Recently, Dr. Nolan was asked to provide testimony in Jefferson City, MO, to the Substance Abuse Prevention & Treatment Task Force. His testimony was given on June 24th, 2026. The following is part of his testimony, which has been edited for brevity and clarity.
As we think about what is needed to address the substance use crisis in Missouri, I think it might be helpful to level set so that we can come to a shared understanding of what substance use and addiction are. Contrary to how society has frequently viewed addiction, decades of science demonstrate that this is not a simple binary behavioral problem. In other terms, we cannot view this problem as whether someone uses drugs or does not use drugs. The American Society of Addiction Medicine defines addiction “as a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.” This is important to understand – substance use is a complex phenomenon driven by intrinsic and extrinsic factors such that treating only one aspect, as is often the case, will lead to failure. I might be able to bail water out of a sinking boat, but if I do not understand why the boat is sinking, I will eventually drown. Historically, substance use policy tries to address only one aspect – the binary action of using drugs – without truly addressing the dozens of other factors that influence that action.
The current model for most substance use care in Missouri requires patients to seek out treatment in specialized facilities. Many hospitals and primary care clinics are ill-equipped, or flat-out refuse, to provide the services needed to care for people who use drugs. And the places that do provide this care often represent static locations with fixed hours and multiple other barriers that might preclude less-resourced folks from accessing them. The patients I serve – those at the highest risk of overdose and harm – are frequently not accessing these spaces. For many, there are competing priorities, such as safety, food, and avoiding withdrawal. For those who are motivated, barriers such as inadequate insurance, lack of a government ID, and difficulty in system navigation might prevent them from engaging in care.
You asked that I come here to answer a simple question – to suggest one change to Missouri’s approach to substance use prevention and treatment. You will have to forgive me if I cheat a bit – my answer, which is one concept, is going to expand into many more specific discussion points. If I could change one thing about Missouri’s approach to substance use, it is to treat substance use more holistically by recognizing that substance use is a manifestation of a deeper systemic problem. Lacking a holistic focus risks missing opportunities to really help people overcome addiction.
Let me start simply – the status quo is not working for most patients who use drugs. Those who are resourced and motivated are able to make it to treatment centers. All others are left to fend for themselves in an increasingly hostile system. Just yesterday, I had to care for a patient who was discharged from the hospital without his medications for substance use – something he was stable on for months – because his hospital doctor did not feel comfortable prescribing them. While I won’t name any names, this is a hospital in St. Louis that calls itself the number 1 hospital in Missouri. When I say there are gaps, what I mean is that for most patients, it is a chasm they must cross to get the care they desperately need. Fortunately, this patient was able to call me from a hospital phone, and I was able to get him his medications before discharge – he specifically pleaded with me to help him avoid relapse. I shudder to think about the patients that do not know Street Med STL’s phone number.
What would I change about Missouri’s substance use policy? First, I would recognize that many people who need these services are not accessing them in the places we hope or expect. Despite being blocks away from FQHCs, many patients in the homeless camps in downtown St. Louis prefer the care of my organization. I think that Missouri should learn from this and consider how it might creatively fund outreach care that proactively works to build relationships with people who need services. Outreach care that is person-focused can often reach patients who otherwise struggle to engage in traditional models of care. I would avoid funding based strictly on fee-for-service, but would consider opportunities to think about capitated services, focused managed care plans, or in lieu of service/1115 waivers. These teams should be multi-professional, featuring mental health, medical, and social work care that treats patients in total rather than focusing solely on a use disorder.
