More than 5 million Americans struggle with opioid use disorder, a physical addiction entwined with America’s health crisis, homeless crisis and mental health crisis. The most successful, evidence-based road to recovery is medication coupled with counseling, like that offered at Comprehensive Treatment Centers.
Still, 75 percent of people with opioid use disorder don’t have access to these FDA-approved medications, including buprenorphine, methadone and naltrexone. Despite federal regulations that should improve access to these medications, lack of oversights and stigma at the point of care often prevent successful treatment.
Why? Studies across the United States show an upsetting trend: treatment centers, recovery residencies, and Narcotics Anonymous are prohibiting and stigmatizing medications for opioid use disorder (MOUDs).
“The stigma associated with substance use and substance use disorder is certainly among, if not the greatest, obstacle that people with substance use disorder (SUD) face when they consider accessing care. The stigma, experienced as dehumanizing and discriminatory, can lead to diminished treatment-seeking among people with SUD as well as the lower quality SUD care,” said Dr. Joseph G. Liberto National Mental Health Director, Substance Use Disorders, Office of Mental Health, VHA.
The problem is widespread and systemic. A study in North Carolina found that most of the state’s residential treatment centers prohibit these medications. Throughout the state, the most common residential treatment provider is faith-based, abstinence-only, and mandates labor.
“The issue is that many places that purport to offer residential services offer something that is residential and nothing that qualifies as services,” said one of the study authors, Jennifer Carroll.
These clinics fall through regulatory loopholes. For example, a center may be licensed to provide day treatment but advertises as a residential center. “People have an ideological idea of what drug use and addiction is that predates the science,” Carroll said.
From a policy perspective, the United States has widely switched from a failed war on drugs to a harm reduction model. During Donald Trump’s first term, his administration expanded coverage of MOUDs to Medicare recipients and Medicaid patients with SUPPORT. Last year, after multiple actions by the Biden administration that improved access to opioid medications, including a change to the Controlled Substances Act, overdose deaths decreased for the first time since 2018.
“Locally, we’ve seen a decrease in overdose deaths and a lot of that is related to improved access to medications,” said Caitlyn McClure, clinical director at Northern Illinois Recovery, which focuses on comprehensive treatment. The center opened in 2019 in response to the raging opioid epidemic and loss of life.
McClure recalls resistance from clients and the community. “I think there are parts of the recovery community that are tied to the old philosophy, which is rigid and unfounded, and unfortunately becomes a danger to the people they’re trying to help.”
When people relapse, medication could be the difference between life and death. A recent Yale study found that people who receive treatment for opioid use disorder without medications have significantly higher rates of death from overdose than people who receive no treatment at all.
“Medications like buprenorphine treat the physiological aspects of addiction, opening the door for psychological and behavioral health interventions. They can be likened to antidepressants,” said Evan Espinosa, the director of clinic leadership at Recovia, a multi-disciplinary pain clinic and behavioral health center in Arizona. “There isn’t an amount of therapy that’s going to take away the risk for relapse when someone is physically addicted.”
Many people don’t have the means, and, often, insurance gives people the bare minimum level of care. Then there’s a lack of oversight, which can be pretty pervasive across multiple states, Espinosa said.
The drugs entering the U.S. market are increasingly dangerous and easy to transport. “Fentanyl isn’t coming across the border. It’s coming through the mail,” Carroll said.
More than 100,000 people died of opioid-related overdose in 2023. Despite bipartisan recognition of comprehensive treatment as the gold standard, not enough people receive care. Why?
Yngvild Olsen, the director of SAMHSA, Center for Substance Abuse Treatment, said one common reason is “people not recognizing that they might need or benefit from help, worrying what others may think if they did seek treatment, especially with methadone or buprenorphine, and concerns about cost.”
Two trends are clear: drugs entering the market are becoming more deadly, and forcing people to white-knuckle recovery often makes things worse.
“Taking away a risky substance without considering the harm of its replacement has been our way of policing drugs for ages and it hasn’t worked,” Carroll said.
