempted to receive treatment.
Noteworthy, is that in 2018, among those aged 18 or older, 11.7% used illicit drugs in the past month and among those who were full-time employees, 12.6% used illicit drugs in the past month, as did 14.8% among part-time employees and 23.1% among the unemployed. What is being described here is a “treatment gap” between those needing treatment and those receiving it.
This “treatment gap” is one reason the United States lost over 70,000 people to a drug overdose in 2017. There is an urgent need in our nation to identify substance use problems before they develop into substance use disorders, increase access to treatment, make treatment services and care more widely available, and ensure that the services provided are evidence-based and high quality.
As part of his larger strategy to end the addiction epidemic in this country, President Trump signed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act in 2018. This critical legislation requires the Office of the National Drug Control Policy (ONDCP) to develop “a plan to expand treatment of substance use disorders.”
Expanding Americans’ access to effective evidence-based substance use disorder treatment is a key pillar of the President’s National Drug Control Strategy (Strategy). Treating addiction is best addressed locally when policymakers, health and provider systems and networks, and community-based support programs address addiction as a chronic illness requiring quality integrated treatment services, essential support structures, and ongoing continuing care or recovery support services. Research shows that substance use disorders can be treated, with success rates similar to those of asthma, diabetes, and other chronic illnesses. As such, the Strategy prioritizes increasing access to evidence-based addiction treatment, including Medication Assisted Treatment (MAT) for Opioid Use Disorder (OUD) (sometimes referred to as Medications for Opioid Use Disorder (MOUDs). It also prioritizes supporting those in recovery with peer support services, access to housing, training, educational, and employment opportunities to foster a sense of stability, pride, and full engagement in the community.
Through consultations with public health experts, stakeholders and agencies across the Federal government, ONDCP has identified key elements of this treatment gap and has developed a plan to address them. ONDCP’s Treatment Plan to address increasing access to treatment and closing the gap rests on three pillars that are composed of twenty-two areas of focus.
Pillar 1: Improve Efforts to Expand Early Intervention, Treatment and Recovery Support Services Infrastructure (pre-natal through adult) by:
- Enhancing all levels of the professional, mid-level and paraprofessional addiction workforces, including in rural settings;
- Improving services for pregnant and post-partum women, and services for infants born with neo-natal abstinence syndrome;
- Improving access to low-threshold services, including those provided at syringe services programs (SSPs);
- Leveraging technology, when appropriate, to increase access to care and services;
- Improving the uniformity, quality, range, and timeliness of treatment data and expanding collection of other data to better inform treatment policy and services;
- Addressing barriers to treatment, housing, and employment;
- Encouraging workplace support for current employees in treatment and recovery;
- Encouraging medically managed withdrawal services that include initiation of medication to prevent relapse, and appropriate post-stabilization service as part of a treatment program with continuing care
- Building evidence-based recovery support services capacity;
- Promoting quality recovery housing; and
- Continuing Federal parity enforcement and implementation efforts regarding treatment services provided by health plans and issuers.
Pillar 2: Improve Delivery Systems, Provider Efforts, and Services for People with SUD, Including Special Populations, by:
- Conducting outreach to payers, providers, health systems, States, and other stakeholders to help ensure addiction services are provided at parity with comparable medical-surgical services;
- Improving access to specialty addiction treatment services and care in areas where it is insufficient;
- Better integrating specialty addiction treatment services and care into mainstream health by: reducing barriers to access for patients entering treatment;
- promoting screening, as well as brief interventions, referral and linking to treatment, with the goal of increasing accurate diagnosis and subsequent evidence-based treatment initiation;
- promoting access to addiction medicine specialty consultation services for addiction disorders services in primary care, hospitals and other mainstream and general medical and healthcare settings; increasing initiation of evidence-based addiction treatment in general medical settings;
- increasing the number of providers with DATA 2000 waivers to provide MAT and supporting these waivered practitioners in increasing the number of patients they treat for OUD;
- linking specialty addiction service care with settings and providers who provide medical care to persons with SUD or injection-related infections such as endocarditis, skin infections, abscesses, or hepatitis.
- Increasing addiction medicine specialty services in hospitals and emergency departments
- Exploring the potential benefits of including other substances in opioid use disorder treatment models;
- Explore allowing opioid treatment programs to treat stimulant use disorder;
- Expanding access to treatment by: building the capacity to provide effective services to all and particularly to special populations such as pregnant and post-partum women; pre-natal through adolescence; older adults and people with disabilities, and people from rural communities, including Native Americans and people who are homeless; and people involved in the criminal justice system;
- And by improving access to all forms of medication-assisted treatment (MAT) and behavioral counseling to include addressing co-occurring disorders; integrating peer recovery support services; identifying and expanding evidence-based linkage and low-threshold approaches to treatment engagement including interim methadone treatment;
- supporting Addiction Medicine and Addiction Psychiatry fellowship/residency placements in medical schools and health systems; promote workforce initiatives to support special populations;
- utilizing telehealth platforms to increase access to treatment, including MAT;
- encouraging the use of mobile treatment units (vans) by substance use treatment programs as well as the provision of MAT with buprenorphine and extended-release naltrexone by mobile health clinics.
- encouraging and supporting innovations in treatment delivery; and,
- fostering peer outreach, engagement, low threshold, syringe services and intervention efforts;
Pillar 3: Improve the Quality of Treatment by:
- Conducting an environmental scan to identify existing standards for treatment;
- Developing and promoting adoption of model state specialty SUD treatment licensing laws;
- Working aggressively to eliminate fraud and abuse, reducing related patient harm; and,
- Developing protocols, and promoting and educating about medically managed withdrawal services, optimally as part of a treatment program or with linkages to treatment, particularly among criminal justice, rural and Native American populations.
UNDERSTANDING THE TREATMENT GAP
Multiple factors contribute to the “treatment gap.” For the purposes of this document, information has been organized around the following factors as contributing to the gap:
Factor 1: Individuals with SUD may not seek treatment
Factor 2: Individuals with SUD may not know how to access treatment or face financial barriers
Factor 3: Individuals with SUD may seek treatment but face provider shortages
Factor 4: Individuals with SUD may receive inadequate, clinically inappropriate, poor quality, or fraudulent treatment
Factor 5: A treatment episode is inappropriately truncated
Factor 6: Individuals may not receive treatment that is culturally competent or responsive to the individual’s social determinants of health