About special guest, Gary Tsai, MD
Gary Tsai, MD, is a physician executive and the director of the Substance Abuse Prevention and Control, a division of the Los Angeles County Department of Public Health. In this role, he is responsible for leading nearly 500 staff with a budget of approximately $460 million, overseeing a full spectrum of substance use prevention, harm reduction and treatment services for the 10 million residents of Los Angeles County.
Sitting down with The Change Companies Chief Program Officer Valerie Bagley and Train for Change Senior National Director Scott Boyles, Dr. Gary Tsai discusses the opportunities, challenges and solutions for engaging non-abstinent clients in substance use disorder treatment.
Read on for more on how to set patients up for success and long-term wellbeing in recovery.
Q: In a recent editorial, you mentioned data around substance use disorder treatment suggests most people with this condition are not interested in services offered. Can you expand on that?
Gary Tsai: Demand often shapes service delivery — if a service is highly sought after, simply offering it can attract people. However, data shows that only a small number of individuals with substance use disorders seek treatment. According to the 2022 NSDUH, approximately 94.7% of those who do not receive services either aren't interested or don't believe they need help. Even among those who recognize their need, only a small percentage actually seek treatment.
Given this, the approach to substance use treatment should be reimagined to engage those who are not actively seeking help. For example, in pediatric dentistry, the environments are intentionally designed to be inviting and engaging for children. Similarly, treatment services should be structured in a way that attracts and engages individuals who might otherwise be hesitant or disinterested. This "design thinking" approach can help maximize engagement and accessibility for those who are currently outside the treatment system.
Q: How does the model of care impact engagement?
Gary: There’s a common belief that individuals must hit "rock bottom" before seeking treatment. Many treatment programs require near or complete abstinence as a condition for entry. Whereas in other areas of healthcare — such as diabetes treatment — patients aren’t required to improve their condition before receiving care.
In Los Angeles County, our organization is reevaluating these preconditions to determine if they are the best way to engage the largest number of people in services — especially when most individuals with substance use disorders are not actively seeking treatment. Clinicians would benefit from lowering these barriers. The primary requirement for accessing services should be interest. Even when interest is lacking, offering proven harm reduction services could reduce overdose risk, prevent disease transmission and improve overall health.
Q: What’s the most common pushback in response to lowering barriers to entry to substance use disorder treatment?
Gary: We’ve gained insights from listening sessions with the substance use disorder community and treatment providers in Los Angeles County. A key concern is how to manage individuals who may be intoxicated in a treatment setting, without disrupting others’ recovery. Additionally, some have questioned whether the county supports abstinence-based treatment. While abstinence is a valuable goal, requiring complete abstinence as a condition for treatment is not an effective approach.
There’s a need here to shift public and provider mindsets, as many people struggling with substance use believe they must wait until they are “ready” or completely abstinent before seeking help. The fentanyl crisis has demonstrated that waiting is not an option — treatment should be accessible at any stage of substance use. If someone is using three days a week and expresses a need for help, the system should welcome them and provide support rather than turn them away.
Q: How can agencies start creating this culture shift to meeting people where they are?
Gary: Culture change is essential for implementing low-barrier approaches to substance use treatment. A key aspect is reevaluating discharge policies. Rather than automatically discharging individuals for a return to use, decisions should be made on a case-by-case basis to keep people engaged in treatment when they are still interested in help.
To drive meaningful culture change, leadership and staff at all levels must engage in open discussions to clarify misconceptions. Some may believe that low-barrier approaches mean not supporting abstinence or eliminating discharges entirely, but the goal is a more nuanced approach that balances support with accountability. Many providers also struggle with concerns that harm reduction enables substance use. However, supporting individuals where they are in recovery does not necessarily facilitate continued substance use.
The field itself shapes how clients understand and engage with treatment. Many individuals are unaware of available options — such as medications for addiction treatment — because providers may not consistently discuss them. To align practice with a new approach, both verbal and written communication must be updated, and organizations must educate their staff and the public. To support these efforts, Los Angeles County has developed resources, such as the Reaching 95% Initiative, to address operational and communication challenges.
Q: How do you concurrently support those individuals who've chosen non-abstinence alongside those who've chosen abstinence?
Gary: Mixing clients at different stages of recovery within a treatment program is a common concern. I’d recommend that agencies have open conversations with clients about their treatment approach, particularly the low-barrier model, to set clear expectations. Since treatment providers shape client perceptions of services, transparency is essential.
In reality, mixing individuals at different levels of readiness can be beneficial. Those further along in recovery may find it therapeutic to reflect on their own journey, while newer clients can gain motivation from seeing others’ progress. However, mixing can also be counterproductive, such as when someone newly sober is exposed to a person who is intoxicated, potentially triggering cravings.
So the key is individualized care — understanding clients’ needs and explaining the rationale behind mixed groups. If clients know that the structure is intentional and designed to provide diverse perspectives rather than cause distress, it can enhance the therapeutic process. Providers should assess whether this approach strengthens a client’s recovery or could be harmful, and adjust accordingly.
It’s important to have individual conversations with those who struggle with being around others in early recovery. Triggers vary. Some may be at risk of immediate return to use just by being around someone in active use, while others may just feel discomfort.
Rather than avoiding these situations entirely, clinicians can explore the underlying reasons behind these reactions as a learning opportunity. The reality is, that in everyday life, individuals may encounter others who are intoxicated. This is an opportunity to help them develop the skills to manage these situations effectively.
Q: Can you share some insights about the Reaching the 95% initiative in California?
Gary: Efforts to implement low-barrier substance use disorder care models in Los Angeles County began in 2023. This cultural change and ongoing education to address misconceptions about what these models entail is crucial. Through listening sessions and one-on-one training, we aim to clarify that low-barrier care does not mean abandoning abstinence as a goal but rather creating a more inclusive system that meets individuals where they are in their recovery journey.
A key component of this effort is the Reaching the 95% initiative, which aligns with ASAM’s clinical guidance and SAMHSA’s advisory on low-barrier SUD treatment. To support this initiative, we have developed a website that provides practical information, including FAQs designed to help programs and jurisdictions across the country navigate potential challenges. This resource will continue to evolve based on feedback and new developments.
While some programs have already embraced this model, many have not. This further highlights the need for continued outreach and education. The overall goal is to make low-barrier care a standard approach, ensuring that individuals at varying stages of recovery feel welcomed and supported in seeking treatment.
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