Building an Addiction Treatment System That Works (with Dr. Suzette Glasner)

Recovery is possible. Recovery is possible.

Recovery is possible.

Recovery is possible.

Recovery is possible.

Recovery Dialogues in Soberies. Some recoveries get headlines because they're rare. The real question is, how do we make recovery ordinary? Predictable, accessible, expected. Hey friends, Antonio Matta here, and this is Recovery Dialogues and Sober Stories. Where recovery isn't just possible, it's practical. Our philosophy is simple: the recovery process is an individual reaching their fullest potential through deliberate life changes. Inner work plus real access. Our guest today, on a recent episode of her podcast, the Dr. Suzette Glasner Podcast, revealed two staggering realities. One, only 17% of Americans with opioid addiction receive evidence-based medication treatment, and family therapy remains underutilized and underfunded. Two, evidence-based treatment for opioid and other substance addictions is effective and saves lives, yet 87% of those with substance use disorders remain untreated. Before I bring her into the conversation, I'd like to comment on medication for opioid use disorder, the significance of family support, and evidence-based treatment, not just for opioid use disorder, but for addictions in general. My recent Recovery Month episode emphasized that recovery is possible and probable, but it doesn't happen through wishful thinking or passive desire. It is possible when the right treatment, support, and resources are made available and used to their fullest capacity. Here's how I'm thinking about today's conversation: with humility for the science, respect for lived experience, and a clear eye on what actually works. On Recovery Dialogues and Sober Stories, we believe recovery is a person reaching their fullest potential through deliberate life changes that improve the quality of their existence. Self-directed choices, graded with mental wellness and support. Addiction is not a character flaw; it's a chronic medical condition shaped by biology, psychology, and social context. For opioids in particular, the stakes are painfully high. Nearly 110,000 people died from overdose in 2022, a crisis supercharged by fentanyl, Detox or abstinence-only approaches, done alone, don't just fall short; they can be dangerous, with the period after detox carrying the highest overdose risk. That's why an integrated model wins: medication to stabilize the body, evidence-based therapies to build skills and address co-occurring mental health needs, and structured family involvement to repair relationships and sustain change. Let's talk medications for opioid use disorder (MOUD). When people receive methadone or buprenorphine, overdose risk drops dramatically—roughly 59% with methadone, up to 76% with buprenorphine. and serious opioid-related ER visits fall as well. Extended-release naltrexone can help some, but across large real-world samples, it hasn't shown the same reductions in overdose or acute care use, and it's harder to start because it requires a 7- to 10-day opioid-free period. The headline is simple: If you or someone you love has OUD, The odds of being alive in a year are better on methadone or buprenorphine than without them. That isn't substituting one addiction for another. It's evidence-based care that keeps people breathing while they rebuild. Medication is necessary, but it's not sufficient. Pairing MOUD with high-intensity psychosocial care—think several days a month of individual, group, or family therapy—reduces the risk of stopping buprenorphine by about 29% in the first 6 months. That protective effect comes from proven therapies that tackle behaviors, thinking patterns, and motivation. Contingency management offers immediate, tangible rewards for desired behaviors, like negative drug screens, and is one of the most effective behavioral tools we have across substance use disorders. Cognitive behavioral therapy gives people concrete coping strategies for cravings, triggers, and co-occurring depression or anxiety. Motivational interviewing meets ambivalence with empathy and helps people build their own "why," including around starting or sticking with MOUD. Together, these approaches help people stay, not just start. Families are part of the treatment team. Powerfully. Imperfectly. Necessarily. Structured family therapies such as Community Reinforcement and Family Training, the Adolescent Community Reinforcement Approach (ACRA), and Brief Strategic Family Therapy (BSFT) improve communication, reduce conflict, and raise engagement. For youth, ACRA can lower opioid, alcohol, and marijuana use by rearranging life so that sobriety is more rewarding than using. BSFT improves family functioning and with it retention and relapse rates. More broadly, families already provide a huge amount of unpaid care. Get accurate information about MOUD prevents harmful coercion, and builds a home base where recovery can actually take root. If the blueprint is clear, the bottlenecks are just as clear: stigma, policy, and payments. Many clinicians still hold more negative views of patients with OUD than of those with other chronic conditions, which lowers the likelihood they'll offer MOUD or refer appropriately. In some regions, cultural beliefs further discourage dispensing life-saving meds. Patients often absorb that stigma, hearing labels like "junkie" or worrying about an "addict" tag in their chart, which pushes people away from care or off medication early. Meanwhile, policy and operational rules box out access. Methadone is confined to highly regulated opioid treatment programs. Privacy rules like 42 CFR Part 2 make care coordination harder than it has to be, because it is a federal privacy rule that gives extra strong confidentiality to substance use disorder treatment records, stricter than HIPAA. And only a minority of jails offer all 3 forms of MOUD with real continuity on release. Pile onto that prior authorization delays, workforce shortages, and fee-for-service incentives that reward volume over outcomes, and we've built a maze when what we need is a ramp. Fixing the maze isn't hypothetical. Its policy work we can name: Modernize methadone roles, for example, allow mobile and pharmacy-based dispensing. Protect buprenorphine access, eliminate prior authorization, and pay for what works by tying reimbursement to retention, coordination, and recovery outcomes. Fund hub-and-spoke infrastructure with an explicit focus on retention, and require all three forms of MOUD in correctional facilities with warm handoffs into the community. At the same time, grow a confident workforce. Integrate addiction medicine and stigma reduction training into medical, nursing, and pharmacy schools. Support prescribers with telementoring like Project ECHO and extend telehealth parity. Because for many, privacy and geography are real barriers. Let's also equip primary care with measurement-based tools that flag OUD, track recovery, and prompt evidence-based next steps, paired with behavioral health support so clinicians aren't flying solo. Two final notes for the whole substance use disorder community, not just OUD. First, the integrated playbook—medication when indicated, high-intensity behavioral support, and family involvement—translates across substances, even as the specific medications or therapy targets change. Second, story ethics matter. Every time we share a remarkable recovery, we should name the denominator—how often people can't access the same mix of care—so hope doesn't become harmful exceptionalism. Our job together is to make the right care ordinary. If you're listening as a clinician, a policymaker, a parent, or someone in recovery, This isn't abstract. It's a blueprint. Now, we'll hear about moving from principle to practice. As Recovery Month ended in September, UCLA addiction scientist Dr. Suzette Glasner sat down with Beverly Vance-Akins—yes, the vice president's mom—to talk frankly about her 15-year opioid addiction and what finally worked. Medications for Opioid Use Disorder, and Family Healing. It's a powerful reminder that evidence-based care saves lives, but it's not reaching most people who need it. Dr. Glasner now seeks to bring greater awareness and urgent action to expand access to evidence-based addiction treatment, safeguard tele-MOUD, and elevate family therapy. So stories like Beverly's become the norm. Thank you, Dr. Glassner, for taking the time to help us cut through the confetti today and answer the questions that actually move systems. Firstly, if you had a $100 million one-time appropriation to expand access in 12 months, what single intervention comes first? And how do we measure success beyond more prescriptions?

