Effective treatment for substance problems exists and reaches a small proportion of those who would benefit, and the reasons are documented.
The treatment gap
Surveys consistently find that a small minority of people with substance use disorders receive treatment.
Which is a larger gap than for most other health conditions.
The reasons identified include stigma, not recognising a problem, cost, availability and fear of consequences including employment and child protection.
What treatment involves
Assessment establishing the pattern, severity, physical health and any other conditions.
Psychosocial interventions, including structured counselling approaches with evidence.
Pharmacological treatment where it exists for the substance concerned.
And support with the practical circumstances — housing, employment, relationships — that affect outcomes substantially.
Withdrawal
Varies enormously by substance in both severity and danger.
Alcohol and sedative withdrawal can be medically dangerous and should be managed with medical supervision rather than attempted alone.
Opioid withdrawal is extremely unpleasant and generally not dangerous, though relapse afterwards carries elevated overdose risk because tolerance has fallen.
Which is a specific and important point — the period after detoxification carries higher overdose risk than before it.
Medication
Opioid substitution treatment has substantial evidence for reducing mortality, transmission of infection and criminal activity.
Which is among the better-evidenced interventions in the field and remains contested in public discussion.
Medications supporting alcohol reduction and abstinence also exist with reasonable evidence and are underprescribed.
Harm reduction
Approaches reducing harm without requiring abstinence.
Which includes needle exchange, overdose reversal medication distribution, drug checking and supervised consumption facilities.
Evidence for the first two is substantial, and the others have evidence and remain politically contested.
The underlying argument is that people who are not ready to stop should not die in the meantime.
Mutual aid
Peer groups following various models.
Recent systematic reviews of the twelve-step approach have found outcomes comparable to or better than other approaches for alcohol, which revised earlier assessments.
Alternative models exist for people who find that framework unsuitable.
Families
Affected substantially and generally offered little.
Which is why family support organisations exist, and they provide information and peer support independent of whether the person is in treatment.
Getting help
A doctor is a route and can refer, and specialist services frequently accept self-referral.
Helplines provide information confidentially and are a low-barrier starting point.
Anyone at immediate risk should contact emergency services, and overdose reversal medication is available to the public in several jurisdictions.
Dual diagnosis
Co-occurring mental health and substance use conditions are common and have historically been served badly.
Which happened because services excluded people — mental health services declining to treat while someone was using, and substance services declining to treat the mental health condition.
Integrated approaches treating both are recommended in guidelines and are inconsistently available.
Alcohol specifically
The most widely used substance and the one producing the largest population harm in most countries.
Which is under-recognised relative to illicit substances in public discussion.
Brief interventions in primary care — a short structured conversation about consumption — have reasonable evidence for reducing intake in people drinking at risky levels.
Prescription and over-the-counter medicines
Dependence on prescribed medication is a distinct problem requiring managed withdrawal rather than abrupt stopping.
Which applies particularly to sedatives, opioid painkillers and some others.
Stopping abruptly can be dangerous, and support with gradual reduction is the appropriate route.
Recovery
Frequently involves multiple attempts, which is the normal course rather than evidence of failure.
Which is well established in outcome research and is not how relapse is generally experienced by the person or their family.
Housing, employment and relationships predict sustained outcomes substantially, which is why support addressing them matters.
Stigma
Consistently identified as a barrier to seeking help and to receiving good treatment when it is sought.
Which includes stigma from healthcare staff, documented in studies of clinician attitudes.
Language matters measurably here, and terminology guidance has been adopted by professional bodies for this reason.
Funding and availability
Treatment services in several countries have seen substantial funding reductions over the past decade.
Which produced reduced capacity and longer waits at a point when harms were rising.
Some of this has been partially reversed following reviews linking capacity to drug-related deaths.
Criminal justice interface
A substantial proportion of people in contact with the justice system have substance problems.
Which makes treatment provision within and after custody consequential for outcomes.
Continuity of treatment on release is a documented weak point, and the period immediately after release carries markedly elevated overdose risk.
Talking to someone using
Confrontational approaches perform poorly in outcome research.
Which is a robust finding, and approaches based on exploring the person's own reasons for change perform better.
Family support organisations teach this directly and are worth contacting before an intervention is attempted.
Anonymity
Specialist services generally operate confidentially within normal clinical limits.
Which people frequently doubt, and asking directly what will be recorded and shared is reasonable.