Raina Mcmahan, a 42-year-old recovery coach, spent roughly half her life seeking treatment for her own opioid use disorder.
She tried detoxing multiple times at different inpatient facilities, but those programs usually discharged her after a week or two without any follow-up care.
She paid one doctor $500 to treat her with buprenorphine, a medication that helps reduce opioid cravings, but he administered that medication improperly. When she got sick, he told her she was allergic — a falsehood she believed for years.
She tried methadone, another medication used to treat opioid addiction, but the hurdles proved insurmountable. The only clinic that had space for her was two hours away by subway, required her to report in person every day and stopped serving patients at 10 a.m. sharp. “If you got there at 10:01, they would shut the window in your face,” she told me recently. When that happened, she would have to either go without medication for the day and wind up in withdrawal or use street drugs and risk a positive urine test (which could get her expelled from the program) or an accidental overdose (which could kill her).
She tried other things, too — residential programs and outpatient programs and 12-step programs and more. But nothing stuck. “The entire system sets you up to fail,” she said, “and then blames you for failing, over and over, until you give up.”
More than 48 million Americans are living with a substance use disorder right now, according to the best estimates of the nation’s premier health agencies. Only about 5 percent of them are getting any kind of help for the condition. It’s easy to shrug off such dismal statistics — to assume, as many people do, that addiction is untreatable or that if effective therapies exist, most people with addictions have no interest in trying them. But both of those assumptions rest on fallacy.
In fact a growing roster of treatments (medications, behavioral therapies, counseling and other supports) have proved just as effective at managing addiction as statins are at managing cholesterol or aspirin is at preventing heart attacks. Experience suggests that many more people would make use of these treatments if only they were easier to access: In other countries and in many U.S. states, when the barriers to addiction treatment have been lowered, treatment uptake has increased, and overdose rates have fallen.
Still, a vast chasm exists between effective addiction medicine and the people who most need it.
It’s no mystery why. Most medical professionals are still not comfortable or even familiar with the basics of addiction medicine. Neither are the judges, probation officers or wardens who often hold sway over the fates of people with use disorders. The centers that do focus on treating addiction have been hobbled by work force shortages and inadequate funding and are often ill equipped to make use of the latest scientific evidence about what does and does not work. As a result, people with substance use disorders pass frequently through hospitals, courts, jails, prisons and even rehabs without ever being offered the kind of help that could save their lives. For many of them, it remains easier to buy illicit substances on the street or to be lured by charlatans into snake oil programs than it is to receive quality care for addiction from a trained professional.
The moral case for resolving this crisis should be more than enough by itself. Addiction ruins lives, destroys families, devastates entire communities. Drug overdoses have killed more Americans in the past 24 years than all U.S. wars combined, and the annual death toll is rising still. We could prevent many of those deaths and alleviate so much attendant suffering with the knowledge and resources already at our disposal.
But for those not persuaded by moral arguments, there’s also a practical case to be made. Closing the addiction treatment gap would be the most fiscally responsible way to manage the nation’s opioid addiction and overdose crises, which cost upward of a trillion dollars each year in lost productivity, criminal justice, emergency medicine and more.
In many ways, addiction is like any other chronic medical condition. It involves periods of remission and relapse, it can be fatal, and it is often manageable with the right support. Several unique barriers, however, make substance use disorders more difficult to treat. Some people cannot see that they have a problem. Others recognize the trouble they’re in but are too ashamed or afraid to ask for help. The fear is understandable. Even when they are in recovery, people who admit to struggling with drugs or alcohol or who take medications to manage addiction can lose jobs, lose housing, lose custody of their children. They can be denied care in nursing homes, be denied nutritional assistance, be denied organ transplants. They can be judged, be shamed and, perhaps worst of all, be ostracized by friends and family members whose support they desperately need.
“These are problems that most other illnesses do not face,” said Richard Frank, a health economist and the director of the initiative on health policy at the Brookings Institution.