Missouri should also think creatively about how to lower the barrier to mental health and substance use medication access. Currently, my organization delivers medications to housing-unstable individuals, intervening on a common barrier patients experience (e.g., transportation, getting to a pharmacy, etc.). This is labor-intensive and often requires close collaboration with pharmacies. One model that is gaining traction outside of the U.S. is the idea of mobile pharmacy. Connecticut recently licensed the first mobile retail pharmacy, which cared for about 400 patients in 11 months. This model is unique in that it can provide enhanced services, including injectable medications. Emerging evidence suggests that long-acting injectable medications for substance use may offer improved outcomes. We also now have injectable meds for HIV prevention and increasing use of direct-to-inject protocols for patients with severe mental illness. Approximately 3 years ago, we applied for a large NIH grant to study mobile pharmacy programs in Missouri (which would have pre-empted Connecticut), but we were turned down by the Board of Pharmacy. A Senate bill or revision of Board of Pharmacy regulations might pave the way for innovative pharmacy-based programs that can expand access to medications for patients who desperately need them.
While opioid use disorder has multiple FDA-approved medication treatments, stimulant use disorder remains without any clear pharmaceutical treatments. Unfortunately, we are seeing many patients who receive treatment for OUD remain untreated for Stimulant Use Disorder, despite there being clear evidence-based behavioral interventions, namely contingency management and community reinforcement approach. In fact, I have recently heard of stimulant use disorder patients who were declined by local substance use treatment programs, which stated they do not treat stimulant use disorder. This is a current gap in the services Missouri provides – searching for contingency programs in MO brings up a DMH educational page from 2022, but I have yet to find a functioning program I can refer patients to. Unfortunately, data suggests that an increasing amount of overdose deaths involve stimulants, meaning that scaling up medications for opioid use disorder without associated opportunities for stimulant use disorder treatment may miss the opportunity to treat an increasingly prevalent problem.
Let me end with a story that illustrates the model of care I am proposing. I recently encountered a homeless patient named Trent. He is in his mid-30s and struggling with opioid use disorder. I encountered him after he left the hospital prematurely because he felt he was not being treated well. He had a large arm wound that had recently had surgery. On our first visit, I was not allowed to touch the wound – all he wanted was wound care supplies. On his second time seeing us, he asked if we could clean his wound. During that encounter, an intimate process of cleaning and dressing his wound, we discussed how he had sustained it. As he discussed his injection drug use, I advised him on ways to avoid future infections. My team and I continued to see him week after week, cleaning his wound and providing gentle education through motivational interviewing. Approximately 4 weeks into his care, he announced he took our advice and stopped injecting. Approximately six weeks into care, he announced he was decreasing his use because, for the first time, he was interested in sobriety. He then mentioned that as his use decreased, some of his PTSD was coming back, so we started working on mindfulness exercises and trying to connect him to mental health care. We are still working with Trent, and for the first time in almost a decade, he is taking steps to work on getting his life organized. This didn’t happen because he went to a treatment program – it happened because we brought a patient-centered treatment program to him. He still has countless hurdles – including getting housed. But for the first time in a long time, he is future-oriented and now focused on sobriety.
Let me reiterate – substance use is a very complicated phenomenon that involves many psychosocial factors. In the larger, macro level, it is intimately tied to economic opportunities, adverse childhood events, individual and generational trauma, and many other factors that are difficult to intervene upon at an individual level. In the absence of radical change in many of these domains, I suggest leaning into alternative treatment approaches that seek to lower barriers to treatment engagement. These approaches should be patient-centered, not focused solely on abstinence, and should explore ways to create novel opportunities to engage other allied health professionals, such as pharmacists and mental health providers. I believe focused outreach is key to reaching those who are not currently engaging in care. And I think Missouri currently underfunds treatment for stimulant use disorder.
Finally, I want to say that I am a native Missourian. I have never lived anywhere else. I grew up in Missouri, went to multiple excellent state schools, and intentionally chose to spend my career serving underserved Missourians. I can think of no group more underserved than my housing-unstable patients in St. Louis, particularly those with substance use. I am proud to be here testifying on their behalf and would welcome the opportunity to continue this dialogue to amplify and highlight their unique needs.
Nathanial Nolan, MD MPH MHPE
