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A recent study estimates that 52.6 million people need treatment for a substance use disorder (SUD), yet only 23% of those that need treatment receive it. Addiction medicine exists precisely to close that gap.
What is addiction medicine?
Addiction medicine is a dynamic multi- and sub-specialty spanning family medicine, internal medicine, psychiatry, and beyond that equips providers to address the challenges of substance use and addiction.
In this Grand Strides session, addiction medicine specialist Jacob "Gus" Crothers, MD sat down with Erica Bristol DNP, MSN, RN, FNP-C—regional medical director and family nurse practitioner at Marathon Health—to share best practices for reducing addiction-related stigma while improving care access, continuity, and patient outcomes. Before recently co-founding Tokaido Health, Dr. Crothers was the chief medical officer of Groups Recover Together, the nation’s largest provider of value-based treatment for substance use disorders.
Understanding substance use disorder, a disease hiding in plain sight
Q: Your career spans frontline medicine, health tech, and value-based care. What experience has most shaped how you view SUD?
Dr. Crothers: It was primarily family, not professional experience, that planted the seed. Growing up around family members who struggled with alcohol, stimulants, and opioids, I saw the waxing and waning pattern of substance use disorder throughout their lives—before I knew anything about the physiology or epidemiology.
When I entered medicine, I trained in family medicine and primary care. During my residency in the early 2010s—the peak of the opioid overprescribing epidemic—something shifted. I came in with a beginner's mindset and could just tell: something is not right. I didn't care what the guidelines or pharmaceutical companies said—I could see these medications were making people worse, not better. And frankly, it turned me off of primary care.
Addiction medicine wasn't something we got much training in, but I was exposed to a mentor prescribing buprenorphine to a small panel of patients with opioid use disorder. A lightbulb went off: this is someone who's actually helping, not making the problem worse.
Q: How is SUD similar to—or different from—other chronic conditions treated in primary care?
Dr. Crothers: What became clear early on was how rewarding it was to treat SUD, for both the patient and the provider. The disease is so symptomatic that patients want treatment; they want to get better. They open up in ways that patients with other chronic diseases rarely do.
It's rare for a patient to share how their high blood pressure has upended their life over 20 years, because odds are it hasn't. So much of primary care is convincing people to take asymptomatic conditions seriously. That's a hard battle. You don't have to fight it in addiction medicine.
Addiction is symptomatic, with broad-reaching impacts—professional, spiritual, and on family dynamics. Once I learned to ask about substance use, that it wasn't taboo, that there were ways to create space for it in an appointment—I saw people open up.
Standardize, don't stigmatize
Q: Stigma remains a massive barrier to care. How can primary care teams build empathy and create safer environments for these patients?
Dr. Crothers: A mentor once told me: "Standardize, don't stigmatize." Early in my career, I caught myself allowing stereotypes to influence which patients I screened for SUD—not with malicious intent, but an unconscious bias. I learned the importance of a standardized care model, and it's now something I advocate for and help institutions build.
But it goes beyond screening. Caring for this population can be genuinely challenging—addiction wreaks havoc on people's lives. Opioids hijack executive functioning and decision-making. That's why stigma develops.
A few reminders that help:
- Recognize the pathophysiology: This isn't a bad person—you're seeing what the opioid or alcohol molecule is doing to them.
- Standardize your approach to difficult behaviors: A patient will inevitably show up late or cause a scene. Having protocols posted in the exam room lets you stay impartial: this is how I treat everyone.
- Remember human condition: Although addiction isn't universal, the desire to alter consciousness is part of the human condition. People do it differently—alcohol, caffeine, fasting, meditation, my three-year-old spinning on the kitchen floor. Some people, due to genetics, socioeconomic circumstances, and peer groups, are just unlucky and end up on a harder road. It really could happen to any of us, and it does happen to a lot of us.