They are also a feature of the current system, not a bug. For most of the modern era, medical professionals and policymakers have viewed addiction not as a health condition but as a matter for the criminal justice system to handle. That thinking has shifted in recent decades, but the addiction treatment system and the culture that undergirds it have yet to shift in tandem. “It’s quite popular to talk about addiction as a health issue now,” said Dr. Sarah Wakeman, the senior medical director for substance use disorders at Mass General Brigham. “But our policies and our clinical models still reflect this notion that really, it’s a bad behavior that people need to be punished for.”
One such punishment seems to be withholding care. Dr. Wakeman, who treats addiction in some of Boston’s hardest-hit communities (and whose own clinics take a different approach), said that among other indignities, patients are often made to jump through pointless hoops to “prove their commitment to treatment” and are frequently expelled from programs for the pettiest of infractions. “I have one patient who was kicked out of a residential program for talking to a member of the opposite sex on a Tuesday, because that was only allowed on, like, Thursdays or something,” she said. “We would never, ever do that to someone with diabetes or cancer or any other health condition.”
Ms. Mcmahan remembers subtler but more cutting slights, like the time she was hospitalized with a heart infection, sick and shivering cold, and nurses refused to give her a blanket. “I begged,” she said. “But the concept of treating me like a human was so foreign to them in that moment.” Such was her desperation to avoid further humiliation that after one relapse, she lanced her own skin abscess, a common side effect of injection drug use, in the back of the animal shelter where she was volunteering and then dosed herself with cat antibiotics so that she would not have to see a doctor.
It’s easy to blame drug users for their poor choices, but sensible options can be scarce in a broken system — and not just for people who are addicted. In Massachusetts, for example, desperate families often turn to a law known as Section 35, which enables them to have a loved one treated involuntarily for up to 90 days. It’s a Hail Mary move that has helped shepherd some people into recovery, but Dr. Wakeman, Ms. Mcmahan and others I spoke with said that in far too many cases, it has done more harm than good.
“I truly empathize with families who feel driven to this point,” Dr. Wakeman said. “But what they often don’t realize is that the person is not necessarily being connected to treatment. Sometimes they are just held for a week or two in a setting similar to a prison and then released without any support.” Hard numbers are difficult to come by, but doctors, recovery coaches and people who use drugs have said that, anecdotally, at least, quick relapses are not uncommon after a Section 35 commitment. Neither are overdoses. Or deaths.
The first step to solving these problems is clear: Instead of making good treatment difficult to obtain, policymakers and providers should strive to make it as easy and straightforward as possible. Clinics should welcome walk-ins. Medication should be cheap or free. Above all, patients should be met with acceptance instead of judgment. Even relapses should be treated as part of the recovery process, not cause for punishment.
Treatment should be voluntary, not coercive, but providers shouldn’t necessarily wait for patients to come knocking on the clinic door. “There’s no telling how many more people you could reach if you made the effort to identify and engage them,” Dr. Frank said. “But as a system, we’re terrible at outreach. Our entire paradigm is built on doctors sitting at their desks waiting for patients to come to them.”
In the early 2010s, Dr. Wakeman and her colleagues started a program — now known as the Bridge Clinic, for its focus on bridging the gap between addiction and the rest of medicine — meant to employ exactly these principles. Their approach has been to address addiction head-on and with radical empathy, not only welcoming patients in all stages of use and recovery but also seeking them out in emergency rooms, community centers and the streets, where they often congregate and sometimes live. It has worked for Ms. Mcmahan, who met Dr. Wakeman more than a decade ago when she landed in the emergency room with a recurrence of endocarditis. Ms. Mcmahan’s opioid addiction has now been in remission for 10 years — long enough for her to build a career, buy a home and start a family.
It’s also working for Nick Lehmann, a 55-year-old native of Chelsea, Mass., who became addicted to opioids after a doctor prescribed them for an injured back. Like Ms. Mcmahan, Mr. Lehmann met Dr. Wakeman when he landed in the hospital (for untreated diabetes, in his case). He had not been looking for help with his use disorders, but he liked Dr. Wakeman right away. “I am not kidding you,” he told me. “She looked like an angel, walking into the room with the sunlight lit behind her.” So when she suggested he try buprenorphine, one of the most effective treatments for opioid use disorder, he agreed.