I think that one of The most potentially transformative tools to expand access to evidence-based treatment is digital health interventions. I would build a digital intervention that leverages cutting-edge technology. It would incorporate AI, smartphone, and biosensor technology. For monitoring progress, delivering evidence-based psychotherapeutic content, and providing access to telehealth, both telemedicine and behavioral therapy through telehealth. We would integrate those technology-based tools to deliver personalized evidence-based behavioral treatments as well as medications for addiction care. While monitoring physical health and biometric clinical progress indicators. That would be my approach to creating a single intervention that could really drive impact in this space. And it's a great question around how you would measure success beyond more prescriptions. Success really isn't about prescriptions written because for many people, psychosocial evidence-based care is sufficient to drive health behavior change. I have worked with people for whom behavioral therapy is the sole intervention they use and they find great success with it. Of course, there are individuals who benefit from medications as well, and it depends on the type of substance use disorder, how central the medication piece might be to optimizing clinical outcomes. Success would be measured based on what I would consider to be target clinical as well as functional outcomes. So on the clinical side, you'd be looking at reduction or cessation of a drug or alcohol use, and then you'd be looking at improved mental health as well as physical health, but you'd also be looking at functional outcomes. Is the person able to work? What's their quality of life like? How are their family relationships and their ability to function in multiple roles in their lives that are bringing fulfillment and helping them to live a rewarding life?

