Substance Use Disorder Treatment Research Articles

"My addiction doesn't define me": Healing from the stigma of addiction for mothers with opioid use disorder.

About 1 in 8 children under age 17 live with a parent who has a substance use disorder. Research on treatment access identifies stigma as a significant barrier to treatment, particularly among mothers with young children. Well-meaning but punitive state policies further perpetuate stigma, which harms families and children. Explore the experiences of the stigma of addiction on mothers before, during and after treatment for substance use disorder. Procedures/data/observations: Descriptive Phenomenology was used to describe the experiences of stigma of mothers with opioid use disorder (OUD) through all stages of treatment and recovery. Mothers (n=20) participating in an outpatient treatment program interviewed. A semi-structured interview schedule was used to guide the interviews and thematic analysis was used identify themes related to stigma. Our analysis identified several main themes and subthemes related to internal and external sigma, including stigma against medication for opioid use dis order, stigma from the public and healthcare professionals, internalized shame, and how mothers learned to recover and heal from stigma.

Insights from California on Involuntary Commitment for Substance Use.

Involuntary commitment (IC) for the treatment of substance use disorders is a highly controversial and poorly understood practice, with California offering a striking example. The state's involuntary commitment laws, known collectively as Lanterman-Petris-Short, authorized IC for grave disability related to chronic alcoholism. These provisions remain shrouded in obscurity, and data on their usage are lacking. Amid the ongoing debate over the utility of IC as a tool to treat severe substance use disorders and legislation expanding IC for substance use disorders (SUDs) in California and other states, this article highlights the need to better study the use and effectiveness of existing legislation as well as to consider upstream interventions, such as expansion of community-based treatment models.

Expert Panel Consensus on the Effectiveness and Implementation of Models to Support Posthospitalization Care Transitions for People With Substance Use Disorders.

Hospitals are increasingly offering treatment for substance use disorders (SUDs) during medical admissions. However, there is a lack of consensus on the best approach to facilitating a successful transition to long-term medical and SUD care after hospitalization. We aimed to establish a hierarchy of existing SUD care transition models in 2 categories-effectiveness and implementation-using an expert consensus approach. We conducted a modified online Delphi study that convened 25 interdisciplinary clinicians with experience facilitating posthospitalization care transitions for patients with SUD. Panelists rated 10 prespecified posthospitalization care transition models according to 6 criteria concerning each model's anticipated effectiveness (eg, linkage to care, treatment retention) and implementation (eg, feasibility, acceptability). Ratings were made on a 9-point bidirectional scale. Group consensus was determined using the interpercentile range adjusted for symmetry. After 3 rounds of the Delphi process (96% retention across all 3 rounds), consensus was reached on all 60 rating criteria. Interdisciplinary addiction consult teams (ACTs) and in-reach from partnering outpatient clinics were rated highest for effectiveness. Interdisciplinary ACTs and bridge clinics were rated highest for implementation. Screening, brief intervention, and referral to treatment; protocol implementation; and postdischarge outreach received the lowest ratings overall. Feasibility of implementation was perceived as the largest challenge for all highly rated models. An expert consensus approach including diverse clinician stakeholders found that interdisciplinary ACT, in-reach from partnering outpatient clinics, and bridge clinics had the greatest potential to enhance posthospitalization care transitions for patients with SUD when considering both perceived effectiveness and implementation.

Comments on contingency management as an evidence supported treatment for substance use disorders using the Tolin criteria.

Comments on contingency management as an evidence supported treatment for substance use disorders using the Tolin criteria.

Ethical Issues in Treating Substance Use Disorders: Counselor Perspectives

ABSTRACT Ethical issues arise frequently in the treatment of substance use disorders (SUD). Counselors need guidance to navigate ethical dilemmas but receive limited training in resolving ethical issues. To narrow the gap between the ethical dilemmas counselors face and their training, this qualitative study assessed ethical issues that counselors encounter, how they resolve them, and desired training. We conducted qualitative individual interviews with 20 front-line counselors working in two SUD treatment programs, presenting brief vignettes that depicted the ethics code of the national organization representing SUD counselors. The interviews asked open-ended questions about how counselors dealt with issues and their ideas for future ethics training. All participants had encountered ethical dilemmas. Areas of concern included confidentiality and privacy, mandatory reporting, fairness/equity, client-counselor boundaries, tensions between workplace and client welfare, and meeting clients’ complex needs. Ways participants resolved ethical issues included consultations, using direct approaches to resolve ethical dilemmas, and commitment to providing client-centered care. Useful training in the workplace was sparse. Participants expressed needs for ongoing support to resolve workplace ethical dilemmas. Although the importance of ethical issues is widely acknowledged in treating SUD, this study underscores the need for ongoing and interactive training and supervision about ethical issues.