She started him on the medication immediately and, as soon as he was discharged, connected him to her clinic, where a therapist, recovery coach and support group were waiting to welcome him. He’s been abstinent from heroin for nearly a decade now.
That’s not to say his life is perfect. He has endured bouts of homelessness in that time, and he is still estranged from most of his family. When I first met him at the clinic in September, he had just relapsed on crack after making it 10 months without the drug, but he was also on the right side of stable: His diabetes was under control, and a decade of therapy and ample support from his care team were helping him prevent one bad night from turning into a monthslong catastrophe. “I still have the rent money, like $800, to return to my brother today,” he said. “In the past, I would have blown through all of that and been high for days, but this time, I pulled myself right back up.”
The solutions to America’s addiction and overdose crises are not new. Think tanks, advocacy groups, academic institutions, scientific bodies and media outlets have spent decades laying out the same ones, over and over. Progress has been made in recent years. Some of the strictures that impede access to buprenorphine and methadone have been lifted, others are being legally challenged, and programs like the one Dr. Wakeman and her colleagues have built in Boston are emerging in other communities across the country. But with overdose deaths at an all-time high, the gap between knowledge and action is still unacceptably vast.
Finally and fully closing this gap will be a daunting task, but the nation has prevailed against similar challenges. At the height of the AIDS epidemic, when H.I.V. was still shrouded in mystery and patients faced harsh stigma, Congress passed the Ryan White Care Act, a bipartisan bill that committed billions of dollars to treating and supporting people who tested positive for the virus. In so doing, they helped turn the course of a devastating and deadly epidemic.
We don’t need to wait for new drugs or treatments to do the same for addiction. We just need to use the insights we’ve already gained and the tools we’ve already developed. Stop dehumanizing people who use drugs. Make use of evidence about which treatments and approaches work and which do not. Address the dire work force shortages plaguing behavioral health, in part by changing the way addiction treatment is funded. Lower the barriers to long-proven therapies like methadone. Ensure that those therapies are accessible to the most vulnerable populations, including the incarcerated (roughly half of whom struggle with addiction) and those newly released from jail or prison.
It will take far broader solutions — legal, geopolitical, educational — to fully resolve the national trauma that opioids, in particular, have wrought. None of those larger efforts can succeed without a robust, accessible, evidence-based addiction treatment system, similar to the one that already exists for most other life-threatening health conditions.
It’s been nearly 40 years since addiction researchers at Johns Hopkins showed that positive reinforcement — rewarding people for the behaviors you are trying to encourage — could help those who are addicted to opioids remain in treatment. It’s been at least 20 years since researchers in Vermont showed that a similar strategy involving shopping vouchers could help people with cocaine use disorder achieve abstinence. And it’s been more than 15 years since Steven Shoptaw, a psychologist and addiction researcher at U.C.L.A., demonstrated that contingency management, yet another version of the same approach, could help gay and bisexual men reduce their methamphetamine use, to great effect.
Still, hardly any addiction treatment program in the country employs this strategy. Aside from a commendable initiative run by the Department of Veterans Affairs and another by California’s Medicaid program, no health system seems willing to begin a large-scale trial or to put a program in place. “There’s all these studies showing that it works,” Dr. Shoptaw said. “But instead of trying something that’s got actual evidence behind it, they’re pouring all this money into things that have no mark of efficacy. Zero.”
The United States has invested billions of dollars in addiction research in the past 50 years. That work, though hardly perfect, has yielded scores of insights about which treatments do and don’t work for which use disorders. It has led to hundreds of randomized trials parsing the relative benefits of cognitive behavioral therapy, motivational interviewing and contingency management. And it has helped produce a small roster of medications, especially to treat alcohol addiction and opioid addictions.
Some of these treatments are extremely effective. Buprenorphine can work better at reducing opioid fatalities than statins do at lowering cholesterol.
All of these treatments are clinically useful. Medication and therapy can’t cure addiction any more than insulin injections can cure diabetes, but when used correctly — ideally, in concert — they can nudge people into remission and help keep them there longer.
