Marginalized Pop. Timeline

The Marginalization of Patients with Substance Use Disorders in Healthcare Over Time

1914

1971

1935

1929

The War on Drugs

Alcoholics Anonymous (AA) Founded

Narcotic Farms Act

Harrison Narcotic Act

2019

1990

2010

2008

HHS Opioid Tapering Guidance

Addiction Medicine recognized as "Self-Recognized Specialty"

The Affordable Care Act (Obama Care)

Mental Health Parity and Addiction and Equality Act

2023

2022

Present Day: 2025

Consolidated Appropriations Act

Bipartisan Safer Communities Act

Fatal Overdose Reduction Act & SAMHSA Funding Shift After Executive Order

References

Alcoholics Anonymous, (2025). The start and growth of A.A. https://www.aa.org/the-start-and-growth-of-aa Alcoholics Anonymous, (2025). What is A.A.? https://www.aa.org/what-is-aa Beronio, K., Po, R., Skopec, L., & Glied, S. (2013, February 19). Affordable care act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans. ASPE. https://aspe.hhs.gov/reports/affordable-care-act-expands-mental-health-substance-use-disorder-benefits-federal-parity-protections-0Consolidated appropriations act, 2023 summary of appropriations provisions by subcommittee. (n.d.).https://democrats-appropriations.house.gov/sites/evo-subsites/democrats-appropriations.house.gov/files/FY23%20Summary%20of%20Appropriations%20Provisions.pdfCourtwright, D. T. (1992). The social and legislative origins of narcotic control. In D. R. Gerstein & H. J. Harwood (Eds.), Treating drug problems (p. 9). National Academies Press.McCarty, D., Priest, J. C., & Korthuis, T. D. (n.d.). The evolution of federal drug court policy and its impact on treatment for opioid use disorder: A brief history. Addiction Technology Transfer Center Network. https://attcnetwork.org/the-evolution-of-federal-drug-court-policy/SAMHSA. (2023). Laws, regulations, and policies. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/about/laws-regulations-policiesSullivan, M. D., & Ballantyne, J. C. (2023). Questioning the right to pain relief and its role in the opioid epidemic. Mayo Clinic Proceedings, 98(8), 1216–1224. https://doi.org/10.1016/j.mayocp.2023.03.008U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2025, July 29). Dear colleague: Guidance on SAMHSA discretionary grant funding following Executive Order 14321 – Ending Crime and Disorder on America’s Streets. https://www.samhsa.gov/sites/default/files/dear-colleague-letter-executive-order-ending-crime-disorder-americas-streets-07302025.pdfU.S. Narcotic Farm. (n.d.). Kentucky Historic Institutions. Kentucky Historic Institutions. Retrieved November 15, 2025, from https://kyhi.org/other/u-s-narcotic-farm/U.S. Senate. (2025). Fatal Overdose Reduction Act of 2025, S. 665, 119th Cong.. Retrieved from https://www.congress.gov/bill/119th-congress/senate-bill/665

Present Day

There have been several notable policy moves in 2025 that affects our population:

Policy that help REDUCE Marginalization:

Policy that may INCREASE Marginalization:

• Fatal Overdose Reduction Act
• Bill introduced to creating Medicaid- funded Health Engagement Hubs that integrates social, medical, and addiction services.
• Helps with low-income and high-risk individuals.
• Hubs will help provide readily accessible care without requiring appointments or proof of payment.
• Not currently passed yet, in legislative stage.

• SAMHSA Funding Shift After Executive Order (July 2025)
• Federal policy now restricting funding to only certain "evidence-based" programs.
• Substantial staff and funding cut.
• Some hard reduction services may lose support (i.e., non-abstinence based and low barrier services).
• Reduces access to tools such as safer-use supplies that helps prevent overdose.

(U.S. Senate, 2025)

(U.S. Department of Health and Human Services [HHS], 2025)

The Affordable Care Act

How this Act benefitted those with SUD

• The ACA provided the "largest expansion of substance use disorder coverage" (Beronio et al., 2013)
• 32.1 million Americans gained access to benits related to substance use disorders (Beronio et al., 2013)
• ACA applied federal parity protections to these benefits (Beronio et al., 2013)
• The Act increased access to quality care for SUD and provided coverage for this care

(Beronio et al., 2013)

2019 HHS Opioid Tapering Guidance

Address harms from rapid or forced opioid tapering.

