The middle-aged patient seemed to embody all the twists and contradictions of the opioid crisis. A white-collar professional with a history of addiction, he had become hooked on prescription painkillers again after a knee operation. When doctors would no longer prescribe the opioids, he returned to heroin. But recently he had developed an abscess at an injection site on his leg. Now he was in Highland Hospital, in Oakland, Calif., claiming to have been bitten by a spider.
Andrew Herring, a specialist in emergency medicine at the hospital, vividly remembers this man, the first person he would ever treat with the drug buprenorphine. The patient was hoping to receive a few opioid pills to help with his “spider bite.” But he had also caught wind of a trial program Herring was just then starting in the emergency department. He and his colleagues were interested in buprenorphine — itself an opioid — as a way to treat addiction to more powerful opioids like heroin. The patient wanted to try that instead of attempting to finagle pills. Struck by his forthrightness and honesty, and by his evident desire to escape the downward spiral of addiction, Herring sent him home with a prescription.
This was in 2016. The previous year, doctors at the Yale School of Medicine published what would come to be seen as a seminal study in the field of addiction medicine. Their study subjects, primarily people who were using heroin or prescription opioids, had been divided into three groups. One received a referral to addiction-treatment services outside the hospital. Another group received a similar referral, along with a brief counseling session at the hospital. And a third group received both the referral and the counseling while also starting on buprenorphine, taken daily as a tablet. After a month, this last cohort was about twice as likely as the other two groups to remain in treatment. This one medicine doubled these patients’ likelihood of staying the course and greatly improved their odds of avoiding a fatal overdose.
An unusual aspect of the study was its setting: the emergency room. Addiction treatment usually didn’t happen in the emergency department, a place generally seen as reserved for acute medical issues, not disorders like drug addiction that require long-term treatment. Yet Herring couldn’t stop thinking about the implications of the Yale research — about how many lives might be saved if E.R. doctors embraced this approach.
And there was already evidence of buprenorphine’s effectiveness, at the population level, in combating overdose deaths. Although the United States government had partly funded buprenorphine’s development as a treatment for opioid addiction, France was one of the first countries to most fully exploit the drug’s potential. In the 1990s, French health authorities began allowing any doctor to prescribe buprenorphine. By the early 2000s, overdose deaths there from heroin and other opioids had declined by nearly 80 percent.
Intrigued by this and other evidence, Herring, who was head of emergency-medicine research at Highland, decided to try the drug in his own E.R. Its transformational potential was quickly apparent. Opioid users often arrived in the E.R. in withdrawal — sick to their stomachs, cranky, itchy, mean. Doctors and nurses dreaded dealing with them. But when Herring gave these patients buprenorphine, their pain and nausea subsided quickly. Herring could sense human warmth where before he was seeing only anguish. “This is why I became a doctor,” he says he recalls thinking. “It really does feel like a restoration of health.” (The middle-aged patient who claimed to have a spider bite got his life in order and eventually moved abroad.)
That same year, Herring and his colleagues established what is now called the Alameda Health System Bridge Clinic, an addiction-treatment program that has since become a model for hospitals and physicians in California and other states. In the decade that followed, the scourge of opioids only worsened. In 2022, more than 107,000 Americans died from drug overdoses, most of them from fentanyl, a fatal-overdose rate nearly quadruple what it was 20 years earlier. More people died from opioid overdoses in that period — more than 700,000, according to C.D.C. data — than perished in all U.S. wars and conflicts going back to World War I.
Over time, opioid users have transitioned from taking prescription drugs like OxyContin to heroin to the fentanyl that now dominates the illicit drug market. The epidemic has crested in different communities at different times. Initially, white Americans died in the greatest numbers. But around 2020, death rates among Black Americans caught up with and then surpassed those of their white counterparts. Today the opioid crisis disproportionally kills African Americans and Native Americans.
Many see illicit fentanyl, said to be about 50 times as powerful as heroin and 100 times as powerful as morphine, as the worst drug epidemic the country has ever seen. At the same time, experts have reached a consensus: Medication-for-addiction treatment, or M.A.T. — using medicine like buprenorphine or methadone to help patients recover from their opioid-use disorder rather than trying to get them to quit cold turkey — is the best course of treatment. Merely starting people on buprenorphine, research suggests, can cut their chances of dying from overdose by between 50 and 80 percent, compared with patients receiving talk therapy and other nondrug interventions.
