Transforming lives and empowering communities: evidence, harm reduction and a holistic approach to people who use drugs.

PURPOSE OF REVIEW: We reviewed the global state of harm reduction for people who use and/or inject drugs. KEY FINDINGS: Although harm reduction is now the key response to HIV among people who use drugs globally, intervention coverage remains suboptimal, exacerbated by chronic under-funding, declining donor support and limited domestic investment, particularly in low-income and middle-income countries. We describe the current environment and review recent innovations and responses, including peer distribution of naloxone, low dead space syringes, drug consumption rooms and drug-checking services. However, despite efforts by people who use drugs and supporting partners to sustain harm reduction services and to develop and implement novel interventions, programmes are often under-scaled and under-resourced and people who use drugs continue to face significant barriers to accessing services. SUMMARY: There is an urgent need to bring existing harm reduction programmes to scale and to broaden their scope, as well to complement them with innovative interventions targeting new populations and new substances. Under and disinvestment in harm reduction and the absence of enabling legal environments threatens to undermine the global HIV response and exacerbate the morbidity and mortality associated with the current epidemic of opioid overdose.

A Review of Integrated Care for Concurrent Disorders: Cost Effectiveness and Clinical Outcomes.

Objective: The recognition of concurrent disorders (combined mental health and substance use disorders) has increased substantially over the last three decades, leading to greater numbers of people with these diagnoses and a subsequent greater financial burden on the health care system, yet establishing effective modes of management remains a challenge. Further, there is little evidence on which to base recommendations for a particular mode of health service delivery. This paper will further summarize the existing treatment models for a comprehensive overview. The objectives of this study are to determine whether existing service models are effective in treating combined mental health and substance use disorders and to examine whether an integrated model of service delivery should be recommended to policy makers. The following two research questions are the focus of this paper: (1) Are the existing service models effective at treating mental health and substance use disorders? (2) How are existing service models effective at treating mental health and substance use disorders? Methods: We used various databases to systematically review the effectiveness of service delivery models to treat concurrent disorders. Models were considered effective if they are found to be cost-effective and significantly improve clinical and social outcomes. Results: This systematic review revealed that integrated models of care are more effective than conventional, nonintegrated models. Integrated models demonstrated superiority to standard care models through reductions in substance use disorders and improvement of mental health in patients who had diagnoses of concurrent disorders. Our meta-analysis revealed similar findings, indicating that the integrated model is more cost-effective than standard care. Conclusions: Given the limited number of studies in relation to service delivery for concurrent disorders, it is too early to make a strong evidence-based recommendation to policy makers and service providers as to the superiority of one approach over the others. However, the available evidence suggests that integrated care models for concurrent disorders are the most effective models for patient care. More research is needed, especially around the translation of research findings to policy development and, vice versa, around the translation from the policy level to the patients' level.

Seven Core Principles of Substance Use Treatment System Design to Aid in Identifying Strengths, Gaps, and Required Enhancements.

OBJECTIVE: System planners and funders encounter many challenges in taking action toward evidence-informed enhancement of substance use treatment systems. Researchers are increasingly asked to contribute expertise to these processes through comprehensive system reviews. In this role, all parties can benefit from guiding frameworks to help organize key questions and data collection activities, and thereby set the stage for both high-level and on-the-ground strategic directions and recommendations. This article summarizes seven core principles of substance use treatment system design that are supported by a large international evidence base and that together have proven applicable as a framework for several systems review projects conducted predominantly in Canada. METHOD: The methodology was based on a narrative review approach. RESULTS: The principles address a wide range of issues. Specifically, a broad systems approach is needed to address the full spectrum of issues; accessibility and effectiveness are improved through collaboration across stakeholders; a range of system supports are needed; need for services should be grounded in self-determination, holistic cultural practices, choice, and partnership; attention to diversity and social-structural disadvantages are crucial to equitable system design; systematic screening and assessment is needed to match people to appropriate treatment services in a stepped service framework; and, last, individualized treatment planning must include the right mix of evidence-informed interventions. CONCLUSIONS: By bringing researchers and stakeholders back to the high-level goals of substance use treatment systems, these principles provide a comprehensive, evidence-based, organizing framework that has the potential to improve the quality of system design and review internationally.

Exploring the costs and effectiveness of the Drug and Alcohol Withdrawal Network: a home-based alcohol and other drug withdrawal service.

