These medicines are cheap and easy to distribute. People who take them use illicit drugs at far lower rates, and are at far lower risk of overdose or death. By beating back the cravings and agonizing withdrawal symptoms that result from trying to quit opioids “cold turkey,” methadone and buprenorphine can help people addicted to opioids escape an existence defined by drugs and achieve stable, healthy lives.
But a yearlong investigation by STAT shows that virtually every sector of American society is obstructing the use of medications that could prevent tens of thousands of deaths each year. Increasingly, public health experts and even government officials cast the country’s singular failure to prevent overdose deaths not as an unavoidable tragedy but as a conscious choice. (...)
“More than 80,000 people are dying of opioid overdose every year, and yet we have a tool, medication-assisted treatment, that we know dramatically reduces overdose deaths,” said David Frank, a medical sociologist at New York University who takes methadone for opioid addiction. “But because it’s so difficult to access, people that could and should be alive continue to die.”
STAT’s examination of the overdose epidemic is based on hundreds of interviews with patients, doctors, policy experts, lawmakers, scientists, and other major figures in drug policy and addiction medicine. It relies on an exhaustive review of legal documents, tax filings, financial disclosures, patient records, lobbying reports, and peer-reviewed academic research. And it includes a first-of-its-kind analysis of the ownership and practices of America’s roughly 2,000 methadone clinics, detailing for the first time how private equity firms have acquired a major stake in the nation’s addiction-treatment infrastructure while opposing calls for reform. (...)
In an interview, Nora Volkow, the director of the National Institute on Drug Abuse, estimated that if methadone and buprenorphine were made universally available nationwide, opioid overdoses would fall by half, if not more.
“We have these very effective medications, and the question is why are they not being implemented,” she said. “I estimate that we would have at least 50% less people dying, and that’s conservative. I think it would probably be much more consequential.” (...)
Despite the medications’ remarkable effectiveness, the country’s view of buprenorphine and methadone is built largely on myths and stigma. In 2017, Tom Price, then health secretary to President Trump, referred to what is called medication-assisted treatment as “just substituting one opioid for another.” Law enforcement agencies like the Drug Enforcement Administration, while widely criticized for allowing the proliferation of OxyContin and other painkillers that fueled the opioid epidemic in the 1990s and 2000s, now forcefully regulate buprenorphine and methadone, even as illicit fentanyl floods the market.
“They are not changing one drug for another,” said Volkow, who has led the federal government’s $1.6 billion addiction research institute since 2003. “They’re not different from other medications you may need to take, like antihypertensive medications or antidiabetic medications. They allow for your physiology to be normalized, which is necessary to achieve recovery.” (...)
Yet instead of providing people with pharmaceuticals known to treat their condition, in the United States, common approaches to treating opioid addiction still include undergoing painful and ineffective “detox”; 12-step approaches like Narcotics Anonymous; or even “equine therapy,” a form of treatment that centers on spending time with horses.
While such programs often rely heavily on hope, mindfulness, and religion, they often ignore the physiological realities of addiction — in particular, the debilitating withdrawal that occurs when regular opioid users attempt to suddenly stop. In any other medical field, favoring prayer over proven medication would be considered malpractice. Yet for addiction treatment in the U.S., it’s simply the way things work.
“There is a core belief, that’s different from other countries, that people with opioid addiction don’t deserve care in the way that somebody who has cancer or diabetes does,” said Ayana Jordan, a researcher and addiction psychiatrist at NYU Langone Health. “People genuinely have no idea how effective these medications are at preventing people from dying.”
‘That’s how nuts this is’
The U.S. laws and practices governing addiction medicine are not just out of step with the latest science — they are also out of step with laws in most of the Western world.
At Arud, a substance use clinic in Zurich, Switzerland, patients receiving addiction medications are free to come and go as they please. They pick up weeks’ worth of methadone, and other powerful addiction drugs, at a pharmacy, and are not forced to undergo drug testing or regular counseling sessions as a condition of receiving their medication. While American law enforcement officials and methadone industry representatives have warned that easier access could increase methadone misuse and even overdose, Switzerland’s results have been the opposite. There, and throughout Western and Central Europe, countries that have increased addiction medications’ availability have consistently seen overdose deaths and infectious disease transmission plummet to rates vastly lower than in the United States.
