Still Here Doesn't Mean the System Worked

A note before we begin: this piece is more personal than my usual policy analysis. It includes my own experiences with addiction, chemsex, and recovery, shared during National Recovery Month, and it discusses trauma and substance use throughout.

I saw a friend post something recently that stopped me: "I'm still here, but that doesn't mean the system worked." I've been chem sober for three and a half years, and that line is the closest thing I have to an honest summary of how I got here.

Before the pandemic, I was already coming apart quietly. Years of unresolved childhood and religious trauma had been compounding under a clinical level of burnout, depression, ADHD, and a marriage that was more performance than partnership. When COVID hit, I was laid off twice, my marriage ended violently, and the life I'd built to prove I was acceptable collapsed inside a few months. I chose to cope through sex and drugs, and that became my life for nearly two years, until I had almost nothing left and was moving toward psychosis and, most likely, an overdose. The only reason I got sober, and have stayed that way so far, is that I have a relentlessly supportive family and enough privilege to afford high-quality trauma therapy my insurance didn't cover. It has cost more than $30,000 out of pocket. That is not a system working. It is luck, and luck is not policy.

I'm writing this during National Recovery Month because the standard version of the addiction story in this country leaves people like me out, and the omission costs lives.

The Wave Nobody's Treating

For a quarter century, the overdose crisis has been narrated as an opioid story, and for good reason. But the numbers have moved. In 2023, roughly 105,000 people died of a drug overdose in the United States. About 76% involved an opioid, but 33% involved psychostimulants like methamphetamine and 28% involved cocaine, according to the Centers for Disease Control & Prevention (CDC). Among the 37 states and the District of Columbia reporting detailed data, 47% of overdose deaths involved both an opioid and a stimulant.

The encouraging news is real. Overdose deaths fell 27% in 2024, from 105,007 to 79,384, the lowest total since 2019, with provisional data pointing to roughly 70,000 in 2025. The Commonwealth Fund attributes the decline to naloxone reaching saturation, expanded access to medications for opioid use disorder, and better linkage to care for people leaving incarceration. As one addiction medicine physician told STAT, "no one should die from an opioid-related overdose when we have an antidote."

We have no such antidote or treatments for stimulants. There is no FDA-approved medication for stimulant use disorder, a gap the agency itself acknowledged in October 2023 when it issued its first draft guidance to help manufacturers develop one. So the treatment system that bent the opioid curve, a system organized around what a clinician can prescribe, meets a rising stimulant crisis with an empty formulary. The wave is here. The tools are not.

Chemsex, Trauma, and the Syndemic

For gay and bisexual men, the stimulant crisis rarely arrives alone. It travels with chemsex, and underneath both sits trauma that most of us were never given a way to treat.

Chemsex refers to the intentional use of drugs like methamphetamine, GHB/GBL, mephedrone, and ketamine before or during sex to lower inhibition, heighten sensation, and sustain sexual encounters that can run for hours or days. The definition varies across studies by which drugs and what frequency count, which is part of why prevalence is hard to measure (Sabença et al., 2025).

The scale is larger than the silence around it suggests. A 2025 systematic review and meta-analysis in Drug and Alcohol Dependence, pooling 238 studies and more than 380,000 participants, found chemsex prevalence among men who have sex with men of 22%, with methamphetamine-specific sexualized use at 8% and GHB/GBL at 13%. Men living with HIV-HCV co-infection reported the highest rates of all. In broad US community samples, chemsex prevalence runs closer to 9 to 10%, though clinic- and app-recruited samples run much higher. That gradient is worth sitting with. My own sense, from inside the community rather than the literature, is that real-world use exceeds what surveys capture, and the distance between representative samples and clinical ones suggests I'm not wrong to think so.

What drives it is where the analysis has to be careful, and honest. Most of this evidence is cross-sectional and cannot establish cause. What it can establish is association, and the associations are consistent. Methamphetamine-using men who have sex with men report higher frequencies of childhood sexual abuse, emotional abuse, emotional neglect, physical abuse, and physical neglect than non-users, and higher depression severity regardless of HIV status. Past homophobic victimization is associated with increased odds of methamphetamine use, partly through the pathway of unstable housing, and internalized HIV stigma is associated with later stimulant use. When researchers ask men why, the most commonly reported reason for chemsex is dealing with painful emotions or stressful events, followed by the desire to belong and to escape. I recognize every word of that. My substance use was a reaction to my reality and the options I believed I had, built on layers of trauma stacked since childhood.

The syndemic tightens from there. Sexualized drug use is associated with higher odds of HIV, bacterial STI, and hepatitis C diagnoses. It also erodes the tools we use to prevent transmission: inconsistent PrEP engagement is more than twice as likely when one partner uses methamphetamine and nearly four times as likely when both do. The same collapse hits treatment adherence. The clinical literature notes that people forget medications during sessions, indirectly reducing therapeutic effectiveness. The plainer version is mine: it is hard to remember to take your antiretrovirals when you don't know what day it is because you've been awake for three or four days having sex with strangers.