The Drug and Alcohol Withdrawal Network (DAWN) is a home-based withdrawal service based in Perth, Western Australia. Literature on outcomes, costs and client attitudes towards this type of home-based detoxification in Australia is sparse. Therefore, this study assessed these factors for clients enrolled over a 5-year period (July 2011-June 2016). Client experience was explored through semi-structured interviews with 10 clients. Over the study period, 1800 clients (54% male, mean age 38 years) were assessed, and there were 2045 episodes of care. Although most first-episode clients (52%) listed alcohol as the primary drug of concern, the proportion listing methamphetamine increased from 4% in 2011-12 to 23% in 2015-16. In 94% (n=639) of withdrawal detoxification episodes with completed surveys, clients used their 'drug of primary concern' most days or more often at baseline; this had reduced to 23% (n=149) at the conclusion of detoxification. Five-year direct costs were A$4.8million. Clients valued the person-centred holistic approach to care, including linking with other health providers. Barriers included low awareness of the program and difficulties finding an appropriate support person. Further exploration of cost-effectiveness would substantiate the apparently lower per client cost, assuming medical suitability for both programs, for home-based relative to inpatient withdrawal.

Randomised controlled trial to improve health and reduce substance use in established psychosis (IMPaCT): cost-effectiveness of integrated psychosocial health promotion.

BACKGROUND: There is mounting evidence that people with severe mental illness have unhealthy lifestyles, high rates of cardiovascular and metabolic diseases, and greater risk of early mortality. This study aimed to assess the cost-effectiveness of a health promotion intervention seeking to improve physical health and reduce substance use in people with psychosis. METHODS: Participants with a psychotic disorder, aged 18-65 years old and registered on an enhanced care approach programme or equivalent were recruited from community mental health teams in six mental health trusts in England. Participants were randomisation to either standard community mental health team care (treatment as usual) or treatment as usual with an integrated health promotion intervention (IMPaCT). Cost-effectiveness and cost-utility analyses from health and social care and societal perspectives were conducted alongside a cluster randomised controlled trial. Total health and social care costs and total societal costs at 12 and 15 months were calculated as well as cost-effectiveness (incremental cost-effectiveness ratios and cost-effectiveness acceptability curves) at 15 months based on quality of life (SF-36 mental and physical health components, primary outcome measures) and quality adjusted life years (QALYs) using two measures, EQ-5D-3 L and SF-36. Data were analysed using bootstrapped regressions with covariates for relevant baseline variables. RESULTS: At 12-15 months 301 participants had full data needed to be included in the economic evaluation. There were no differences in adjusted health and social care costs (£95, 95% CI -£1410 to £1599) or societal costs (£675, 95% CI -£1039 to £2388) between the intervention and control arms. Similarly, there were no differences between the groups in the SF-36 mental component (-0.80, 95% CI -3.66 to 2.06), SF-36 physical component (-0.68, 95% CI -3.01 to 1.65), QALYs estimated from the SF-36 (-0.00, -0.01 to 0.00) or QALYs estimated from the EQ-5D-3 L (0.00, 95% CI -0.01 to 0.02). Cost-effectiveness acceptability curves for all four outcomes and from both cost perspectives indicate that the probability of the health promotion intervention being cost-effective does not exceed 0.4 for willingness to pay thresholds ranging from £0-£50,000. CONCLUSIONS: Alongside no evidence of additional quality of life/clinical benefit, there is also no evidence of cost-effectiveness. TRIAL REGISTRATION: ISRCTN58667926 . Date retrospectively registered: 23/04/2010. Recruitment start date: 01/03/2010.

Mixed methods inquiry into traditional healers' treatment of mental, neurological and substance abuse disorders in rural South Africa.

