A conference in Washington, D.C., brought together health care professionals and people working on substance abuse issues to take a look at what four communities have done to use the health care system as part of a strategy to address substance abuse. The four communities are Vallejo (California), Santa Barbara (California), Little Rock (Arkansas), and Gloucester (Massachusetts). Each of these communities, three of which receive funding from the Robert Wood Johnson Foundation's "Fighting Back" program, is struggling to address substance abuse problems cost effectively in a changing health care environment. The communities face many different problems, but their approaches to strengthening and using the health care system share the following elements essential for success: (1) strong leadership; (2) a "vision" or blueprint for change; (3) sufficient financial resources; (4) a strong network of groups with different interests; and (5) a lead agency guiding the efforts of many groups working toward a common goal. Profiles of the four programs show specific strategies they have used. Enlisting the cooperation of schools, especially for referrals, is an important factor. (SLD)