Yet the drug remains drastically underprescribed. Only somewhere between 10 and 27 percent of those who could potentially benefit from it — people using a variety of illicit opioids, but especially fentanyl — are taking it, according to various analyses. One of the many tragedies of the opioid epidemic is that this medicine has been available in the United States for 23 years; tens of thousands of lives, and maybe even a few hundred thousand lives, might have been saved. The confounding question today is why, with ample evidence of its effectiveness, it still remains so underused.
Experts cite a tangle of reasons buprenorphine has not been adopted more quickly: limited funding; onerous regulation in the past; doctors’ lack of familiarity with it; the hesitation by hospitals and other health care providers to fully engage with the specialty of addiction medicine; and persistent stigma. Buprenorphine also belongs to the same class of drugs as the painkillers and illicit opioids that have led to so much anguish in the first place, most likely causing many physicians to avoid it reflexively. And as an opioid, it’s monitored by the Drug Enforcement Administration, which probably further bolsters doctors’ reluctance. No physician wants to unduly attract the agency’s attention.
Herring and others around the country are on a mission to change all this. One goal at A.H.S. Bridge is to demonstrate that, contrary to still-pervasive assumptions, a good treatment for opioid addiction exists — and that doctors can deploy it easily in their emergency departments. “Our big project,” Herring says, “is to free buprenorphine.”
Today, fentanyl — a drug that, a dozen years ago, few outside the medical profession had even heard of — is a leading killer of Americans in the prime of life. To understand how we got here, Herring sees it as critical to know how the opioid epidemic unfolded in the United States. Many observers view it as arriving in three waves, each one building on its predecessor — with a fourth now underway, perhaps, as opioids even more powerful than fentanyl have appeared, sometimes mixed with other extremely potent drugs.
The first wave began roughly 30 years ago when doctors, encouraged by what is now acknowledged to have been deceptive marketing by the pharmaceutical industry, began overprescribing medical opioids. Between 1991 and 2012, these prescriptions more than tripled in the United States, to almost 260 million yearly. At that point, the height of the prescription phase of the opioid crisis, doctors were prescribing enough opioids for every American adult to get their own bottle of pills.
For the first half of the opioid epidemic, in other words, America’s doctors didn’t just fail to address a snowballing problem; they sped it along. And the problem quickly escaped the confines of doctor-patient relationships, because of a vast diversion of legally prescribed pills into the general population through clandestine networks.
The missteps of the medical establishment didn’t stop with the first wave. The second wave of the opioid epidemic began when that establishment, realizing what it had unleashed, made medical-grade opioids much harder to obtain. Though this might have seemed like a reasonable and corrective step to take, the problem, some experts now argue, was that patients on opioids had developed a kind of disease: opioid-use disorder, more commonly referred to as opioid addiction. This would have been the opportune moment to deploy medicines, like buprenorphine, to set users on a path to recovery. Instead, the medical profession “abandoned millions of people,” Herring says. “We let millions of people just fall.” Physicians who might have wanted to prescribe buprenorphine faced significant hurdles, like training requirements and limits on the number of patients who could be treated.
Herring likens the neglect that followed to leaving a sick patient untreated. “If I don’t treat a biomedical problem, the disease will progress,” he says. “We just stood by.” People hooked on opioids were now unable to stop taking them, because their bodies needed the stimulation they provided to function normally — to work jobs, to take kids to school, to avoid descending into the agony of withdrawal. Huge numbers of people, cut off by doctors, turned to the black market.
At that point, extremely high-quality heroin, produced in Colombia, dominated the illicit drug markets in the eastern United States. In a short period, demand for that heroin roughly tripled. According to Daniel Ciccarone, a professor of family and community medicine at the University of California, San Francisco, the Colombian cartels were just then exiting the heroin business, resulting in the unusual situation of shrinking supply in the midst of booming demand.