BACKGROUND: Traditional healers are acceptable and highly accessible health practitioners throughout sub-Saharan Africa. Patients in South Africa often seek concurrent traditional and allopathic treatment leading to medical pluralism. METHODS & FINDINGS: We studied the cause of five traditional illnesses known locally as "Mavabyi ya nhloko" (sickness of the head), by conducting 27 in-depth interviews and 133 surveys with a randomly selected sample of traditional healers living and working in rural, northeastern South Africa. These interviews were carried out to identify treatment practices of mental, neurological, and substance abuse (MNS) disorders. Participating healers were primarily female (77%), older in age (median: 58.0 years; interquartile range [IQR]: 50-67), had very little formal education (median: 3.7 years; IQR: 3.2-4.2), and had practiced traditional medicine for many years (median: 17 years; IQR: 9.5-30). Healers reported having the ability to successfully treat: seizure disorders (47%), patients who have lost touch with reality (47%), paralysis on one side of the body (59%), and substance abuse (21%). Female healers reported a lower odds of treating seizure disorders (Odds Ratio (OR):0.47), patients who had lost touch with reality (OR:0.26; p-value<0.05), paralysis of one side of the body (OR:0.36), and substance abuse (OR:0.36) versus males. Each additional year of education received was found to be associated with lower odds, ranging from 0.13-0.27, of treating these symptoms. Each additional patient seen by healers in the past week was associated with roughly 1.10 higher odds of treating seizure disorders, patients who have lost touch with reality, paralysis of one side of the body, and substance abuse. Healers charged a median of 500 South African Rand (~US$35) to treat substance abuse, 1000 Rand (~US$70) for seizure disorders or paralysis of one side of the body, and 1500 Rand (~US$105) for patients who have lost touch with reality. CONCLUSIONS: While not all healers elect to treat MNS disorders, many continue to do so, delaying allopathic health services to acutely ill patients.

Opium trade and the spread of HIV in the Golden Crescent.

The Golden Crescent region of South Asia-comprising Afghanistan, Iran, and Pakistan-is a principal global site for opium production and distribution. Over the past few decades, war, terrorism, and a shifting political landscape have facilitated an active heroin trade throughout the region. Protracted conflict has exacerbated already dire socio-economic conditions and political strife within the region and contributed to a consequent rise in opiate trafficking and addiction among the region's inhabitants. The worsening epidemic of injection drug use has paralleled the rising incidence of HIV and other blood-borne infections in the region and drawn attention to the broader implications of the growing opiate trade in the Golden Crescent. The first step in addressing drug use is to recognize that it is not a character flaw but a form of mental illness, hence warranting humane treatment of drug users. It is also recommended that the governments of the Golden Crescent countries encourage substitution of opium with licit crops and raise awareness among the general public about the perils of opium use.

An organisational change intervention for increasing the delivery of smoking cessation support in addiction treatment centres: study protocol for a randomized controlled trial.

BACKGROUND: The provision of smoking cessation support in Australian drug and alcohol treatment services is sub-optimal. This study examines the cost-effectiveness of an organisational change intervention to reduce smoking amongst clients attending drug and alcohol treatment services. METHODS/DESIGN: A cluster-randomised controlled trial will be conducted with drug and alcohol treatment centres as the unit of randomisation. Biochemically verified (carbon monoxide by breath analysis) client 7-day-point prevalence of smoking cessation at 6 weeks will be the primary outcome measure. The study will be conducted in 33 drug and alcohol treatment services in four mainland states and territories of Australia: New South Wales, Australian Capital Territory, Queensland, and South Australia. Eligible services are those with ongoing client contact and that include pharmacotherapy services, withdrawal management services, residential rehabilitation, counselling services, and case management services. Eligible clients are those aged over 16 years who are attending their first of a number of expected visits, are self-reported current smokers, proficient in the English language, and do not have severe untreated mental illness as identified by the service staff. Control services will continue to provide usual care to the clients. Intervention group services will receive an organisational change intervention, including assistance in developing smoke-free policies, nomination of champions, staff training and educational client and service resources, and free nicotine replacement therapy in order to integrate smoking cessation support as part of usual client care. DISCUSSION: If effective, the organisational change intervention has clear potential for implementation as part of the standard care in drug and alcohol treatment centres. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12615000204549 . Registered on 3 March 2015.

Rates of Mental Illness and Addiction among High-Cost Users of Medical Services in Ontario.