And yet, almost none of these treatments are in widespread use. By official estimates, fewer than a quarter of people with opioid use disorder and fewer than 1 percent of those addicted to alcohol are being treated with medications. Data on behavioral therapy (which can help treat almost any type of substance use disorder) is harder to come by, but experts suspect that those numbers, too, are small.
Part of the problem is certainly the reluctance of many addicted people to accept help, but a far bigger issue is this: The nation’s addiction treatment apparatus is not designed or equipped to deliver evidence-based medicine in the first place.
That needs to change, but in the midst of the largest overdose epidemic the nation has ever known — even as advocates clamor for a significant expansion of addiction treatment programs — almost no attention is being paid to the quality of care that such programs offer.
The challenges of incorporating clinical research findings into real-world medicine are not unique to addiction; the National Institutes of Health has devoted an entire institute to this problem. Yet those challenges are greater when it comes to substance use disorders, in part because of the ways that addiction care is siloed from the rest of medicine. The earliest programs were created and run almost exclusively by former drug users and kept well apart from traditional clinics and hospitals. They tended to be ideological, to eschew medical research (which was scant at the time, in any case) and to rely heavily on formulaic one-size-fits-all approaches, including the 12-step method made popular by Alcoholics Anonymous.
“What you had were mom-and-pop franchises,” said Dr. Frank. “They didn’t get much money or support, but they also weren’t held to any real standards.” Not enough has changed since then, he said, despite how much addiction medicine itself has evolved. Addiction treatment programs are still vastly underregulated, almost as a rule. Most don’t have full-time doctors on staff, according to multiple surveys and reports. Many don’t have well-trained therapists, either. As a result, the 12-step method tends to prevail — but while Alcoholics Anonymous and Narcotics Anonymous have helped millions of people, they have also been known to actively discourage the use of lifesaving anti-addiction medications.
In 2021, Dr. Frank and his colleagues published a secret shopper study showing that even addiction treatment programs accredited by the Joint Commission or by the Commission on Accreditation of Rehabilitation Facilities routinely offered people admission without properly evaluating them, discouraged the use of medications for people with opioid use disorder and offered rigid, program-centric courses of treatment without considering the individual patient. “It’s a bit like the Wild West out there,” Frank said. “They’re doing things that are not only not evidence-based but that are actively opposed to the evidence.”
Those findings will not come as a surprise to the countless families that have been outright swindled or that wasted tens of thousands of dollars on treatments that were well intentioned but ineffective — often while loved ones circled the drain. It’s no wonder so many come to believe that real addiction medicine does not exist.
In an ideal system, prospective patients would be evaluated at the outset and offered a combination of medications, therapy and peer support based largely on their individual needs. The most widely available treatments would be those backed by evidence. Innovation would be incentivized, and programs would be monitored — not only to ensure adherence to best practices but also so that the real-world effectiveness of treatments could be continually assessed.
The single most important thing lawmakers and health officials could do to usher in such changes is to improve their oversight of the addiction treatment industry. Too many states have not updated their regulations for addiction treatment facilities since the 1960s or ’70s. Many rely instead on independent accrediting agencies to separate good programs from bad ones. That approach frequently fails, as secret shopper studies and innumerable investigative reports have shown. “Accrediting organizations should feel humiliated by what we’ve seen from facilities that have their stamp of approval,” said Keith Humphreys. “But their incentive is to accredit everyone, because that’s how they get paid.”
Such flimsy policies are unconscionable, especially when more people died of drug overdoses last year alone than could fit into the country’s largest football stadium.
Addiction treatment programs of every kind, in every state, should be governed by sensible, up-to-date policies that include clear standards for safety, effectiveness and ethical practice. Programs that fall short of those standards should be held to account. Programs that egregiously violate them should lose their operating licenses and their insurance eligibility. These should not be big asks: policymakers and health officials at every level already do as much for all the rest of medicine.
