Mallory Berry was ready to give up. It was 2019, and her addiction—prescription opioids had led her to heroin—had left her bedridden. An infection had eaten through parts of her pelvic bones, stomach muscles, and vertebrae, causing a pain so excruciating that she was afraid to move. Her partner, Randy, placed buckets under her body when she needed to use the bathroom. Bathed her and fed her. Before long, Mallory stopped eating entirely, subsisting on sweet tea and water, wasting away.
Four years later, Mallory would recount this memory to me over the phone from her house—a five-bedroom, three-bathroom colonial with a walk-in closet and a two-car garage—that she paid for with her earnings as a manager at a mortgage company, where she oversaw 10 direct reports.
When I spoke with her in March last year, she largely credited this remarkable turnaround not to her own willpower, or the grace of God, but to a widely available medication called buprenorphine.
The world of opioid addiction is one of morbid statistics. People struggling with opioid addiction have a mortality rate 10 times higher than the general population in the United States. The relapse rate for those in recovery is as high as 70 percent. As one doctor, an addiction specialist named Stephen Martin, put it to me, “The natural history of opioid-use disorder is: People die.”
Which is why the numbers describing buprenorphine’s impact stand out. Buprenorphine can stop cravings for opioids, and people who use it are 38 percent less likely to die of an overdose. After buprenorphine was adopted at scale in the midst of France’s opioid crisis in the 1980s and ’90s, overdose deaths dropped by 79 percent.
About a year ago, when I began reporting this story as part of an Atlantic podcast series, I asked Mallory how important this treatment was to her recovery. She, too, reached for a number. “If you want a percentage,” she told me, “75 percent.” Yet being on buprenorphine at all made Mallory an outlier. As of 2021, about one in five patients struggling with opioid-use disorder is taking this or other medications for treating addiction. One of the most effective tools for defusing a crisis that in recent years has killed more than 80,000 people annually is going unused.
Underpinning this failure is a quiet conviction among doctors and patients alike that taking buprenorphine doesn’t count as success—that people who use drugs to recover from drug use are still addicts, the sobriety they achieve is fake, and the drugs saving their lives could spark the next wave of the opioid epidemic. At the same time, the drugs that have made addiction even more deadly—synthetic opioids such as fentanyl—are making buprenorphine more complicated to use. As a result, the window in the U.S. for this treatment to fulfill its greatest promise is nearly closed.
When buprenorphine arrived in the U.S. in 2002, the country was immersed in what would later be categorized as the first wave of the opioid epidemic. That year, 11,920 people died from opioid overdoses, which at the time sounded alarms in the medical community. (The annual death toll would increase sevenfold over the next two decades.)
The triumph in France was already well known to addiction specialists. Many believed that once more of their colleagues in health care understood the silver bullet they’d been handed, the treatment would find its way into primary care, Martin told me. The crisis could be stopped in its tracks.
But buprenorphine’s strength as a treatment is also a weakness. Buprenorphine is an opioid. Like methadone, the tightly regulated treatment for opioid addiction used in America since the 1950s, it acts on receptors in the brain to satisfy cravings.
Compared with methadone, buprenorphine is more difficult to overdose on and easier to access. It also has a stronger affinity for opioid receptors than opioids such as heroin or fentanyl, which can protect patients against overdose if they relapse. In a brain flooded simultaneously with buprenorphine and another opioid—the brain of a buprenorphine patient relapsing on fentanyl, for example—buprenorphine has dibs on the relevant receptors. Without available receptors, both the high and the harm of an opioid such as heroin or fentanyl are greatly reduced or eliminated. This is why buprenorphine can be a powerful medication. It strikes at the root of addiction, and protects patients when they slip up.