This opioid-starved marketplace set the stage for a third wave, starting on the East Coast. Around 2013, entrepreneurs in China began selling illicit fentanyl. The powerful drug was introduced in the 1960s as an intravenously administered pain medicine and was well known to physicians. In the right doses and settings, fentanyl is considered a critical medicine. Doctors use it in emergency departments, operating rooms, cancer wards and other places where they need to rapidly control excruciating pain. It takes effect more quickly than other opioids — within 30 seconds, compared with minutes for morphine, a clear advantage when trying to manage anguish from broken bones or other acute injuries. And it causes fewer side effects than other opioids.
Though fentanyl occasionally appeared on the black market in earlier decades, it wasn’t until the mid 2010s that illicit sales took off. Initially, some sellers shipped it directly to American buyers over the dark web. It was often mixed with heroin or into counterfeit pills, most likely because adding fentanyl could make a small amount of heroin, then in short supply, go a lot further. Mexican trafficking organizations eventually took over the production of this powerful new drug flooding into the black market. Today, though the precursor chemicals used to make fentanyl generally originate in China, and to a lesser degree India, they are usually cooked into fentanyl in Mexico and then smuggled north. (The flow of fentanyl across the border is one reason President Trump has threatened tariffs against China, Mexico and Canada — although experts say the amount of fentanyl originating in Canada is negligible.)
In excess, opioids kill by causing the brain to stop telling the lungs and diaphragm to breathe, a self-suffocation called “respiratory depression.” Fentanyl’s potency means that it must be administered very carefully, something that almost certainly doesn’t happen outside a medical setting. “We don’t see too many other drugs where you take a very small amount of a drug and you die,” Christopher Colwell, chief of emergency medicine at Zuckerberg San Francisco General Hospital and Trauma Center, told me.
Even more alarming, chemists in China continue to tinker with the precursor chemicals they ship to Mexico — some of these molecules are 10,000 times as powerful as morphine — which leads to a wide variation in potencies of the final product. There are maybe dozens, if not a hundred, different versions of what we call fentanyl trafficked on the streets, according to Ciccarone. This variability in the black-market supply — the “undulation,” he calls it — makes it very difficult for users to gauge how much to take. “It’s not just the potency, it’s the fact that it comes in different potencies,” Ciccarone says. “They change.”
Outside the entrance to the emergency department where Herring works in Oakland sits a metal dispenser not unlike those that, where they still exist, give out alt-weekly newspapers. This dispenser contains free boxes of naloxone, the overdose-reversal drug also known as Narcan, for anyone who wants it. “That’s how we start,” Andrew Herring told me one fall day. Making the drug more widely available around the country may be paying dividends already. In 2023, according to C.D.C. data, fatal overdoses declined nationally for the first time since 2018.
But for Herring, it is buprenorphine, a drug fewer people have heard of, that can be the true lifesaver. Unlike naloxone, which only helps in the moment of acute, opioid-induced emergency, buprenorphine can get someone started on a durable recovery — and the drug is safer than most other prescription opioids. Its lack of toxicity stems partly from its unique action in the body. As an opioid itself, buprenorphine excites opioid receptors, preventing withdrawal symptoms. But unlike with other opioids, including methadone, which is also used to treat opioid addiction, there’s a limit to how much buprenorphine can stimulate those receptors. That ceiling protects against overdose. The molecule is also unusually “sticky” on those receptors — more so than both heroin and fentanyl, for example — so flooding the body with buprenorphine can block the effects of more potent opioids that patients going through a relapse might procure on the street. In the last decade, the F.D.A. approved new forms of the drug that can be given as a shot weekly or even once a month, so patients can avoid the hassle of having to take it daily.
At A.H.S. Bridge, patients can be treated with buprenorphine minutes after they show up, right inside the emergency room, not in some distant wing of the hospital. And the program forgoes nearly all the initial paperwork for people with substance-use disorder. “You can’t take care of unhoused people if you’re futzing around with insurance cards,” Herring said.