• Shifted focus from punitive approaches to harm reduction and patient safety.
• Emphasized compassion and collaboration, countering "drug-seeking" label which helped reduction of stigma.

The Bipartisan Safer Communities Act

• Allocated funding for mental health and substance use programs
• $800 million from 2022-2025
• $150 was used to support the crisis hotline (988)
• All remaining funding was given to the Substance Abuse and Mental Health Services Administration's (SUMHSA) Center for Mental Health Services

(SAMHSA, 2023)

President Nixon's War on Drugs

In 1971 President Nixon declared a "war" on drugs, further increasing the stigma around addiction diseases and creating a rhetoric of criminality. Persons with substance use disorders were looked at as criminals in need of punishment, rather than individuals suffering from a medical disorder needing treatment.

https://action.aclu.org/send-message/biden-end-war-drugs-start-clemency

Balancing the Scales

The implementation of this federal law aimed to give mental health services the same "weight" and consideration for coverage that medical/surgical needs received by insurance companies. More strict limitations and seperate financial requirements also CANNOT only apply to mental health benefits.

https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity

Alcoholics Anonymous (AA) Founded

How it Started? It all started with a conversation between two alcoholics in Akron, Ohio. New York stockbroker, Bill and surgeon, Dr. Bob met together and shared their story with alcoholism. Bill convinced Dr. Bob that alcoholism was a disease which at the time was not something that physicians learned. Seeing how working with other alcoholics helped in maintaining sobriety, these two men worked together with fellow alcoholics at Akron’s City Hospital. Their first member achieved sobriety and the three men made up the first Alcoholics Anonymous (AA) group (Alcoholics Anonymous, 2025). Present Day AA is a fellowship of alcoholics who come from all different backgrounds with different stories yet share the same want to achieve sobriety. AA groups are free to attend and welcome anyone regardless of age or education. The main goal of the group is to help alcoholics achieve sobriety. Today AA groups are available throughout 180 nations worldwide (Alcoholics Anonymous, 2025).

Narcotic Farms Act (1929)

This act implemented federally funded care of the treatment of opioid use disorder. Participants were either voluntarily admitted or involuntarily admitted as federal narcotic offenders. Treatment facilities were in Lexington, Kentucky and the Fort Worth Texas Institution and were co-managed by the United States Public Health Service and the United States Bureau of Prisons (McCarty et al., n.d.).

(U.S. Narcotic Farm, n.d.)

Harrison Narcotic Act of 1914

What was this Act? • It became illegal to produce, distribute, or use opioids without the approval of a physician. Approved distributors of narcotics (e.g. physicians) had to register with the government, record the transaction, and pay a small tax upon distribution (Courtwright, 1992). Why was this Act Important? • The United States displayed an understanding of how opioids can be addictive if misused by implementing policy to regulate opioid production, distribution, and use. Was there Stigma? Yes! Opioid use was acceptable for pain control, whereas opioid use for the treatment of addiction was prohibited in medical practice. This act helped those in need of pain control but did nothing for those who were already addicted, needing treatment (Sullivan & Ballantyne, 2023).

Consolidated Appropriations Act

What did this act do?

• Funded the SAMHSA with...
• $4.2 billion for treatment, recovery, and prevention
• $237 million for substance use preventative services
• $20 million to implement response teams for those in crisis

(Consolidated Appropriations Act, 2023 Summary of Appropriations Provisions by Subcommittee, n.d.)

TESTING

THIS WILL HAVE 90S EVENT

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"Addiction Medicine"

What does "Self-Recognized Specialty" imply?

Why not create a board certification for addiction medicine? By simply allowing physicians to self declare themselves to be Addiction Medicine Specialists, the AMA has contributed to the stigmatization of addiction diseases. Specializing in addiction medicine should require the same niche training and certification requirements as other specialties, such as Oncology. https://www.asam.org/membership/about-membership/students-residents-fellows/why-specialize-in-addiction-medicine