Orlando Veterans Affairs stratification tool for opioid risk mitigation (STORM) very high risk interdisciplinary team review: A brief report

BackgroundCompared to the general population, Veterans Health Administration (VHA) patients have higher rates of mental illness, chronic pain, and substance use disorders (SUD), conditions that increase risk for opioid-related adverse events. VHA developed the Stratification Tool for Opioid Risk Mitigation (STORM) and mandated case reviews by an interdisciplinary team (IDT) for patients identified as very high risk, a process implemented and led by clinical pharmacist practitioners at the Orlando Veterans Affairs Healthcare System (OVAHCS) in 2018. ObjectiveTo evaluate and describe the implementation and process for IDT reviews of patients identified as very high risk by the STORM clinical decision support tool at OVAHCS. MethodsA single center, retrospective, observational chart review was conducted. Veterans reviewed by the STORM IDT between January and September 2018 were reviewed for change in Morphine Equivalent Daily Dose (MEDD), naloxone, nonopioid analgesics, medications for SUD, benzodiazepines, engagement with clinical services (e.g., mental health, SUD, and pain clinic), and overdose or suicide attempts in the year prior versus the year after IDT review. The frequency of follow-up IDT reviews was evaluated. ResultsSeventeen patients were identified. Four were excluded due to nonopioid related death within 12 months after review. The average baseline MEDD was 82.2 mg (range 10–496 mg) and average 12 months after review was 7.5 mg (range 0 – 67.5 mg), a decrease of 74.7 mg, or 90.9% reduction. An increase in medications for SUD (3 patients; 23%), SUD engagement (3 to 6 patients), and urine drug tests was observed (79% increase). Benzodiazepine use decreased by 50%. ConclusionThis report provides insight on the IDT case review process at OVAHCS, a process that may vary widely across facilities. A reduction in MEDD, increase in SUD treatment, and improved risk mitigation was observed. The central role of clinical pharmacy and expanded process for continued follow-up warrants further study.

Traditional Medicine, Culture, and Psychedelic Science: New Pathways for Recovery From Substance Use Disorders.

This article provides an intercultural transdisciplinary perspective on the Indigenous roots of the resurging field of psychedelic science in the management of substance use disorders (SUDs). Ritual uses of entheogens (i.e., psychedelics of natural origin) are elaborate technologies for navigating, containing, and therapeutically directing non-ordinary states of consciousness induced by these compounds. A narrative review of the literature on the therapeutic potential of ayahuasca, peyote, psilocybin-containing mushrooms, Incilius alvarius-derived 5-MeO-DMT (5-methoxy-N,N-dimethyltryptamine), and iboga for the treatment of SUDs was conducted. This article also describes the application of some of these entheogens within a pilot intercultural clinical program implemented by the Yaqui tribe in Sonora, Mexico, for the treatment of SUDs and other mental health challenges. Observational research and preliminary clinical studies indicate the therapeutic potential and relative safety of these compounds in appropriate contexts, including the use of careful screening practices and complementary psychotherapeutic interventions. Preliminary research points to the potential therapeutic value of integrating entheogenic plant and fungi medicine with culturally attuned therapeutic strategies. Respectful intercultural dialogue across worldviews and scientific paradigms allows for the further development of new perspectives at the intersection of entheogens, addiction treatment, mental health, and traditional medicine. More interdisciplinary research is necessary in this field.

Acute effect of different types of moderate intensity physical exercise on affective response and mood state in individuals with substance use disorder

Substance use disorder (SUD) affects a significant percentage of people around the world, negatively influencing aspects of physical and mental health. Physical exercise can promote acute and chronic effects on the affective response and mood of individuals and has shown promising effects in all phases of rehabilitation. The objective of this study was to verify the acute effects of two types of physical exercises at moderate intensity on the mood state and on the affective response of individuals hospitalized for the treatment of SUD. For this purpose, 43 individuals (31 men and 12 women) underwent two physical exercise sessions (one aerobic and one functional) and a control session. Before and immediately after the sessions, subjects answered questionnaires about mood, affective valence, and perceived arousal. Generalized estimating equations (GEE) followed by the Bonferroni post hoc test were used to assess the effect of timing and session on the variables. The results showed significant improvements after both physical exercise sessions in mood (reduction in levels of tension, depression, anger, fatigue, and confusion) and in affective valences (feeling of pleasure and arousal perception), with no changes after the control session. It is observed that different types of physical exercises can positively impact the mental health of individuals undergoing treatment for SUD and should be used as a non-pharmacological strategy in the rehabilitation process.