Better oversight of addiction treatment would be much easier to establish and maintain if health officials at every level made a concerted effort to improve their data collection. Experts tend to agree that even the most commonly cited data points (such as the roughly six million people with opioid use disorder, according to the latest federal data) are gross underestimates, in large part because unlike other epidemics — including H.I.V. and Covid — the opioid crisis has not spurred any meaningful effort to improve surveillance. If policymakers and treatment providers are to have any hope of gauging what is and is not working or where and how to target their efforts, they will need a much more accurate portrait of the problem.
Ultimately, however, if they want to expand the amount of evidence-based treatment that’s available to people with substance use disorders, officials will have to find ways to professionalize and unify the addiction treatment work force. Nonmedical workers will need more training and support, and many more doctors and psychiatrists will have to jump into the fray.
The nation’s addiction treatment work force is in crisis. As overdose fatalities and alcohol-related deaths soar and as methamphetamine use surges, addiction treatment providers say they don’t have nearly enough doctors, nurses, therapists, counselors or social workers for their programs to function. The problem is not new. Experts have warned of catastrophic behavioral health shortages since at least 2015, when, according to the Pew Charitable Trusts, there were just 32 such specialists for every 1,000 people. In the wake of Covid, however, it has grown far worse.
“There’s a lot of burnout,” said Ann-Marie Foster, the chief executive of Phoenix House, a New York-based addiction treatment program. “We saw so much progress undone in such a short time. Relapses increased. New cases increased. Overdoses skyrocketed. And as all that was happening, the state actually reduced our funding.” In New York, at least, Ms. Foster said, officials have since corrected course and are now allocating more money to addiction treatment. Those new funds have been slow to materialize, however, and will not be enough to resolve a problem so many years in the making.
Treating addiction is hard and often heartbreaking. It can take herculean efforts to stabilize someone in crisis and almost nothing to lose whatever ground has been gained from one day to the next. Compensation for this work is typically abysmal, and as longtime staff members retire, many of their would-be replacements are choosing higher-paying alternatives (including at wellness start-ups that offer signing bonuses). As the work force dwindles, treatment providers in Oregon, Pennsylvania, New York and elsewhere say they have been forced to operate at well below capacity — or to close up shop.
In the meantime, fewer than 1 percent of the nation’s medical doctors specialize in addiction, a condition that contributes to countless deaths every year. Only about 5 percent of eligible providers have obtained the special license that’s required to prescribe buprenorphine, and recent efforts to repair that deficit have fallen short. (Lawmakers have taken several steps to lower the barriers to buprenorphine prescribing. More clinicians have gotten licensed as a result, but very few have begun treating addiction patients.)
Clearly, more is needed.
The current addiction treatment system was forged in a vast shadow of neglect. When the nation first declared war on drugs some 50 years ago, most doctors did not consider drug abuse part of their remit. In fact, most did not think of addiction as a medical condition at all. Neither did the hospitals, clinics, health insurance systems or professional societies to which they belonged. Overlooked and suffering, people struggling with addiction turned to one another for help instead.
The virtues of that mutual aid were clear. People with shared experience can be a crucial source of perspective and support in any crisis, especially in one as stigmatizing as addiction. But so were the challenges. “Historically, it was largely just one person with addiction helping another person with addiction,” said Dr. Katherine Watkins, a psychiatrist and addiction policy researcher at the nonprofit RAND Corporation. “That approach was not really compatible with medical care.”
The system has evolved in recent decades, Dr. Watkins said. The American Board of Medical Specialties formally acknowledged addiction medicine in 2016, but meaningful change has been slow to come.
Most doctors still receive little to no training in the treatment of substance use disorders. As a result, many believe that the condition is not treatable or that, in any case, treatment should not fall to them. Use disorders tend to be complicated, and patients’ needs often stretch well beyond the medical. Doctors, by contrast, are incentivized to treat people as quickly as possible. They also tend to hold the same biases and stigmas as everyone else. “I’ve had doctors tell me that they didn’t go to medical school plus residency for seven years to have ‘addicts’ in their waiting rooms,” said Dr. Shoptaw.