“We have a precedent in France,” said Volkow, the NIDA director. “What the French did was basically provide buprenorphine to every single person that needed it. And you see this dramatic reduction in overdoses — they basically stopped.”
For decades, American physicians needed to obtain a special license known as the “X-waiver” just to prescribe buprenorphine. As of 2021, just 75,000 of the nation’s roughly 1.1 million physicians had obtained the waiver. The Biden administration effectively eliminated that requirement in early 2021, but according to data from the Centers for Disease Control and Prevention, the overall buprenorphine prescribing rate nonetheless decreased from 2021 to 2022.
Methadone, which is widely accessible across Europe, is available in the U.S. only at specialized clinics known as opioid treatment programs, or OTPs. These clinics typically require patients to report in person each day to receive a single dose, forcing them to structure their lives around the clinic’s dosing schedule.
“This is practically the only medication in the entire country that is treated this way,” said Rep. Don Norcross (D-N.J.), who has co-authored legislation that would allow specialized addiction doctors to prescribe methadone directly to patients. “The medication for abortion — that is easier accessed than methadone. That’s how nuts this is. The idea that the only way to do this is to go to the methadone clinic is just insane.”
‘The system creates barriers to care’
Paradoxically, it is often those who claim to be most sympathetic to the cause of addiction treatment who are among the biggest opponents of expanded access to methadone and buprenorphine.
The recovery group Narcotics Anonymous — perhaps the country’s largest provider of addiction treatment — has taken a hard line against addiction medication. The organization’s own literature acknowledges that people taking methadone or buprenorphine are often banned from speaking at meetings, but offers a concession: “NA may be compatible for addicts on medically assisted protocols if they have a desire to become clean one day.”
In other words: In the view of Narcotics Anonymous, even people who have relied on methadone or buprenorphine to achieve stable recovery are not considered “clean.” Instead, their full participation in the program would require a pledge to stop taking medications they were prescribed by a doctor, and that first helped them quit illicit drugs.
Narcotics Anonymous did not respond to STAT’s requests for comment.
Methadone clinics have also opposed calls to expanded access to medication treatment. The American Association for the Treatment of Opioid Dependence, a trade group representing methadone clinics, has lobbied not just against the deregulation of methadone treatment, but also against a bill that passed in 2022 with overwhelming bipartisan support that made it easier for doctors to prescribe buprenorphine. And in recent decades, methadone treatment has become big business: A majority of methadone clinics now operate as for-profits, and nearly one-third are owned by private equity firms. As calls for reform have grown far louder in recent years, the methadone industry has guarded its monopoly fiercely, and remains staunchly opposed to allowing other doctors to prescribe the medication to patients in need.
Separately, according to federal survey data, at least 751 substance use treatment facilities offer treatment for opioid addiction but reject clients using methadone and buprenorphine. More than 2,000 addiction treatment facilities did not respond to the federal survey, meaning the true number of facilities banning medication is probably significantly higher.
Many medical schools still don’t require any training in addiction medicine, or prescribing addiction medications. Many hospitals still do not offer patients buprenorphine or methadone, even in the immediate aftermath of an overdose. Many pharmacies choose not to stock buprenorphine. And insurers, in an effort to pad profit margins, sometimes refuse to pay for newly developed injectable buprenorphine formulations, which last weeks or months and are shown to help patients remain in treatment — but cost far more than cheaper versions that must be taken daily.
The American criminal justice system also remains skeptical of medication as treatment. The Drug Enforcement Administration has long displayed hostility to buprenorphine and methadone, and many jails and prisons refuse altogether to provide incarcerated people with either medication. Many judges with no medical training — even in “drug court” systems supposedly meant to aid addiction recovery — have historically barred people arrested for low-grade drug offenses from taking any opioid, including addiction medications.
As workers, people taking addiction medications face immense discrimination. Many employers, labor unions, and professional societies ban their members from taking addiction medications in any circumstance.
“There are a lot of ways that the system creates barriers to care,” said Weinstein, the Boston addiction doctor. “We start to believe that if the system is created that way, it must be necessary, there must be a good reason. But that may not be true: The reason may be outdated, or never existed, or was based on stigma.”
by Lev Facher, STAT | Read more:
Image: Joe Raedle/Getty Images