‘Yoga is a way of life’: A qualitative study of the experiences of using yoga as a treatment for substance use: An interpretive phenomenological analysis

AbstractIntroductionYoga is a form of complementary medicine for substance use disorder (SUD). Randomised controlled trials involving yoga for the treatment of SUD have found that yoga practice reduces the risk of relapse and improves mood and well‐being for people undergoing treatment for SUD; however, the lived experience of yoga practice involving the benefits of reducing SUD is unknown. The aim of this study was to examine the in‐depth experience of yoga to inform the treatment of SUD.MethodsFive semi‐structured interviews explored experiences of yoga among people with a prior history of substance use. Four out of the five participants reported prior use of alcohol, and one reported the use of ‘GBL’ and methamphetamine. Data were analysed using interpretative phenomenological analysis.ResultsThe analysis resulted in three final superordinate themes: (1) growing awareness of the body, mind and emotions; (2) yoga opens a positive way of life; and (3) blending the worlds of yoga and 12‐step recovery. Yoga was reported to enhance awareness of muscle tension, reduce physical stress, increase positive emotions and build tolerance to negative emotions. The integration of the eight‐limb philosophy of yoga, notably withdrawing of the senses, helped combat internal cues and triggers (negative thoughts and emotions) for relapse. Yoga was reported to be compatible with an abstinence‐based lifestyle found in 12‐step mutual aid programmes and helped extend social networks to support long‐term abstinence.ConclusionsThe experience of integrating the eight‐limb philosophy to support abstinence and the asana practice helped participants to reduce cue reactivity. Yoga appeared to enhance interoceptive awareness, which is useful for reducing physical stress related to triggers for relapse, making yogic practice a valuable tool to integrate within mainstream group and individual relapse prevention programmes. Therefore, programmes and health policymakers may want to consider treatments that integrate yogic practices to enhance and support long‐term abstinence for SUD.

Cognitive Dysfunction in the Addictions (CDiA): A Neuron to Neighbourhood Collaborative Research Program on Executive Dysfunction and Functional Outcomes in Outpatients Seeking Treatment for Addiction.

Substance use disorders (SUDs) are pressing global public health problems. Executive functions (EFs) are prominently featured in mechanistic models of addiction. However, there remain significant gaps in our understanding of EFs in SUDs, including the dimensional relationships of EFs to underlying neural circuits, molecular biomarkers, disorder heterogeneity, and functional ability. To improve health outcomes for people with SUDs, interdisciplinary clinical, preclinical and health services research is needed to inform policies and interventions aligned with biopsychosocial models of addiction. Here, we introduce Cognitive Dysfunction in the Addictions (CDiA), an integrative team-science and translational research program, which aims to fill these knowledge gaps and facilitate research discoveries to enhance treatments for people living with SUDs. The CDiA Program comprises seven complementary interdisciplinary projects that aim to progress understanding of EF in SUDs and investigate new biological treatment approaches. The projects draw on a diverse sample of adults aged 18-60 (target N=400) seeking treatment for addiction, who are followed prospectively over one year to identify EF domains crucial to recovery. Projects 1-3 investigate SUD symptoms, brain circuits, and blood biomarkers and their associations with both EF domains (inhibition, working memory, and set-shifting) and functional outcomes (disability, quality of life). Projects 4 and 5 evaluate interventions for addiction and their impacts on EF: a clinical trial of repetitive transcranial magnetic stimulation and a preclinical study of potential new pharmacological treatments in rodents. Project 6 links EF to healthcare utilization and is supplemented with a qualitative investigation of EF-related barriers to treatment engagement for those with substance use concerns. Project 7 uses innovative whole-person modeling to integrate the multi-modal data generated across projects, applying clustering and deep learning methods to identify patient subtypes and drive future cross-disciplinary initiatives. The CDiA program has promise to bring scientific domains together to uncover the diverse ways in which EFs are linked to SUD severity and functional recovery. These findings, supported by emerging clinical, preclinical, health service, and whole-person modeling investigations, will facilitate future discoveries about cognitive dysfunction in addiction and could enhance the future clinical care of individuals seeking treatment for SUDs.

