The drug overdose epidemic continues to be a top public health priority in the United States.¹ National efforts have primarily focused on curtailing opioid use, but other alarming trends have emerged from misuse of other classes of drugs. For example, stimulant-related overdose deaths surpassed opioid-related overdose deaths in many states as of 2019.² While recent data suggest overall trends in opioid-related overdose deaths may be decreasing — a first in this century, the COVID-19 pandemic has only exacerbated this already devastating crisis, with reports that overdose deaths are spiking around the country.³

These trends, however, do not adequately describe the human experience with addiction, the most severe form of a substance use disorder, nor a person's ability to manage it.⁴ To curtail current and emerging drug-related overdose crises, evidence-based, harm reduction strategies coupled with expanded access to affordable treatment will be key among the array of strategies proposed, like involuntary civil commitment, as discussed in two articles in the latest issue of Journal of Law, Medicine, and Ethics. ^{Reference Phillips, Ford, Bonnie, Evans, Harrington, Roose, Lemere, Buchanan, Udwadia and Illes5} These elements, at their core, demand the understanding that addiction is a disease, and people with substance use disorders are patients to be treated by the health care system — not problems to be dealt with by the justice system.⁶

To reach this goal, we must first eliminate the stigma that surrounds the disease of addiction.^{Reference Volkow7} Substance use disorders are one of the most stigmatized conditions in the world.^{Reference Yang, Wong, Grivel, Hasin, Phillips and Shaw8} Even the words society uses to talk about the condition reflect this stigma and influences its treatment by practitioners.^{Reference Kelly, Saitz and Wakeman9} For example, many stigmatizing myths persist around opioid use disorder (OUD) treatment, such as using buprenorphine merely replaces one addiction with another.^{Reference Wakeman and Barnett10} The reality is that patients take buprenorphine to manage their chronic disease.¹¹ This myth, and others like it, perpetuates stigma that can reduce a patient's willingness to seek treatment because of fear or shame they experience, and it can negatively influence practitioners' beliefs that may impact the way they care for patients.^{Reference Hadland, Park, Bagley, Kelly, Wakeman and Saitz12} Recent research suggests that pharmacists report not stocking, rationing, or routinely refusing to fill prescriptions for buprenorphine in some parts of the US citing stigma and other reasons.^{Reference Cooper13} This is just one specific example of the havoc stigma can wreck on patient care and demonstrates why eliminating stigma and the barriers it sustains remains a top priority.

Harm reduction plays another key role in supporting patients who use drugs and is slowly gaining acceptance in the US.^{Reference Nadelmann and LaSalle14} Harm reduction is a public health strategy that aims to reduce adverse consequences that a person who uses drugs may experience while respecting that person's individual rights.¹⁵ In short, it is an approach that meets people where they are.¹⁶ One example of harm reduction is expanding access to naloxone, the opioid-reversal agent, through mechanisms like standing orders, government sponsored distribution programs, and co-prescribing to patients at high-risk for overdose.^{Reference Penn17} It is estimated that an upwards of 29% of patients prescribed opioids for chronic pain report misusing them and 12% develop OUD.^{Reference Vowles, McEntee, Julnes, Frohe, Ney and van der Goes18} Patients with OUD have alarmingly high morbidity and mortality, and expanding access to naloxone is associated with a reduction in opioid-related overdose deaths.^{Reference Hser, Mooney, Saxon, Kerensky, Walley, Abouk, Pacula, Powell, McClellan, Lambdin, Ali and Mutter19} That is because naloxone is a safe, effective, minimally invasive, and overall much more humane approach to preventing opioid-related overdose deaths in the immediacy, especially in comparison to other stigmatizing, non-evidence-based interventions like involuntary civil commitment.^{Reference Jain, Christopher and Appelbaum20}

Expanding access to and ensuring affordability of substance use disorder treatment is also key to ensure patients who need it receive it.^{Reference Orgera and Tolbert21} The gold standard of treatment varies depending on the type of substance use disorder. For example, the most optimal therapy to manage OUD includes medication (buprenorphine, methadone, or naltrexone) plus psychosocial support, and evidence suggests that treatment costs are offset by decreased healthcare utilization costs, such as inpatient admissions, emergency department visits, and their associated costs.^{Reference Mohlman22} By contrast, for stimulant use disorder or cannabis use disorder, there are no FDA-approved medications, and cognitive behavior therapy or similar interventions have the strongest supporting evidence.^{Reference Gorelick23}

Connecting patients to these evidence-based treatments is critical because they are not only effective, but they can decrease mortality.^{Reference Sordo, Barrio, Bravo, Gunne and Gronbladh24} Yet, a wide gap exists for substance use disorder treatment in the US for patients who need it versus receive it, with an estimated 21.6 million persons age 12 and older needing treatment but only 4.2 million receiving it in 2019.²⁵ This gap persists for many reasons, such as stigma, cost of care, availability and location of providers, federal and state policies, and more, but a common theme is that the US health care system not optimized to manage the disease of addiction.²⁶ One example of this is that providers have to take steps to obtain a special waiver from the Drug Enforcement Agency and meet other requirements imposed at the federal and state level to prescribe buprenorphine to manage OUD.²⁷ Once waivered, then arbitrary limitations are placed on those providers on the number of patients they can treat.²⁸ Similar prescribing hurdles do not exist for other disease states.

Solutions, however, should not be siloed to a singular system, such as the justice system, but rather shared in a multi-system, interdisciplinary approach and championed by the health care system, as addiction is best understood as a chronic brain disease and not a moral failing.²⁹ The failed “War on Drugs” demonstrated that relegating the responsibility to curtail drug misuse to the justice system is not effective.^{Reference Coyne and Hall30} In fact, nearly 50 years later, that punitive approach created drug-related hysteria, stigmatized people who use drugs, spawned draconian policies that had a disproportionate, adverse impact on minority populations, and more.³¹ Centering efforts on the justice system that may penalize persons with substance use disorders under the guise of promoting public safety is a misstep that the US cannot afford to repeat. Rather, the judiciary and law enforcement are best positioned to support sick patients by connecting — not confining — them to the treatment they need to manage their disease, which they are well positioned to do.³² The answer to drug misuse was not punishment decades ago, and it is not the answer now, either. It is by promoting evidence-based, harm reduction strategies and improving access to affordable treatment for all persons with substance use disorders that meaningful steps towards ending the epidemic may be made.