OBJECTIVE: To quantify the burden of mental illness and addiction among high-costing users of medical services (HCUs) using population-level data from Ontario, and compare to a referent group of nonusers. METHOD: We conducted a population-level cohort study using health administrative data from fiscal year 2011-2012 for all Ontarians with valid health insurance as of April 1, 2011 (N = 10,909,351). Individuals were grouped based on medical costs for hospital, emergency, home, complex continuing, and rehabilitation care in 2011-2012: top 1%, top 2% to 5%, top 6% to 50%, bottom 50%, and a zero-cost nonuser group. The rate of diagnosed psychotic, major mood, and substance use disorders in each group was compared to the zero-cost referent group with adjusted odds ratios (AORs) for age, sex, and socioeconomic status. A sensitivity analysis included anxiety and other disorders. RESULTS: Mental illness and addiction rates increased across cost groups affecting 17.0% of the top 1% of users versus 5.7% of the zero-cost group (AOR, 3.70; 95% confidence interval [CI], 3.59 to 3.81). This finding was most pronounced for psychotic disorders (3.7% vs. 0.7%; AOR, 5.07; 95% CI, 4.77 to 5.38) and persisted for mood disorders (10.0% vs. 3.3%; AOR, 3.52; 95% CI, 3.39 to 3.66) and substance use disorders (7.0% vs. 2.3%; AOR, 3.82; 95% CI, 3.66 to 3.99). When anxiety and other disorders were included, the rate of mental illness was 39.3% in the top 1% compared to 21.3% (AOR, 2.39; 95% CI, 2.34 to 2.45). CONCLUSIONS: A high burden of mental illness and addiction among HCUs warrants its consideration in the design and delivery of services targeting HCUs.

Examining the pathways for young people with drug and alcohol dependence: a mixed-method design to examine the role of a treatment programme.

INTRODUCTION: Young people with drug and alcohol problems are likely to have poorer health and other psychosocial outcomes than other young people. Residential treatment programmes have been shown to lead to improved health and related outcomes for young people in the short term. There is very little robust research showing longer term outcomes or benefits of such programmes. This paper describes an innovative protocol to examine the longer term outcomes and experiences of young people referred to a residential life management and treatment programme in Australia designed to address alcohol and drug issues in a holistic manner. METHODS AND ANALYSIS: This is a mixed-methods study that will retrospectively and prospectively examine young people's pathways into and out of a residential life management programme. The study involves 3 components: (1) retrospective data linkage of programme data to health and criminal justice administrative data sets, (2) prospective cohort (using existing programme baseline data and a follow-up survey) and (3) qualitative in-depth interviews with a subsample of the prospective cohort. The study will compare findings among young people who are referred and (a) stay 30 days or more in the programme (including those who go on to continuing care and those who do not); (b) start, but stay fewer than 30 days in the programme; (c) are assessed, but do not start the programme. ETHICS AND DISSEMINATION: Ethics approval has been sought from several ethics committees including a university ethics committee, state health departments and an Aboriginal-specific ethics committee. The results of the study will be published in peer-reviewed journals, presented at research conferences, disseminated via a report for the general public and through Facebook communications. The study will inform the field more broadly about the value of different methods in evaluating programmes and examining the pathways and trajectories of vulnerable young people.

Cost-effectiveness analysis of brief and expanded evidence-based risk reduction interventions for HIV-infected people who inject drugs in the United States.

AIMS: Two behavioral HIV prevention interventions for people who inject drugs (PWID) infected with HIV include the Holistic Health Recovery Program for HIV+ (HHRP+), a comprehensive evidence-based CDC-supported program, and an abbreviated Holistic Health for HIV (3H+) Program, an adapted HHRP+ version in treatment settings. We compared the projected health benefits and cost-effectiveness of both programs, in addition to opioid substitution therapy (OST), to the status quo in the U.S. METHODS: A dynamic HIV transmission model calibrated to epidemic data of current US populations was created. Projected outcomes include future HIV incidence, HIV prevalence, and quality-adjusted life years (QALYs) gained under alternative strategies. Total medical costs were estimated to compare the cost-effectiveness of each strategy. RESULTS: Over 10 years, expanding HHRP+ access to 80% of PWID could avert up to 29,000 HIV infections, or 6% of the projected total, at a cost of $7,777/QALY gained. Alternatively, 3H+ could avert 19,000 infections, but is slightly more cost-effective ($7,707/QALY), and remains so under widely varying effectiveness and cost assumptions. Nearly two-thirds of infections averted with either program are among non-PWIDs, due to reduced sexual transmission from PWID to their partners. Expanding these programs with broader OST coverage could avert up to 74,000 HIV infections over 10 years and reduce HIV prevalence from 16.5% to 14.1%, but is substantially more expensive than HHRP+ or 3H+ alone. CONCLUSIONS: Both behavioral interventions were effective and cost-effective at reducing HIV incidence among both PWID and the general adult population; however, 3H+, the economical HHRP+ version, was slightly more cost-effective than HHRP+.