Implementing family-based interventions in opioid treatment programs: Preferences for method of delivery.

Interventions for substance use disorders (SUDs) are typically delivered face-to-face or remotely via telehealth. In recent years, there has been a rapid rise in the number of SUD services delivered using telehealth. However, the literature on which mode of service delivery SUD patients and providers prefer is still emerging, particularly with respect to family-based interventions in Opioid Treatment Programs (OTPs). This study sought to identify/explain preferences for delivering family-based programs among OTP patients and providers. Data collection from a total of 40 participants (20 patients and 20 providers) was conducted from August 2022 to October 2022 at two OTPs in Florida. An online survey was used to collect demographic data, while individual qualitative interviews were conducted to explore preferences for delivering family-based programs. Audiotapes of interviews were transcribed, coded, and thematically analyzed. Analyses revealed that patients and providers had similar preferences, with the most salient being (a) concerns about keeping children engaged during telehealth sessions, (b) concerns about communication barriers when using telehealth, (c) preference for telehealth using live video (as opposed to prerecorded content), and (d) preference for telehealth over face-to-face due to greater convenience for patients. These findings show that preferences for delivering family-based services are varied and may differ somewhat from preferences for delivering traditional individual therapy services. The data presented here can be used to develop and further refine protocols for adapting and delivering family-based interventions in OTP settings, and are especially timely as legislative discussions are currently occurring about expanding telehealth services in these facilities. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Feasibility of using real-world data to emulate substance use disorder clinical trials: a cross-sectional study

IntroductionReal-world evidence is receiving considerable attention as a way to evaluate the efficacy and safety of medical products for substance use disorders (SUDs). However, the feasibility of using real-world data (RWD) to emulate clinical trials evaluating treatments for SUDs is uncertain. The aim of this study is to identify the number of clinical trials evaluating treatments for SUDs with reported results that could be feasibly emulated using observational data from contemporary insurance claims and/or electronic health record (EHR) data.MethodsIn this cross-sectional study, all phase 2–4 trials evaluating treatments for SUDs registered on ClinicalTrials.gov with reported results were identified. Each trial was evaluated to determine if the indications, interventions, at least 80% of eligibility criteria, comparators, and primary end points could be ascertained using contemporarily available administrative claims and/or structured EHR data.ResultsThere were 272 SUD trials on ClinicalTrials.gov with reported results. Of these, when examining feasibility using contemporarily available administrative claims and/or structured EHR data, 262 (96.3%) had indications that were ascertainable; 194 (71.3%) had interventions that were ascertainable; 21 (7.7%) had at least 80% of eligibility criteria that were ascertainable; 17 (6.3%) had active comparators that were ascertainable; and 61 (22.4%) had primary end points that were ascertainable. In total, there were no trials for which all 5 characteristics were ascertainable using contemporarily available administrative claims and/or structured EHR data. When considering placebo comparators as ascertainable, there were 6 (2.2%) trials that had all 5 key characteristics classified as ascertainable from contemporarily available administrative claims and/or structured EHR data.ConclusionsNo trials evaluating treatments for SUDs could be feasibly emulated using contemporarily available RWD, demonstrating a need for an increase in the resolution of data capture within a public health system to facilitate trial emulation.

The Association Between COVID-fear with Psychological Distress and Substance Use: the Moderating Effect of Treatment Engagement.

The purpose of this brief report was to examine the association between COVID-fear with psychiatric symptoms severity and substance use risk in an outpatient population with co-occurring substance use and mental health disorders and whether these associations were moderated by treatment engagement, especially after providers had shifted from an in-person care model to a telehealth format. A total of 136 patients receiving outpatient treatment for comorbid substance use and mental health disorders completed self-report questionnaires on their psychiatric symptoms, substance use, and treatment engagement (i.e., frequency, length, and helpfulness of phone and video sessions with a mental health counselor, psychiatrist, or primary care provider) in the past month between November 2020 and March 2021. Results showed that COVID-fear was significantly associated with psychiatric symptom severity, but not substance use risk. Additionally, perceived helpfulness of phone counseling sessions moderated the associations between COVID-fear and global psychiatric symptom severity, such that COVID-fear and global psychiatric symptom severity were positively associated when perceived helpfulness was low, and not associated if perceived helpfulness was high. The present results highlight the importance of directly addressing fears specific to a national emergency, as well as for providers to build strong rapport with their clients.