Yet it requires prescribers, regulators, and patients to accept that a person can be sober while taking an opioid every day. That idea cuts against the narrow definition of sobriety that America’s addiction model was—and to a large extent still is—built on. Whereas many European countries have successfully implemented coordinated, low-barrier access to treatments like methadone and buprenorphine, abstinence-based opioid addiction treatment is alive and well in America. In many Narcotics Anonymous meetings, for instance, attendees taking buprenorphine are treated the same as those in active addiction: They can listen, but not speak. In many sober houses, the first stop after rehab, residents are not permitted to take buprenorphine. “There’s a particular path to treatment and recovery” in those settings, Erin Madden, a professor at Wayne State University who studies stigma and addiction, told me, and “medications can’t be a part of it.” Asking people whose lives were destroyed by opioid dependence to depend on a different opioid is already a hard sell. Asking them to accept this dependence in a culture of abstinence is nearly impossible.
Fear that buprenorphine would be abused also worked against its broad adoption. In the early days of the crisis, prescription opioids such as oxycodone were driving a sharp rise in deaths. The DEA, for one, was skeptical that another prescription opioid could be the solution to widespread abuse of prescription opioids in part because the Department of Justice reported some evidence of buprenorphine abuse, particularly in the Northeast, as early as 2004. And opioid-addiction treatments do have a history of abuse: Heroin, for example, was once considered an effective treatment for codeine and morphine addiction. The year buprenorphine was approved, the DEA restricted its dispensation. Buprenorphine was moved from a Schedule V controlled substance (like codeine) to Schedule III (like ketamine). Physicians had to complete special training to prescribe the drug, and could prescribe to a pool of only 30 patients.
After its approval, buprenorphine never came close to achieving the scale needed to slow down the crisis. By some estimates, for every patient who received the drug, four more might have benefited from it.
Mallory’s younger brother, Quincie, had, like her, started with pills. Then he began using intravenous drugs; he showed her how to shoot up. Before long, he was overdosing regularly, sometimes twice a day, and depending on Narcan, the overdose-reversal drug, to revive him. Quincie was caught in a terrible loop: overdose; Narcan; emergency room. Overdose; Narcan; emergency room.
Then one day an outreach specialist approached Quincie at the emergency room and handed him her card. Call me when you’re ready, she said. He did, and eventually found his way into rehab and onto a buprenorphine product called Suboxone. As I reported in the podcast, he told his mom, Jennifer Hornak, “This keeps me from going off the deep end. I can work. I can live a real life on this medication.”
For a time, Quincie and Mallory were on roughly the same path. But in 2020, the paths split. Mallory finished rehab and entered a halfway house, while still on Suboxone. She was lucky, in a way: Many sober houses operate on the principle that an opioid is still an opioid, and for that reason won’t accept people on buprenorphine. And Quincie ran into exactly that problem at the sober houses near him. Because he needed a place to live, he saw little choice but to stop taking Suboxone. When Jennifer asked, “Are you sure you can do that?” he told her, “I think I can.”
About a month later, Jennifer was having a pool party at her house when Mallory told her that she saw a Facebook post that read “Rest in peace Quincie.” He had died of an overdose.
Quincie was caught between two approaches to addiction treatment. Inside rehab, his recovery was built around medication, not willpower. But outside, the infrastructure available to him was built on abstinence.
When Quincie died, Mallory’s family expected her to relapse. She’d been sober for only a few months, and her little brother’s death was a major blow—but she didn’t. She didn’t relapse when her grandfather died the next year. She didn’t relapse when Randy, who had cared for her when she couldn’t walk, died the year after that.
One day, Mallory got busy at work. Before she knew it, she ran out of time to make it to her doctor’s appointment to refill her Suboxone prescription. The withdrawal symptoms—vomiting, diarrhea—started quickly. For Mallory, missing her dose felt like going through heroin withdrawal—“like I’m dying,” she told me. She could go to her sober network for a few spare doses, but she feared their judgment. Asking for pills was addict behavior.
Eventually a friend gave her a pill, which she broke into pieces to last until she could refill her prescription. But the experience scared her. “What if something like this happens again?” she asked herself. “Do I want to be on a medication where if I don’t have it, I feel like I’m dying?” She realized that she didn’t want to be on Suboxone for the rest of her life. She was also tired of telling doctors she was taking the drug, which she felt led them to treat her differently than they would other patients.