The Bridge clinic’s nerve center is a room full of administrators called “substance-use navigators.” These navigators locate long-term treatment programs, follow up on prescriptions, connect patients with the correct doctors for their other health problems, remind patients about appointments and generally try to keep them engaged in their own care. Carmela Yomtoubian, an emergency-medicine doctor who has set up several Bridge-based programs in the Los Angeles area, describes the navigators as “the essential piece” that makes the whole model work. They take on all the busywork needed to navigate the byzantine U.S. health care system so that those seeking treatment, who might be in withdrawal or without homes, don’t have to. “It’s like your own personal assistant that will get you on the right track,” she told me.
When Herring and his colleagues started Bridge in 2016, between 10 and 20 people arrived weekly. Now A.H.S. Bridge sees more than 100 patients per day, two-thirds of them by virtual means. As it has grown, Bridge has become a regional and, to some extent, national model of how to initiate potentially lifesaving care in a place — the emergency room — that historically has not prioritized the treatment of patients struggling with opioid addiction. Nora Volkow, the director of the National Institute of Drug Abuse at the National Institutes of Health, describes Bridge and similar programs as taking advantage of “an extraordinary opportunity”: Anyone having an opioid-related crisis will most likely end up in the E.R., making it an ideal place to intervene.
In 2018, Herring and his colleagues founded a sister organization, now called the Bridge Center at the Public Health Institute, to help set up similar programs around the state. It has received $110 million from California and overseen the distribution of more than half that amount to support 282 hospitals — approximately two-thirds of the state’s hospitals. That effort has produced what the Bridge Center contends is the largest increase nationwide in the availability of M.A.T. in emergency departments. Andrew Kolodny, the medical director for the Opioid Policy Research Collaborative at Brandeis University, describes Bridge programs as a “terrific model” that gets those struggling with addiction “plugged in immediately.”
In at least one instance, another hospital independently came up with the same idea — and the same name. Mass General Brigham in Boston has E.R.-linked Bridge clinics. Sarah Wakeman, the hospital system’s senior medical director for substance-use disorder, says that buprenorphine can prompt a “Lazarus-like recovery” in some of the sickest patients she sees. “There is nothing I do in medicine that has as dramatic an effect, as lifesaving an effect,” she told me. “You give them medicine and watch their life, their health, everything change.”
But even as awareness of buprenorphine has spread, the extent of its use is nowhere near what experts think is needed. “Every county should have at least one place where someone could walk in and that same day get buprenorphine regardless of their ability to pay for it,” Kolodny says. But a 2022 study found that only about half of the nation’s top-ranked hospitals said they provided buprenorphine in their emergency department. Hundreds of counties still lack any M.A.T. providers at all, according to a recent report from the inspector general’s office at the Department of Health and Human Services. And where those providers do exist, they often won’t accept Medicaid or Medicare patients. (Many providers won’t accept any insurance at all, Kolodny says.)
The reasons experts give for this slow uptake are myriad. Kelly Pfeifer, a director with the California Health Care Foundation and an early champion of Bridge, cites the effort it takes to change any entrenched mind-set among doctors. One of the foremost challenges Pfeifer encounters, she told me, is changing emergency physicians’ deep-seated assumption that the opioid epidemic isn’t really their problem. They often resent that emergency departments have become “dumping grounds,” as Pfeifer puts it, for the bigger societal problems of homelessness and addiction; they also assume that they lack good treatments.
Pfeifer tries to impress on these doctors that they do have an effective tool in buprenorphine, and that, for better or worse, the emergency room functions as the medical safety net in this country. “Yes, it’s an expensive place to manage addiction and an expensive place to manage the symptoms of poverty and homelessness,” she says. “But there’s nowhere else to go.”
Experts also point to the onerous regulations that long governed the use of buprenorphine. It was approved to treat opioid addiction in 2000 — the earliest version available consisted of a tablet dissolved under the tongue — but limits on how many patients doctors could treat with the drug (no more than 30), coupled with training requirements before they could prescribe it to patients, caused many doctors to eschew it altogether. These regulations have been lifted piecemeal over the years. The X waiver, a certification that doctors needed before they could prescribe buprenorphine, was eliminated only in 2023. Yet even as the drug has become freer in a regulatory sense, and therefore easier to give to patients, the number of prescriptions written for buprenorphine has not meaningfully increased, according to C.D.C. data.