You've highlighted the power of family healing. What would it look like to actually operationalize forgiveness in a care pathway? Concretely, what sessions, skills, or milestones would a family therapy protocol include? And how would we know it's working?

Those are some great questions around measurement-based care, which is really so important as a means of validating the clinical outcomes and really the having a metric of success of treatment. Operationalizing forgiveness is not the easiest thing, but it would be the outcome of a process of delivering family therapy where both the individual with with a substance use disorder and their family members are engaging in a process that is leading them to particular types of skills acquisition through family therapy. So what a therapist does in family treatment or family therapy is really teaching the family coping skills. Families deal with mixed emotions towards their loved one with a substance use disorder while they want to see them get well and help them. They also, at the same time, even if they have an understanding of their addiction as an illness, they can't help but feel angry, frustrated, and develop resentment at times, or sad about what's happening to their loved one and the impact on their family. They need evidence-based tools and coping skills for dealing with those complex and conflicting feelings in the most adaptive way possible. Ideally, you want family members to have the opportunity to let out their feelings and talk about them. That is part of gaining an understanding of what they feel, why they feel that way, normalizing it in families dealing with a substance use disorder, fostering a process of healing by having a place to air those feelings in a potentially constructive way and not such a destructive way towards their loved one. That really is starting to provide some of those building blocks. So some of those sessions may involve taking a problem the family isn't sure how to talk about or solve, maybe in relation to a recent slip, relapse, or continued substance use in their loved one, and really coaching the individual members of the family about how to discuss it and come to a solution in a healthy and productive way. What's best for the family? What's best to help the individual with the substance use disorder move towards a process of treatment or healing or recovery? How can that messaging be delivered in a constructive way? Part of what the therapist might do is teach the family members listening skills and assertive communication skills to achieve that and to be productive or have productive, meaningful conversations with their loved one at the right time, in the right place, when the person is not actively under the influence of substances. They're really working on practicing new positive and healthy ways of interacting with one another. It's not atypical for a therapist to assign homework between sessions, like just doing some family things together, eating a meal together, acknowledging positive things that their loved one might be doing rather than focusing all of their interactions only on the addictive behaviors, which often happens because everybody is really preoccupied with and worried about this and has a lot of big feelings about this. But that can make it hard for an individual with an addiction to spend time with their family because it always ends up coming back to the feeling of being lectured or having a negative interaction or feeling criticized in relation to their substance use, uh, or just like doing something fun together, just getting some space between themselves as a family and the topic of their loved one's addiction to take a healthy break from it. Doesn't mean we're not gonna come back to it and work on it. And as far as how you would measure the outcomes of that, a clinician would need to incorporate some objective measures of outcomes that we know to be impacted by family therapy. So what do we know family therapy does for people with addictions and families that are working on overcoming addiction? It's been shown to help people decide to start treatment. Often the goal of that family therapy is just to get their loved one into treatment who might otherwise be ambivalent or hesitant. It can also reduce the risk that their loved one is gonna drop out of treatment prematurely. Family therapy has also been shown to reduce stress. So you'd wanna incorporate some measures of stress as well as the risk of alcohol or substance use among the members of the family who might also have addiction. We know that addiction is very strongly genetically influenced. Often there are other members of the family who are also struggling with an addiction. So We wanna reduce relapse risk among those family members as well. We also know that research shows that family therapy can improve how couples treat each other, how children behave, and really in general how the whole family gets along. There are validated measures of these types of behaviors in families. Those would really be the go-to measurement instruments for monitoring and evaluating the outcomes of this process. This is propelling the family towards forgiveness.

Most systems still grade addiction care with the wrong yardsticks. Which commonly used metric would you retire tomorrow, and what human-centered metric—for example, recovery capital, role functioning, purpose—would you replace it with?