And she wanted to keep the six teeth she has left. (Buprenorphine has been connected with tooth decay, according to an FDA warning.) For Mallory, her dentures represent some never-ending punishment for her years spent in active addiction, a permanent reminder of her past.
Jennifer begged Mallory to stay on Suboxone. “I pray that she’ll stay on it, I really do,” she told me in April 2024. “I just really can’t bear the thought of losing another child.”
Mallory came off Suboxone. In July—the last time I was able to reach her directly—she said she was feeling fine. More recently, whenever I tried to get in touch, she didn’t respond to me. In October, Jennifer told me via text that Mallory had not relapsed, but was dealing with what Jennifer described as “mental and physical health issues.”
Quincie’s death, and Mallory’s story, reflect a stark truth about buprenorphine’s limits, at least in America. Staying on the medication over the long term requires resolve, with limited support and against persistent stigma. Stopping presents its own risks. Diminished tolerance, paired with an ever more potent drug supply, can make buprenorphine cessation deadly if a person starts using drugs again. It might also shatter the fragile stability the medication can provide, as a salve for the mental-health issues that so often underlie addiction. But America’s fractured approach to recovery makes buprenorphine hard to live with, and impossible to live without.
On paper, getting buprenorphine to as many people as possible should be easier now than ever before. Today, patients can get a prescription through telehealth or even a phone call. Special training requirements for would-be prescribers have been eliminated. The widespread buprenorphine abuse feared in the early aughts never came to pass; although some buprenorphine has been sold illicitly, most buyers seem to be people who are using it as a medication, rather than abusing it. The DEA, after decades of strict enforcement, now urges pharmacists to maintain an “adequate and uninterrupted supply” of buprenorphine and similar medications. The regulatory barriers between patients and this medication have never been lower.
But usage rates are relatively flat. In 2022, they fell. According to Rachel Haroz, who leads Cooper University’s Center for Healing, and other experts I spoke with for this story, the stagnant rates can be blamed on stigma, a lack of infrastructure within primary care, and fear of DEA repercussions.
Buprenorphine’s uptake numbers in the past five years also have to do with the synthetic opioids it’s now up against. In earlier waves of the opioid epidemic, clinicians would wait for opioids such as painkillers or heroin to leave those receptors in the brain naturally, and then, at the onset of withdrawal symptoms, they would begin patients on buprenorphine. The drug would reduce cravings and eliminate the need for a protracted, painful withdrawal.
This process can break down if the patient has been using fentanyl, which stays in the body longer than heroin or pain pills. When buprenorphine displaces fentanyl from opioid receptors, it can trigger an instant reaction called precipitated withdrawal, marked by vomiting, diarrhea, and chills. Patients, who already live in constant fear of withdrawal, are reluctant to seek a treatment that triggers its symptoms. And doctors, reluctant to cause such acute pain, are hesitant to start patients on buprenorphine.
So addiction specialists are improvising. When Haroz’s EMS teams revive a patient with Narcan, a drug that reverses overdoses by clearing fentanyl from opioid receptors, they start them on buprenorphine immediately, which can help avert precipitated withdrawal symptoms. Boulder Care, an addiction network in Oregon, is piloting a new approach in which fentanyl users take a dose of Narcan without having overdosed, intentionally triggering a withdrawal before starting on buprenorphine. Lucinda Grande, a professor at the University of Washington School of Medicine, has trialed using ketamine, a dissociative drug, to ease symptoms while her patients transition from fentanyl to buprenorphine.
Introducing buprenorphine is a much easier task for people who use, say, heroin. But today, fentanyl—with all the side effects that accompany its interaction with buprenorphine—has taken over the market for illicit opioids. Having missed the best window to get buprenorphine into patients, this is now what success looks like. And these creative approaches cannot yet be deployed at a scale that would meet the needs of the tens of thousands of Americans who lose their lives every year to overdose. The story of recovery in America is essentially the same as it was 20 years ago, and the barriers to changing that story are higher than ever.
The post Why Has America Ignored Its Best Addiction Treatment? appeared first on The Atlantic.
