The majority of people in England who use opiates and/or crack cocaine, or who are dependent drinkers, are not in structured treatment1, together accounting for what has been described as ‘unmet treatment need.’ All three substances are associated with high levels of harm, but the evidence suggests that getting problematic users into treatment may be associated with significant reductions in harms and associated costs. This study was undertaken to explore the nature of dependent alcohol use and drug use among out-of-treatment users (OOTUs), their previous experiences of treatment, and obstacles to future engagement. Adults who had been out of treatment for at least a year were interviewed in Exborough, an urban area of a large city in the South of England and Northton, a town in the North of England (both pseudonyms). We also undertook interviews with professionals in both sites, conducted an analysis of local and national drug treatment data and undertook a short national survey of treatment services.