I don't know that I would retire any metrics because existing metrics serve different purposes. We know that as far as human-centered metrics, one of the emergent important measures associated with better outcomes and success in achieving goals of treatment is establishing agency in care decisions. It's so important that individuals feel like they have control over their destiny when they've lost control over their substance use and many aspects of their life. By entering into a course of treatment with a trustworthy provider or care team member, that individual is letting them choose their path to the extent that they're able to. The modality of care, the way that medication is incorporated or whether or not it's incorporated, those types of decisions are really important to rest with the individual who is entering care. So I would be measuring the extent to which patient preferences are being incorporated into the care process and into their care plan as a way of establishing one of the quote unquote right types of yardsticks. Of course, there are other meaningful measures including recovery capital as well as role functioning. I like to use the Addiction Severity Index because it has a number of subscales that indicate an individual's level of functioning across different life areas, including their family functioning, their work or employment functioning, their physical health functioning. And if you see that severity score reduce from the beginning to the end of treatment, then you know that you've achieved those goals not only of reducing substance use but improving their overall quality of life and ability to function across multiple domains that are really important to finding meaning and purpose in life.

Stigma inside healthcare can be subtle. What are the most common micro-rationing behaviors you've observed among clinicians toward medications for opioid use disorder? And what training or accountability mechanism changes those behaviors without shaming providers?

One of the potentially detrimental behaviors I've seen around medication prescribing among clinicians, especially with medications for opioid use disorders like buprenorphine, is that underdosing is pretty common. The practice of underdosing may be tied to a little bit of nervousness and hesitancy to quote unquote "overdo it." This is not uncommon among individuals who are not specialty trained in addiction medicine, but have some familiarity with the medications, are willing to prescribe them, but are not completely comfortable Another place it might come from is in some of the stigmatized views, replacing one drug with another is what you're doing with medications for opioid use disorders. Now, if somebody had a belief in that direction very strongly, they probably wouldn't be prescribing medications for opioid use disorders at all. But if they have some degree of ambivalence about whether they're really feeding a drug habit by providing these medications, even if they felt in general like it was probably good practice to provide them. That doesn't mean that they wouldn't have a little bit of ambivalence about it. That might also influence the way that they practice. It's really a matter of training and education on the latest research. I have worked with some providers who were underdosing. And when I say underdosing, this is really in reference to the fact that There's a lot of research that has come out on medications for opioid use disorders that show that when the dosages are too low of buprenorphine, we have much lower rates of treatment success. There is a mindset of a little bit more aggressive dosing given that we know that there's limits to how high you can go with buprenorphine as far as the number of milligrams that are administered. There is this sort of ceiling effect. Where you can't go any higher than a certain dosage. It is considered safe to go up to the maximum dose, but some providers are hesitant to do that. And I think for the most part, that is just a result of them not really having thorough training and education on the latest research. A large proportion of failures in buprenorphine treatment are because of suboptimal dosing. So I think what we really need to do to promote dosing aligned with best practices is to increase the access of providers to training and the motivation for them to complete training, whether that is a requirement or other incentives, maybe for renewal of their license. There should be some kind of incentive for them to attend these trainings to bring them up to date with the latest research. They might be lacking.

Telemedicine and MoUD. If you had to choose one guardrail to keep, one to discard, and one to rigorously A/B test this year, what are they and why?

I think the important guardrails to keep in place for telemedicine are those related to protecting privacy, so HIPAA and also potential certifications that telemedicine entities can acquire in order to demonstrate that they're going to the greatest lengths possible and following really best practices to ensure the security and privacy of the conversations and data collected. That's super important to reassure individuals that this is a safe space where they can share their personal information without the fear of it being leaked or getting into the wrong hands. As far as what to discard, I think when it comes to regulatory guardrails that we have in place, we have some really counterproductive regulatory guardrails around medications for opioid use disorders, particularly methadone. Methadone is highly effective, but is really available only through federally licensed clinics. Because of the many rules and regulations around access to these clinics, we end up with 80% of US counties without a provider. Because that is regulated at the federal level, one of the guardrails that I could see discarding would be that federal regulatory oversight. If we were able to transfer that oversight to individual states to decide how it is safest to dispense and regulate the use of methadone, then that would potentially really broaden access to a much broader, larger population, overcoming that problem of the underutilization of medications for opioid use disorder.

Beverly Vance-Akins credits medication and forgiveness In the average county clinic with thin staffing, what is the minimum viable model that reliably delivers both medication access and family work without adding months-long wait lists?