In part, this might be because the D.E.A. still monitors buprenorphine through its Suspicious Orders Report System. Doctors may fear being investigated if SORS detects a spike in prescriptions, Paul Tonko, a Democratic congressman from New York who has worked to loosen regulation of the drug, told me. And many doctors simply remain unfamiliar with the drug because they never learned how to use it. “You have a whole generation of physicians who haven’t trained with this medicine,” Carmela Yomtoubian says. “Not everyone is comfortable with it.”
Some dire consequences of using buprenorphine that are caused by government bureaucracies may also be slowing down its acceptance. In some states, women taking buprenorphine or methadone to treat opioid addiction have had their children taken away by Child Protective Services after they tested positive for opioid use — even though the opioids had been legally prescribed for them.
Nearly everyone I spoke with mentioned one other obstacle to buprenorphine’s greater uptake: stigma. In the United States, the dominant view on how to manage addiction has traditionally been that abstinence is the best solution. This assumption persists, despite numerous studies’ showing that medication can reduce the risk of overdose far more than abstinence alone — and that in some cases abstinence may even increase the risk of overdose later. “We’ve long treated it as an issue of morality,” Wakeman says. “Embedded in that is the notion that people should just knock it off, pull themselves up by their bootstraps. And that frankly we should make it hard on them. Anything that makes it easier is actually viewed with skepticism or as a bad thing.”
Why do opioids produce such powerful feelings of well-being and euphoria in some people? Our own bodies produce opioids, it turns out, which is why many of our cells bristle with receptors that respond to these molecules in the first place. Scientists call this biomolecular lock-and-key mechanism the endogenous opioid system. Endorphins, released during exercise, are one type of endogenous opioid. They improve mood and your sense of well-being, and scientists think they’re partly responsible for the antidepressant effect of physical activity.
For highly social animals like humans and other primates, the native opioid system may also play a role in social bonding, according to one influential theory. It’s probably involved in not just the intense pleasures of sex and intimacy but also the more subtle sensation of warmth and belonging that comes simply from being part of a friendly group. Loving caresses, shared laughing and group singing release a flood of native feel-good opioids.
Scientists think that the endogenous opioid system evolved, in part, to push animals toward behaviors that aided the species’ survival. But chronic exposure to powerful exogenous opioids like heroin and fentanyl can overwhelm this delicately calibrated system and — counterintuitively — push people into a state of near-constant distress when they are not using.
George Koob, director of the National Institute on Alcohol Abuse and Alcoholism, has christened this state “hyperkatifeia,” an extreme dejection or dysphoria that can occur with long-term drug use. A cruel paradox of this condition is that the usual pleasures and joys of life — the activities and situations that evolution arguably shaped us to seek out — can stop feeling good altogether. Someone might begin taking opioids to manage pain or to induce euphoria, but chronic use can change the brain in ways that make it difficult to find much pleasure in daily life, ultimately driving more drug use to escape the misery. Many assume that people take drugs to feel good, Koob told me. But with long-term opioid use, he says, “people take drugs to not feel bad.”
This is one reason so many doctors have come to think that buprenorphine can be so useful as a treatment for opioid addiction. Not only can it can help stabilize someone whose life has become a harrowing ricochet between ever-more-unsatisfying highs and increasingly inescapable lows; it may also reverse some of the physiological changes caused by chronic opioid use.
Intense, chronic exposure to fentanyl or heroin can cause a decline in the number of opioid receptors on cellular surfaces. The body prunes these receptors — brings them inside its cells — possibly to protect against overstimulation. Scientists suspect that the resulting decrease in sensitivity underlies some opioid users’ reduced ability to feel good about much of anything, not to mention the agonizing withdrawal symptoms that initially attend abstinence. Yet buprenorphine can partly reverse those changes, animal studies suggest. After some time on the drug, opioid receptors can reappear where they had disappeared previously.
Herring often cites this science when faced with the inevitable question: How does replacing one opioid with another, one that is itself habit-forming — if you stop taking buprenorphine suddenly, you’ll experience withdrawal — really help people? The brain can heal on buprenorphine, he responds, at least partly reversing the damage wrought by chronic opioid use.