Advancing effective street outreach to people experiencing unsheltered homelessness: Concepts for public health nursing.

Homelessness, particularly unsheltered homelessness is a public health emergency in the U.S. Street outreach programs have demonstrated efficacy in connecting people to housing, initiating or retaining people in primary care, improving access to mental health services, and increasing treatment for substance use disorder. Effective outreach is generally characterized by trained, multidisciplinary teams that visit clients where they are, forming trusting relationships over time. Public health nurses working on outreach teams have opportunities to exercise their full scope and standards of practice and advance street outreach to the benefit of a distinctly marginalized group.

Cascade of care for substance use and mental health disorders for justice-involved populations

IntroductionJustice-involved populations have dramatically higher rates of substance use disorders (SUD) and mental health disorders (MHD) compared to the general population. Despite high rates of SUD and MHD, treatment for this population is often limited and not evidence-based. The cascade of care model estimates drop-offs in the continuum of care from screening to identification of need, referral, care initiation, care engagement, and care completion. Recently, healthcare providers have utilized the cascade of care to improve the continuity of care for people with SUD and MHD in justice settings. The purpose of the current study is to 1) identify typologies that explain the proportion of new intakes that pass through each level of the cascade of care for SUD and MHD, and 2) describe agency-level factors that predict typology assignments and agency ability to assess client flow through the levels of the care cascade. MethodUsing Latent Class Analysis, we classify 791 agencies serving justice-involved individuals into typologies according to utilization of each stage in the mental health and substance cascades of care. Then, we examined county and agency characteristics that affect three stages of the cascade process: identification of need for behavioral health services, referrals to appropriate services, and treatment initiation. We build on previous work by exploring these patterns for both SUD and MHD treatment. ResultsThe study identified four SUD/MHD treatment patterns: Low Access, SUD-Focused, High Need-High Access, and Lower Need-High Access classes. Factors influencing typology alignment include location, specialized staff availability, warm hand-off coordination, Medicaid reimbursement, and performance measure tracking. Thirty-nine percent (39 %) of agencies could not be classified because they were unable to report their rate of care along the cascade measures. ConclusionFocusing on factors influencing typology assignment can help counties in assessing service delivery, identifying barriers, and targeting areas for improvements in policies and practices, potentially facilitating long-term changes and overall improvement in the care of individuals with mental health and substance use disorders. Identification of these factors and typologies can improve mental health treatment and access in counties and agencies with large resource barriers or limited attention to mental health treatment.

A theory-informed deep learning approach to extracting and characterizing substance use-related stigma in social media

BackgroundStigma surrounding substance use can result in severe consequences for physical and mental health. Identifying situations in which stigma occurs and characterizing its impact could be a critical step toward improving outcomes for individuals experiencing stigma. As part of a larger research project with the goal of informing the development of interventions for substance use disorder, this study leverages natural language processing methods and a theory-informed approach to identify and characterize manifestations of substance use stigma in social media data.MethodsWe harvested social media data, creating an annotated corpus of 2,214 Reddit posts from subreddits relating to substance use. We trained a set of binary classifiers; each classifier detected one of three stigma types: Internalized Stigma, Anticipated Stigma, and Enacted Stigma, from the Stigma Framework. We evaluated hybrid models that combine contextual embeddings with features derived from extant lexicons and handcrafted lexicons based on stigma theory, and assessed the performance of these models. Then, using the trained and evaluated classifiers, we performed a mixed-methods analysis to quantify the presence and type of stigma in a corpus of 161,448 unprocessed posts derived from subreddits relating to substance use.ResultsFor all stigma types, we identified hybrid models (RoBERTa combined with handcrafted stigma features) that significantly outperformed RoBERTa-only baselines. In the model’s predictions on our unseen data, we observed that Internalized Stigma was the most prevalent stigma type for alcohol and cannabis, but in the case of opioids, Anticipated Stigma was the most frequent. Feature analysis indicated that language conveying Internalized Stigma was predominantly characterized by emotional content, with a focus on shame, self-blame, and despair. In contrast, Enacted Stigma and Anticipated involved a complex interplay of emotional, social, and behavioral features.ConclusionOur main contributions are demonstrating a theory-based approach to extracting and comparing different types of stigma in a social media dataset, and employing patterns in word usage to explore and characterize its manifestations. The insights from this study highlight the need to consider the impacts of stigma differently by mechanism (internalized, anticipated, and enacted), and enhance our current understandings of how each stigma mechanism manifests within language in particular cognitive, emotional, social, and behavioral aspects.