I would say that generally county clinics where medications for opioid use disorder are provided have requirements related to counseling. So typically, these requirements tend to be very prescriptive. So it's like a certain amount of time in individual counseling, a certain amount of time in group counseling, and then the medication visit appointments and perhaps some other ancillary services that are provided in conjunction. Because these treatment plans tend not to be very personalized and individualized. That's where you see the limitation that could potentially add waitlists and delays. But there are creative ways that family involvement can be achieved within the care process already established. If you're spending time in individual counseling and that's a predesignated in a county setting, when appropriate, you can invite a family member to join. That way you're not shifting the program structure in a way that's going to create delays in care, but thinking about the individual and their needs more holistically. So bringing the family member into the picture is something you can do somewhat seamlessly. That would really be my suggestion as to how you could deliver both medication access and therapeutic work with a family, incorporating it into an existing model of care in a way that is sensible, tailored, and personalized.

Imagine a rural county jail and ER adopting a "no wrong door" model. Walk us through the first 30 days from first contact to stable community follow-up, highlighting the two handoffs where people are most at risk of falling through.

So this is a pretty important topic. We know from research that there is a very high risk of opioid overdose deaths when people relapse after release from a correctional facility. The reason for that is because if they return to opioid use after a long period of abstinence, they may inadvertently take a larger quantity of opioid than their body's accustomed to, and without tolerance to opioids, their respiratory system can shut down. And that's really the underlying physiological response to an overdose. And quite remarkably, nearly 10% of all deaths from illicit opioids occurs among individuals who were released from a correctional facility, jail, or prison in the past month. My colleagues at UCLA have done a lot of work to reduce mortality rates among criminal justice populations, and they've found that providing medications for opioid use disorders in correctional settings results in significant benefits. Starting or continuing medications for opioid use disorder while incarcerated decreases morbidity after release. It decreases future arrests. Or incarceration. It also increases the likelihood that individuals will engage in treatment and be retained in treatment upon their release. It reduces post-release mortality. One study found that getting treatment with medications for opioid use disorders while in jail was associated with an 80% reduction in overdose deaths during the first month following reentry into the community. There are other medications besides what we call agonist treatments like methadone or buprenorphine. There are other medications for opioid use disorder known as extended release naltrexone. And when that is initiated in a correctional setting, that's also associated with reduced mortality as well as reductions in opioid use after reentry into the community. So we have a variety of FDA-approved medication treatment options that if we could initiate that in the facility, that would really impact not only their potential for return to substance use, but would also be really life-saving for a lot of people. And even though studies don't support mandating psychological treatments, some individuals with opioid use disorder may benefit from behavioral therapy in conjunction with medication. To achieve this sort of treatment initiation, what's recommended by the American Society of Addiction Medicine is that correctional facilities be viewed as part of the community treatment continuum and included in partnerships and coalitions addressing opioid use disorder. Public funding, including opioid settlement funds, For training or technical assistance in supporting Medications for Opioid Use Disorder access should be inclusive of jails and prisons. All correctional settings should provide access to evidence-based opioid use disorder treatment, including FDA-approved medications, either on-site or through transport.

We rarely talk about the nursing workforce as a lever. What would a scalable upskilling program for nurses community colleges included, look like so they can initiate MOUD, coach families, and coordinate care. Curriculum, supervision, and scope.

Nurses are an underutilized resource. Individuals in the nursing field with advanced degrees, such as nurse practitioners, are perfectly well qualified to initiate medications for opioid use disorders. I would see registered nurses as having a role in coordinating care and educating individuals and families about medication for opioid use disorder, even doing some coaching. Nurse practitioners could prescribe and manage medication administration for individuals with opioid use disorders. So there is now this specialty for nurse practitioners in psychiatry and mental health. It's an advanced specialized certification and the training forum where they really learn about psychiatric diagnosis of a substance use disorder, the various psychosocial treatments and medications that are available for substance use disorders. There are an expanding number of treatment programs because of the shortage in the workforce of specialized individuals for addiction and mental health care and the way in which nursing as a field has the potential to really address and help us close that gap. So we really should be leveraging that workforce to prescribe medications for opioid and other addictions, quite frankly. I do personally know several In my role at UCLA, I have previously worked in the nursing department overseeing their research as well as some of the training programs for these psychiatrically specialized nurse practitioners, both through LA as well as through some of the other UCs. You have distance learning programs to certify nurse practitioners in mental health, but that is certainly a specialty that needs to continue to grow and has great promise in helping us fill that need and gap that currently exists in our addiction medicine workforce.