The Syndemic Runs Through Mental Health

Mental health is the tissue connecting all of it, which is why treating it is not optional for anyone serious about ending the HIV epidemic. Mental health disorders increase the risk of HIV acquisition four- to tenfold, and among men who have sex with men in the United States, those with four to five co-occurring conditions faced more than eight times the hazard of transmission compared to men with none. Depression is one of the strongest predictors of poor antiretroviral adherence; across 111 samples, the likelihood of good adherence was 42% lower among people with depressive symptoms. People living with HIV carry major depression at 36% and generalized anxiety at 15.8%, against 6.7% and 2.1% in the general population.

Each step of the HIV care continuum, from diagnosis to viral suppression, runs through mental health we are failing to treat. We cannot bend the curve of the epidemic while ignoring the conditions that keep people from testing, starting treatment, and staying on it.

The Treatments Exist. Access Doesn't.

Here is the part that should provoke us. Effective treatments for stimulant use exist. Most people who need them cannot get them.

The behavioral intervention with the strongest evidence is contingency management, which provides tangible incentives for verified abstinence. A meta-analysis of 50 randomized controlled trials with nearly 7,000 participants found contingency management paired with community reinforcement produced the highest rates of abstinence and retention, and contingency management alone outperformed cognitive behavioral therapy on abstinence. A second review of 27 studies found 95% showed improved abstinence and 78% showed reduced sexual-risk behavior. No other treatment for stimulant use disorder has an evidence base this strong, and it remains underused, constrained by cost, stigma, and regulatory caution about paying patients.

Trauma-informed care shows a similar pattern of proven value and thin availability. A systematic review of trauma-informed care in substance use settings found reductions in substance use, mental health and trauma symptoms, and improved treatment retention. This matters because PTSD is substantially elevated among people with substance use disorders and frequently missed by clinicians, and whether a facility offers trauma-specific programming correlates with payer source: positively with private and state insurance, negatively with self-pay. My $30,000 is that finding rendered as a personal invoice.

For me, the return on that investment went past sobriety. Treating the trauma resolved the root causes, and I no longer have the depressive or generalized anxiety symptoms I once did, or take any medication for them. That is my experience, not a promise; results vary by person. It does point at something the payer data misses. When trauma-informed care reaches the people who need it, it can treat several conditions at their source rather than managing each downstream. Rationing it is not only inequitable. It is inefficient.

We should also widen what we count as success. An analysis of 13 clinical trials found that reduced use, short of total abstinence, was associated with a 60% decrease in craving and a 40% decrease in depression severity. As NIDA Director Nora Volkow put it, abstinence "should be neither the sole aim nor only valid outcome of treatment."

I won't disparage any path to recovery. Everyone is unique, and what works for one person may not fit another. For me, the AA and NA model was not what I needed, and anything religiously affiliated would have reinforced the exact wounds I was trying to heal, a concern clinicians who work with LGBTQ+ people in recovery raise directly. My path ran through trauma therapy. For most people carrying what I carried, that path is closed.

The Access Gap, Quantified

The barriers are not mysterious. 160 million Americans live in mental health professional shortage areas, and more than half of US counties have no practicing psychiatrist. Even people with insurance, as was my experience, are pushed out of network: patients go out-of-network 3.5 times more often for behavioral than for medical or surgical care, 8.9 times more often for a psychiatrist, and 19.9 times more often for sub-acute inpatient care, with no improvement between 2013 and 2021. Meanwhile the need is climbing: the share of people needing SUD treatment rose from 8.2% to 17.1% between 2013 and 2023, with insufficient coverage among the leading reasons care goes unreceived. The CDC puts the gap at its plainest: in 2023, 54.2 million people needed substance use treatment and 12.8 million received it.

Care Over Cages, and the Threats to Progress

Two forces make a hard problem worse. The first is that we still default to incarceration over treatment. Two-thirds of jail detainees and half of prison inmates have a substance use disorder, yet only about 10% of prison inmates receive treatment, and the risk of death in the first two weeks after release runs 12.7 times higher than for the general population.

The second is that we are cutting the programs behind the recent progress. SAMHSA lost more than half its staff in the past year, with roughly $1.7 billion in block grants and $350 million in overdose-prevention funding canceled, alongside an April 2026 directive barring federal funds for harm-reduction supplies. Researchers at Penn's Leonard Davis Institute and Boston University estimate that Medicaid cuts could cost 156,000 people access to opioid treatmentand double the overdose rate in that group.

What We Owe Each Other

I am still here. The system did not make that happen; my family and my bank account did. That should indict a system, not reassure one.

There is also something we owe each other, and it can’t be legislated. The stigma around chemsex and methamphetamine inside the gay community runs as deep as the shame, and the two feed on each other. We stay silent, and the silence keeps people from asking for help until the help comes too late. We could extend one another some compassion instead. Any of us is one circumstance away from a choice we swore we would never make. I know, because I was.

So the asks are specific. Fund and reimburse contingency management as standard treatment for stimulant use, and make trauma-informed care standard in stimulant treatment. Enforce behavioral health parity on network adequacy and reimbursement, so trauma care stops tracking with who can pay out of pocket. Integrate mental health and substance use screening and treatment into every HIV care setting, and treat that integration as a precondition for ending the HIV epidemic rather than an add-on. Protect Medicaid and harm-reduction funding. Choose treatment over incarceration for people with substance use disorders.

We know what works. We have chosen, so far, to keep it out of reach for the people who need it most. We can choose differently, and for those of us still here to say so, we should.