The California Integration Learning Collaborative: a forum to address challenges of SUD-primary care service integration.

The California Substance Use Disorder (SUD)/Health Care Integration Learning Collaborative (CILC) aims to provide an interactive forum where county administrators, SUD provider organization representatives, and other key stakeholders can collaborate to identify successful models and processes for SUD integration into primary health care, as well as common barriers and solutions. We present the topics discussed within the CILC that have focused on common barriers to SUD and health care integration (documentation/data privacy, financing, and partnering with primary care providers). This article describes the discussions, presentations, and lessons learned from the CILC addressing each of these three barriers.

The medicalization of addiction treatment professionals.

In a previous article, the authors described the changes initiated by recent health care legislation, and how those changes might affect the practice of medicine and the delivery of addiction services. This article reviews the same changes with respect to how they have the potential to change the practice activities of addiction physicians, addiction therapists, addiction counselors and addiction nurses, as well as the activities of administrators and service delivery financial personnel. Developments in delivery systems and the impact of those developments on professionals who work in addiction treatment are considered; current problems, potential solutions, and opportunities for clinicians under health reform are addressed. The goals envisioned for health system reform and the potential for realization of those goals via changes in addiction service delivery design and clinical practice are discussed.

New systems of care for substance use disorders: treatment, finance, and technology under health care reform.

This article outlined ways in which persons with addiction are currently underserved by our current health care system. However, with the coming broad scale reforms to our health care system, the access to and availability of high-quality care for substance use disorders will increase. Addiction treatments will continue to be offered through traditional substance abuse care systems, but these will be more integrated with primary care, and less separated as treatment facilities leverage opportunities to blend services, financing mechanisms, and health information systems under federally driven incentive programs. To further these reforms, vigilance will be needed by consumers, clinicians, and policy makers to assure that the unmet treatment needs of individuals with addiction are addressed. Embedded in this article are essential recommendations to facilitate the improvement of care for substance use disorders under health care reform. Ultimately, as addiction care acquires more of the "look and feel" of mainstream medicine, it is important to be mindful of preexisting trends in health care delivery overall that are reflected in recent health reform legislation. Within the world of addiction care, clinicians must move beyond their self-imposed "stigmatization" and sequestration of specialty addiction treatment. The problem for addiction care, as it becomes more "mainstream," is to not comfortably feel that general slogans like "Treatment Works," as promoted by Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment during its annual Recovery Month celebrations, will meet the expectations of stakeholders outside the specialty addiction treatment community. Rather, the problem is to show exactly how addiction treatment works, and to what extent it works-there have to be metrics showing changes in symptom level or functional outcome, changes in health care utilization, improvements in workplace attendance and productivity, or other measures. At minimum, clinicians will be required to demonstrate that their new systems of care and future clinical activity are in conformance with overall standards of "best practice" in health care.

Training the next generation of providers in addiction medicine.