The deeper argument Herring and others are making rests on a particular view of addiction — namely, that opioid addiction is a disease and that, like diabetes, thyroiditis or any other chronic disorder, it’s a disease best treated with the appropriate medicine. This understanding of addiction was not always accepted widely. But scientists have spent decades describing the neurocircuitry and biochemical pathways involved in addiction with a goal in mind, Nora Volkow says: They hope to target the “disease processes” with drugs like buprenorphine (and maybe better ones to come). Along the way, they have been amassing the evidence that might enable doctors to wrest the management of addiction from law enforcement and bring it into medicine’s purview. “We have been dealing with people who are addicted as if they had moral failures,” she told me. Now doctors can point to the science and say: “No. That person is actually unable to control the urges.”
Even for those struggling with addiction, seeing it as a disease that requires long-term treatment can be hard to accept. Herring and Wakeman sometimes recommend that certain patients stay on buprenorphine indefinitely, and the patients themselves resist the idea. “It runs counter to romantic notions of independence or autonomy,” Herring says. They are often naturally — and for good reason, Wakeman adds — suspicious of doctors telling them to rely on an opioid when medical-grade opioids may have gotten them into difficulty to begin with. “There’s a very real and earned distrust of medication and the medical system and the pharmaceutical industry,” she says.
Yet because doctors still have nothing with which to “cure” addiction once and for all — nothing to immediately undo the changes that long-term opioid use causes in the brain and body — addiction specialists see ongoing medical treatment as the best option in many cases. The National Institute of Drug Abuse is funding a study to investigate how best to wean people off buprenorphine who have been on it for a least a year and want to stop taking it. The trial will also explore which strategies are most effective at avoiding relapse. Herring and Wakeman look forward to getting those results. But in the meantime, if addiction is a chronic, lifelong disease — and that’s often how it’s perceived even in abstinence-focused circles — they’re fundamentally arguing that you may have to take medicine for the rest of your life to treat it. Because when treatment is removed, Herring says, “that old wound is still there.”
This highly medicalized view of addiction has its critics. Proponents argue that seeing addiction as a disease like any other will lessen stigma, but some research suggests that it may also incur a cost. While framing addiction as a brain disease may reduce blame (the user is not at fault) and boost support for treatment, it may also increase the perception that those struggling with substance-use disorder are dangerous, leading to greater social rejection.
Critics also posit that thinking of yourself as bereft of agency can undercut your own sense of empowerment — of control in your life — which, they argue, is itself vital to lasting recovery. Indeed, one longstanding critique of the argument that addiction is a chronic, relapsing-remitting disease of the brain is that it fails to account for cases of seemingly spontaneous recovery.
Treating addiction as a medical problem and treating it as a socially influenced or psychological issue are not mutually exclusive approaches, of course. Jasmin Canfield, who is the manager of substance-use disorder treatment at A.H.S. and runs a group-therapy program called Road to Recovery just down the hall from Herring’s Bridge clinic, told me that it is “really difficult for me to do my job as a therapist without medication so that folks are not in withdrawal or having cravings.” But she warned against the idea that medication alone could fully address a problem as complex as addiction, which is so often related to pain and trauma. People need to understand why they feel compelled to take fentanyl or other opioids in the first place, she said. And a drug can’t provide that kind of illumination.
Over the course of a year, the tenor of my conversations with Andrew Herring shifted subtly but noticeably, from “look what’s possible” optimism toward “this won’t work unless” exasperation. There was a good medicine for opioid addiction and a model for delivering it in the emergency department, he said, but neither was being deployed fast enough. The only way buprenorphine would become widely and quickly adopted, he argued, was through a well-funded, top-down “program,” as he characterized it, that provided incentives for hospitals and other health care organizations to offer the treatment.
The idea of rules imposed from on high that accelerate the adoption of new standards has some precedent. The establishment of trauma care centers in the late 20th century, for instance, and the creation and acceptance of protocols for stroke care across the country resulted from a complex mix of carrots and sticks that encouraged health care organizations to adopt agreed-upon standards of care; ultimately, health outcomes for Americans improved. Herring was essentially contending that making buprenorphine widely available required more carrots, but also a few sticks.