Finally, about 75% of those who report ever having an SUD report they are in recovery. That's not the case for other chronic conditions like hypertension, obesity, or COPD. People tend to see positive outcomes with this disease. Sharing that with your patients inspires hope, and hope is the antidote to stigma.
Beyond referrals: Supporting addiction in primary care
Q: Does primary care have a place in addiction medicine beyond simply writing referrals?
Dr. Crothers: Absolutely—and I say that as someone who practiced primary care for five years. Being a generalist is hard, but addiction is so common and so treatable, and the treatments aren't particularly complicated.
For the big three—nicotine, alcohol, and opioids—screening and initiating treatment should be in every primary care provider's toolbox. For alcohol, even just screening and a brief referral has strong evidence for long-term impact. Going further and prescribing naltrexone or acamprosate? Safe meds, no complicated titration—simpler than much of what primary care is already prescribing.
Buprenorphine, used to treat those with opioid use disorder (OUD), makes providers nervous because of its controlled substance status. But for someone already using opioids, it is much safer. It doesn't require complex decision-making with dosing, and there are ways to ease into prescribing it. And the evidence from emergency departments and inpatient settings is clear: that first prescription matters enormously to driving outcomes, even if you never plan to write another.
What's harder is becoming a specialist in poverty. Addiction doesn't discriminate by income, but people who struggle with it tend to face worsening financial and social circumstances. At Groups Recover Together, we built infrastructure for what Medicaid patients with OUD need most: social services, counseling, and community. The medical protocols were the easy part.
In primary care, be honest about what you can take on. At the practice level, investing in flexible scheduling, social workers, and care navigators can be really helpful.
Q: How should providers handle patient relapse, particularly for OUD?
Dr. Crothers: Short answer: help them get back on their treatment and keep them there. Prescribers often worry about errors of commission, but with this disease you're far more likely to harm a patient through omission—withholding a prescription that forces them to seek fentanyl or heroin on the street. Think through that risk-benefit calculus and capture it in your notes. Having practice-level protocols for relapse and strong leadership support helps providers have that language ready.
More broadly: expect relapse. It's normal and it's a signal to intensify care, not abandon treatment. Maybe they need a higher dose, more consistency, or more psychosocial support: a counselor, a group, more community.
Treating the whole person
Q: Since substance use and mental health overlap so often, how do you treat one when a patient is unwilling to treat the other?
Dr. Crothers: They're intertwined—drawing an artificial line between them is an exercise in futility. Through motivational interviewing and persistence, help patients see it that way too. Having resources in-house to address both makes you dramatically more effective at treating either. It's common to focus on one condition and call the other someone else's job. But caring for both really is your job.
What this means for you
Recovery is possible and all stakeholders—especially providers, plan sponsors, caregivers—play a role in supporting patients on this journey. Within your benefits strategy:
- Primary care is uniquely positioned to screen, initiate treatment, and coordinate care—supporting continuity from first conversation to long-term recovery.
- Integrate mental health care—treating these conditions together with connected care teams leads to better outcomes for both.
- Referrals, SDOH resources, and community support shouldn't fall on the patient—provide referral coordination support to connect them to the right help at the right time.
The path to better outcomes starts with a provider willing to ask the question—and a system built to support what comes next.
This interview has been condensed and edited for clarity and brevity.
About Grand Strides
Marathon Health’s Grand Strides series brings our clinical community together for candid conversations with trailblazers in healthcare. These sessions are designed to spark new thinking, share actionable insights, and inspire our teams as we navigate the evolving landscape of care.
Looking for more healthcare optimism? Read the recap from Grand Strides with Dr. Darshak Sanghavi.
About Grand Strides
Marathon Health’s Grand Strides series brings our clinical community together for candid conversations with trailblazers in healthcare. These sessions are designed to spark new thinking, share actionable insights, and inspire our teams as we navigate the evolving landscape of care. Looking for more healthcare optimism? Read the recap from Grand Strides with Dr. Amy Abernethy.