You just put a human face on the data. How do we tell recovery stories publicly without turning exceptional outcomes into the norm? And what editorial standards should podcasts, yours and mine, commit to so hope doesn't become harmful exceptionalism?

So as far as how we tell recovery stories, publicly without turning exceptional outcomes into the norm, I think we just need to tell more of them. In the media, we more often hear stories of tragedy, struggle, and negative outcomes from addictions, arrests, and divorces. Just a lot of negativity around the impact of substance use disorders and people find that entertaining. So we just need to tell more of the recovery stories that should naturally over time help shift this narrative around good outcomes being exceptional. We need to remind people that the latest data show that most people who report that they've ever had a substance use disorder recover. And that's whether through treatment or self-help resources. So recovery actually isn't the exception. Our data do not support that notion. Uh, by expanding access to professionally led care, what we're looking to do is save more lives and optimize longer-term success. But it's not the case that most people with addiction never recover. That's the myth, but that doesn't bear out in the facts. So I think we need to continue citing studies and telling success stories to inspire people that recovery is possible and attainable. Given the extensive evidence-based therapies we have, recovery is the expected outcome for people who engage in care. And we need to showcase more of those stories.

Lastly, what evidence-backed belief do you hold that is unpopular right now? And if we embraced it, what would change for patients and families within a year?

I think a lot of people think that medications like buprenorphine or Suboxone are routinely diverted. And this really fuels the stigma around these types of medications that they're just replacing one drug with another. So you're giving someone with an addiction access to something that they're just going to sell or divert because they don't really want to recover. The evidence-backed belief that I hold is that the diversion of medications like buprenorphine or Suboxone is not the norm. Studies show that generally people who do end up buying drugs like buprenorphine off the street are not buying them to try to get high. Overwhelmingly, they report that when they buy buprenorphine off the street is because they themselves are trying to get off of illicit opioids. They're trying to get off heroin or prescription drugs that they're buying off the street. They know that buprenorphine is the way, but they're having difficulty accessing it, which is not surprising given our access problem. We as a field in addiction care and addiction science would rather that someone illicitly obtain a medication like buprenorphine to try and help them get a— help themselves get a little bit closer to beginning the process of recovery from opioid addiction than to withhold a medication like buprenorphine from somebody who needs it out of fear that they're going to divert it. Because the evidence shows that when it's diverted, more often than not, it ends up in the hands of people who actually need it for treatment. So if people believe this How would it change things? I think it would really reduce the hesitancy, not only that people with opioid addiction sometimes experience in regards to going on these medications, but also their families will often say, "Don't take another medication to replace your heroin or your other opioid. You have to get off of all that stuff completely." And that usually comes from a place of just not knowing how strong and robust the evidence is that medications for opioid use disorder in particular are really the most powerful tool that we have to help people recover and reduce the likelihood of overdose death. If people believed this, then they would be less conflicted about using this form of treatment, and that ultimately would save a lot of lives.

The big takeaway from Dr. Glasner today is simple and urgent. Recovery stops being a miracle when systems do the basics well. Right dose, M-O-U-T, real family involvement, and metrics that reward staying in care, not just starting it. Dr. Glasner, thank you for your time, expertise, and perspective, and for pushing us from confetti to construction. This is our season 4 finale. For Season 5, send your questions and topics with a DM on social or email. If the show matters to you, please chip in at gofundme.com/recoverydialogs. Even a dollar helps keep these conversations alive. We're also looking for sponsors for single episodes and for the full 5th season. Reach out if that's you or your organization. Another way to support the show is to wear your recovery by grabbing Recovery Mantra tees and more with Merch with Meaning at recoverydialogs.com. Thank you for listening and for sharing this space. Please comment, like, and share the episode or past episodes with anyone who could benefit from them. Until next time. Stay curious, stay steady, and keep making room for the next honest conversation. Recovery is possible. Recovery is possible. Recovery is possible. Recovery is possible. Recovery is possible.

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