As a psychiatry resident, I recently completed a rotation at an addiction treatment facility that looked more like a luxury wellness retreat than a medical center. The setting was picturesque: manicured lawns, private rooms bathed in sunlight, daily yoga and mindfulness sessions, and meals prepared by in-house chefs. The staff was warm, compassionate, and abundant, capable of delivering highly individualized, trauma-informed care.

Here, patients were treated not just for their substance use, but for the deeper psychological and emotional wounds that often underlie it. They were met with dignity, patience, and respect. I was deeply moved.

But as I sat in group therapy sessions and individual appointments in that serene environment, I could not help but think of the patients I have met in a very different context. These are the patients who receive care, if it can be called that, in overcrowded emergency rooms and chronically underfunded community clinics. They are often uninsured, undocumented, or barely scraping by. Many of them genuinely want help but are turned away from state-funded detox programs because there are not enough beds. They are handed a stack of phone numbers and told to follow up, knowing full well they cannot afford to miss a day of work, let alone pay for treatment.

One patient in particular stays with me. Let us call him Alex. He presented to our emergency department every few days in alcohol withdrawal. He was uninsured and primarily Spanish-speaking. He shared an apartment with four other heavy drinkers. His family was back in another country, and he was working a factory job to send money home. He did not have a safety net, much less access to residential treatment. All we could offer him was a brief hospital stay and a referral list.

He needed much more, housing, trauma support, long-term rehab, and culturally competent care. But our system offered none of that. And I could not stop thinking: what if Alex had the chance to receive the kind of care I was seeing during my rotation? What if he had money? What if he was not viewed as “the other”?

Two years before this, just one week before my first day as a psychiatry intern, I turned to the r/medicine Reddit community for advice. I asked how to survive the first month of intern year. Of the more than one hundred replies I received, one stood out and has stayed with me ever since. I saved a screenshot of it. It read:

“Try not to get jaded when you see substance abuse after substance abuse. You are going to hear ED staff say things like, ‘frequent flyer,’ ‘druggie,’ ‘meth head,’ or ‘just here for three hots and a cot.’ It is easy to adopt that tone, sometimes without realizing it. But resist it. Try to formulate a plan that gets them out of the cycle. Truly place yourself in their shoes: no family, no housing, no money; what would you do on a cold night? Good luck.”

That advice resonated with me then. It resonates even more now.

Because addiction does not discriminate. I have seen it affect physicians, teachers, lawyers, CEOs, new parents, college students, and people living on the streets. But access to care, that absolutely discriminates. That depends on insurance status, income, language, zip code, and political will.

This inequity is not just something I have observed, it is well documented. According to the Substance Abuse and Mental Health Services Administration, only six percent of people with a substance use disorder in the United States receive any form of specialty treatment. A 2021 study in JAMA Psychiatry found that individuals with low income were three times more likely to face barriers to treatment, including cost, lack of transportation, and family obligations. And while the overdose epidemic continues to grow, with more than 112,000 deaths in 2022 alone, funding for addiction treatment remains grossly inadequate.

Even worse, hard-won progress is now under threat. Proposed budget cuts could strip Medicaid, the single largest payer for substance use treatment in the U.S., of critical funding. Medicaid currently covers forty percent of non-elderly adults with opioid use disorder and helps fund services like methadone clinics, buprenorphine programs, and naloxone distribution. Cutting it would be catastrophic for countless patients.

We already know what works: medication-assisted treatment, housing support, trauma-informed psychotherapy, and harm reduction programs. Studies in the New England Journal of Medicine have shown that medication-assisted treatment can reduce opioid overdose deaths by as much as fifty percent. Yet, fewer than thirty-five percent of treatment facilities in the U.S. offer these services, and even fewer accept Medicaid or uninsured patients.

As Dr. Gabor Maté has said, “The opposite of addiction is not sobriety. It is connection.” During my rotation at the high-end rehab, I saw that principle in action. Patients received not just medication, but also community, including group therapy, family involvement, and staff who were trained to listen and connect, not judge or punish.

In contrast, the patients in our public systems are too often met with barriers instead of bridges. With bureaucracy instead of compassion. With stigma instead of support. They are discharged into homelessness, expected to recover without housing, food security, or even a consistent phone number to call for help.

This is not just a clinical failure, it is a systemic and political one. For decades, addiction has been treated as a crime or a personal failing rather than a disease. The War on Drugs devastated communities of color, filled jails instead of treatment centers, and entrenched a legacy of shame and inequity that still shapes our policies today. Black Americans, for instance, are nearly four times more likely to be arrested for drug-related offenses, despite similar rates of substance use as white Americans.

As a physician-in-training, I have been fortunate to see what effective, humane addiction care can look like. But I have also seen what happens when that care is treated as a privilege instead of a right. The difference is life and death.

We can do better. We must do better.

We need to fully fund public addiction services. We need to integrate substance use treatment into primary care and emergency settings. We need to fight Medicaid cuts and expand access to medication-assisted treatment. And we need to actively dismantle the stigma that prevents people from seeking help in the first place.

Because if addiction does not discriminate, our health care system should not either.

Mariana Ndrio is a psychiatry resident.