Within the United States there exists a profound discrepancy between the significant public health problem of substance abuse and the access to treatment for addicted individuals. Part of the insufficient access to treatment is a function of relatively low levels or professional experts in addiction medicine. Part of the low levels of professional addiction experts is the result of inadequate addiction medicine training of medical students and residents. This article outlines deficits in addiction medicine training among medical students and residents, yet real change in the addiction medicine training process will always be subject to the complexity of producing alterations across multiple credentialing institutions as well as the keen competition between educators for "more time" for their particular subject. Other hurdles include the broad-based issue of stigma regarding alcoholism and other substance abuse that likely impact all systems that regulate physician addiction medicine training. As noted in the discussion of psychiatry residency, even psychiatry residents manifest stigma regarding substance abusing patients. Five currently active processes may allow for fundamental change to the inertia in physician addiction medicine training while also potentially impacting stigma: 1. We appear to be at the beginning of the integration of addiction into traditional medicine through the formation of a legitimized addiction medicine subspecialty. 2. The training of primary care trainees and practitioners in the use of SBIRT is accelerating, thus creating another process of addiction integration into traditional medicine. 3. The PCMH is being established as a model for primary care 4. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) became effective for group health care plan years beginning on or after July 1, 2010; thereby, substance abuse benefits and cost are to be the same as general medical or surgical benefits. 5. The equalizer is prescription drug abuse, which is increasing recognition of addiction among populations where it was previously ignored or denied. The first three activities will create a medical office "experience" that is largely unknown but carries the power to change the perception of addiction: patients visiting their primary care physicians, who then screen them for addiction problems and give the same attention to treatment and prevention of addiction problems as they might give to treatment and prevention of cardiovascular disease and other medical issues. The personal experience of the aforementioned medical scene by members of US society may also provide a very positive impact on psychiatrists, including those who specialize in addiction medicine. It is quite possible that the recognition of addiction medicine as a traditional medical subspecialty as well as the integration of addiction throughout medicine will precede any substantive change in the integration of mental health care with the rest of medicine. Yet, any integration of addiction within the entire field of medicine may open a path for mental health to follow. Psychiatrists, including those who are addiction experts, need to be a part of this new medical integration process. Being a part of new treatment models is why we proposed six future skillsets for psychiatrists who specialize in addiction. The selection of these proposed skillsets anticipates an integrated health care team utilizing some form of a patient-centered approach-three are skillsets that are already required, while the last three address new skillsets that will be helpful in working with the integrative health care team model. Whatever form the future of addiction care takes, psychiatrists who specialize in addiction medicine can provide positive and core contributions as expert addiction and mental health consultants including: 1. How does one screen for major depression and/or an anxiety disorder and also determine a diagnosis? 2. In prescribing, what constitutes legitimate follow-up of patients on antidepressants and antianxiety agents, including how to avoid additional substance abuse problems when prescribing sedative-hypnotics? 3. When and how should patients be referred to a psychiatrist? Finally, it is important to note that any of the potential changes described in this article need to influence only 10% of the approximately 17 million current heavy drinkers to seek treatment to equal the approximately 1.7 million heavy drinkers who are now in treatment, let alone any of the approximately 50 million current at-risk drinkers, virtually none of whom are in treatment. Among other social changes that will alter the future of addiction treatment, the integration of addiction into traditional medicine may go a long way in altering the current ratios of who seeks treatment and is willing to participate in treatment.

Individuals receiving addiction treatment: are medical costs of their family members reduced?

AIMS: To examine whether alcohol and other drug (AOD) treatment is related to reduced medical costs of family members. DESIGN: Using the administrative databases of a private, integrated health plan, we matched AOD treatment patients with health plan members without AOD disorders on age, gender and utilization, identifying family members of each group. SETTING: Kaiser Permanente Northern California. PARTICIPANTS: Family members of abstinent and non-abstinent AOD treatment patients and control family members. MEASUREMENTS: We measured abstinence at 1 year post-intake and examined health care costs per member-month of family members of AOD patients and of controls through 5 years. We used generalized estimating equation methods to examine differences in average medical cost per member-month for each year, between family members of abstinent and non-abstinent AOD patients and controls. We used multilevel models to examine 4-year cost trajectories, controlling for pre-intake cost, age, gender and family size. RESULTS: AOD patients' family members had significantly higher costs and more psychiatric and medical conditions than controls in the pre-treatment year. At 2-5 years, each year family members of AOD patients abstinent at 1 year had similar average per member-month medical costs to controls (e.g. difference at year 5 = $2.63; P > 0.82), whereas costs for family members of non-abstinent patients were higher (e.g. difference at year 5 = $35.59; P = 0.06). Family members of AOD patients not abstinent at 1 year, had a trajectory of increasing medical cost (slope = $10.32; P = 0.03) relative to controls. CONCLUSIONS: Successful AOD treatment is related to medical cost reductions for family members, which may be considered a proxy for their improved health.

Addiction medicine: a model osteopathic medical school curriculum.

The World Health Organization has identified nicotine, alcohol, and illicit drugs as among the top 10 contributors of morbidity and mortality in the world. Substance use disorders are preventable conditions that are major contributors to poor health, family dysfunction, and various social problems in the United States-problems that have a profound economic impact. The American Osteopathic Academy of Addiction Medicine seeks to promote teaching of addiction medicine at colleges of osteopathic medicine (COMs), which-honoring the osteopathic concepts of holistic medicine and disease prevention-are well poised to develop a model addiction medicine curriculum. Educators and students at COMs can use guidelines from Project MAINSTREAM, a core addiction medicine curriculum designed to improve education of health professionals in substance abuse, for developing addiction medicine curricula and for gauging their professional growth. These guidelines should be incorporated into the first 2 years of osteopathic medical students' basic science didactics. The authors encourage the development of addiction medicine courses and curricula at all COMs.