What Chevron doctrine's rejection by Supreme Court could mean for SUD treatment

What Chevron doctrine's rejection by Supreme Court could mean for SUD treatment

Analyzing Dropout in Alcohol Recovery Programs: A Machine Learning Approach.

Background: Retention in treatment is crucial for the success of interventions targeting alcohol use disorder (AUD), which affects over 100 million people globally. Most previous studies have used classical statistical techniques to predict treatment dropout, and their results remain inconclusive. This study aimed to use novel machine learning tools to identify models that predict dropout with greater precision, enabling the development of better retention strategies for those at higher risk. Methods: A retrospective observational study of 39,030 (17.3% female) participants enrolled in outpatient-based treatment for alcohol use disorder in a state-wide public treatment network has been used. Participants were recruited between 1 January 2015 and 31 December 2019. We applied different machine learning algorithms to create models that allow one to predict the premature cessation of treatment (dropout). With the objective of increasing the explainability of those models with the best precision, considered as black-box models, explainability technique analyses were also applied. Results: Considering as the best models those obtained with one of the so-called black-box models (support vector classifier (SVC)), the results from the best model, from the explainability perspective, showed that the variables that showed greater explanatory capacity for treatment dropout are previous drug use as well as psychiatric comorbidity. Among these variables, those of having undergone previous opioid substitution treatment and receiving coordinated psychiatric care in mental health services showed the greatest capacity for predicting dropout. Conclusions: By using novel machine learning techniques on a large representative sample of patients enrolled in alcohol use disorder treatment, we have identified several machine learning models that help in predicting a higher risk of treatment dropout. Previous treatment for other substance use disorders (SUDs) and concurrent psychiatric comorbidity were the best predictors of dropout, and patients showing these characteristics may need more intensive or complementary interventions to benefit from treatment.

Stress and substance use disorders: risk, relapse, and treatment outcomes.

Stress has long been associated with substance misuse and substance use disorders (SUDs). The past two decades have seen a surge in research aimed at understanding the underlying mechanisms driving this association. This Review introduces a multilevel "adaptive stress response" framework, encompassing a stress baseline, acute reaction, and recovery with return-to-homeostasis phase that occurs at varying response times and across domains of analysis. It also discusses evidence showing the disruption of this adaptive stress response in the context of chronic and repeated stressors, trauma, adverse social and drug-related environments, as well as with acute and chronic drug misuse and with drug withdrawal and abstinence sequelae. Subjective, cognitive, peripheral, and neurobiological disruptions in the adaptive stress response phases and their link to inflexible, maladaptive coping; increased craving; relapse risk; and maintenance of drug intake are also presented. Finally, the prevention and treatment implications of targeting this "stress pathophysiology of addiction" are discussed, along with specific aspects that may be targeted in intervention development to rescue stress-related alterations in drug motivation and to improve SUD treatment outcomes.

The Concept of Treatment-Refractory Addiction: Implications for Addiction Treatment Systems and Research.

The concept of treatment-refractory addiction, proposed by Eric Strain in this edition of the Journal, has the potential to invigorate the field of addiction treatment and research by focusing on a phenomenon that is familiar to any clinician treating patients with substance use disorders, namely, the patient who does not experience sufficient improvement from standard treatments. An analogy is drawn to the concept of treatment-resistant depression and the STAR*D study, which demonstrated an algorithmic approach to treatment, where if the first antidepressant medication tried did not result in remission from depression, subsequent trials of medications or cognitive behavioral therapy doubled the proportion of patients achieving remission. Recognizing treatment-refractory addiction challenges our field to develop analogous, stepwise, algorithmic approaches to treatment of substance use disorders, moving away from siloed treatment programs toward integrated treatment systems where alternative treatments are available, offering the kind of personalized, tailored forms of care used in the treatment of most other chronic illnesses. Like in STAR*D, research could focus on samples of patients who have not benefitted from initial trials of standard addiction treatments, addressing the key clinical question of what to do next when previous treatments fail.