Aimee Moulin, chief of addiction medicine within the emergency-medicine department at U.C. Davis and a Bridge founder, pointed out that a top-down approach could help in another way as well: by giving “institutional cover” to doctors who would otherwise be hesitant to prescribe buprenorphine. A directive from some authority could remove the burden of responsibility from physicians’ shoulders, she told me. “Then I’m doing what I’m being told to do,” she said. “These are the expectations.”
As I asked around, however, it was easy to find people who disagreed with anything that resembled a mandate. Representative Paul Tonko of New York, though he lamented to me the slow adoption of buprenorphine, nonetheless suggested that a directive pushing hospitals and doctors to provide the opioid risked sparking a backlash. A much sounder approach, in his view, would be to remove the remaining barriers to the medicine’s full rollout. The D.E.A.’s monitoring of the drug has a chilling effect, he argued, making even pharmacies reluctant to stock too much of it, because they don’t want to attract the agency’s attention. To reduce this “fear factor,” Tonko recently was a sponsor of a bill that would temporarily exempt buprenorphine from the D.E.A.’s oversight.
Then, in November, with the election of Donald Trump and the Republicans’ return to power in Congress, the question of how best to respond to opioid-use disorder was confronted with new uncertainty. For the past decade, the push to expand access to treatment for opioid addiction has enjoyed bipartisan support. But during his campaign, Trump outlined a draconian vision to address the opioid problem, threatening drug dealers and smugglers with the death penalty and promising to “seal” the border. On Feb. 1, he signed an executive order to levy tariffs against China, Mexico and Canada, in part to pressure these countries to halt the flow of fentanyl into the United States. (Soon after, he gave 30-day reprieves to Canada and Mexico.)
Keith Humphreys, a professor of psychiatry and behavioral sciences at Stanford who studies the opioid crisis, says the idea that beefed-up border control could halt or greatly curtail the flow of fentanyl into the country is simply misguided. Fentanyl is so concentrated that the amount needed to supply the entire country’s demand for a year is at most 10 metric tons, he estimates. Law enforcement has to find those 10 tons — the weight of few cars — among the more than seven million trucks carrying goods that cross the border annually. To meaningfully impede the flow of fentanyl, he thinks, you would have to completely close the border, at which point the country would inflict massive economic harm on itself. And even with the border shut, drones, planes and tunnels can easily continue supplying the market. A birthday-card-size letter mailed from abroad could carry a week’s supply of the opioid for someone. “You can’t really keep fentanyl out of such a big country,” he says.
Trump’s expressed desire to slash government spending also worries proponents of medication-for-addiction treatment. Some Republicans are actively seeking ways to cut Medicaid, along with other federal programs. Trump may also try to undo or simply undermine the Affordable Care Act, a favorite target. Either development could be disastrous for the distribution of medication to treat opioid addiction, reversing the gains, however tenuous, made under the Biden administration. Medicaid covers an estimated 40 percent of non-elderly adults with opioid-use disorder in the United States, some two-thirds of whom receive treatment for their addiction through the program.
It’s also possible, however, that Trump will expand the public-health approach he embraced during his first term, which was furthered by the Biden administration, and continue to encourage efforts to roll out M.A.T. Trump signed a law during his first term that removed some requirements for doctors who wanted to prescribe buprenorphine, notes Kassandra Frederique, the executive director of Drug Policy Alliance, a nonprofit that advocates for less-punitive drug policy. And uniquely among Republican presidents, Trump supported the use of some harm-reduction practices like making clean syringes available, according to his first-term surgeon general. Frederique told me she hopes that the current administration will continue to build on the work Trump and others have done to expand access to treatment.
What’s important to remember is just how much evidence exists indicating that buprenorphine can help people with opioid addiction. Sarah Wakeman often points this out as she pushes back against what she sees as a pervasive sense of pessimism around the opioid crisis. The problem is that this medicine isn’t getting to the people who need it quickly enough. “Most people think this is a terribly recalcitrant, untreatable, insurmountable problem,” she says. “That couldn’t be further from the truth.”
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