But it’s not just stigma that deters clinicians. It’s a whole raft of logistical hurdles, including extra privacy protections that make addiction care more difficult to coordinate, low reimbursement rates (and in many cases work that isn’t reimbursable at all), and a host of reasons to avoid even discussing addiction with patients. “Sometimes doctors are afraid to ask because of all the potential fallout,” said Samuel Nwaobi, an addiction medicine fellow at Massachusetts General Hospital. “If the patient says, ‘Yes, I have a use disorder,’ they could be rejected by the nursing home you’re trying to discharge them to. They could lose their housing. They could lose other things.”
Studies have consistently shown that people who receive buprenorphine in the emergency room along with a referral to office-based follow-up care are much more likely to engage in treatment and to stick with it for at least a year. According to a 2021 report from the Legal Action Center, that opportunity is still being largely missed, despite a slew of mandates and recommendations to screen emergency room patients for substance use disorders, start them on anti-addiction medications and refer them to treatment, when appropriate.
There is no shortage of tools with which to remake this landscape. One option is through the courts. Emergency room doctors who overlook the signs of addiction in their patients may be violating federal statutes that require them to screen for and address life-threatening medical conditions. Nursing homes and other entities that deny services to people suffering from addiction may also be breaking laws, including those meant to protect people from discrimination based on medical conditions or other disabilities. The Legal Action Center and others have filed lawsuits in Massachusetts, New York, Pennsylvania and elsewhere, some of which have already been successful.
That’s urgent and commendable work, but policymakers need to build on it. Elected officials should make public funding for medical schools contingent on comprehensive training in addiction medicine so that no doctor graduates without knowing the basics. Tuition reimbursement and loan forgiveness programs for people who choose to enter this field would also be well worth the investment, especially considering how much substance misuse and abuse cost the American economy every year. So would more residency and work force development programs — not just in major medical centers but also in community-based clinics (including federally qualified ones), where the need for behavioral health and addiction treatment is often most dire and the resources for both are most meager.
Reducing barriers to telemedicine would also help. Adjust licensure and credentialing rules so that therapists can provide services where they are most needed, not just in the few pockets of the country where they tend to concentrate. (Imagine if the glut of doctors and therapists in Manhattan could be dispersed electronically to North Dakota, Nebraska or West Texas.) Medicaid and Medicare could jump-start this shift by encouraging what are known as cross-state compacts, in which states in a given region agree to honor one another’s licensures.
Nonprofessionals also have a crucial role to play in addiction treatment. Counselors, recovery coaches and peers who have lived through addiction themselves are often the ones best positioned to meet people with use disorders where they are and persuade them to accept help. They have a wealth of knowledge to share with their medically trained counterparts. And plenty of evidence shows that with clear standards, rigorous training and the right support, they can help deliver high-quality care (including, among other things, cognitive behavioral therapy). To succeed, they need salaries that are livable and commensurate with the import of their work.
For all its complexity, the ideal addiction treatment apparatus is easy to envision. It includes medical professionals and their nonmedical counterparts working together in an integrated system. A designated care manager would handle all the basic day-to-day monitoring of patients while primary-care doctors checked in periodically and handled more serious issues — consulting with or referring people to specialists as needed. Peer support would serve as scaffolding throughout.
Doctors already have a name for this approach: collaborative care. Right now, it’s the exception. With a concerted push and with the right incentives and strictures, it could surely become the rule.
Deborah Manasseh, a nurse with the nonprofit Community Healthcare Network, followed her patient calmly out of the clinic, up Westchester Avenue in the South Bronx, around the corner and back. He was an older gentleman, desperate to quit heroin. Buprenorphine, the medication she had just given him, was supposed to help with that, but at the moment it was making him deeply uncomfortable, and he wasn’t sure he could handle another dose. So she stayed with him — pacing the block, speaking soft reassurances — until his moment of doubt passed.
Buprenorphine is one of the most effective treatments for opioid addiction, but starting patients on the medication is tricky: Give them too much too soon, and you can send their body into a painful tailspin known as precipitated withdrawal. Give too little, and you risk losing them to a relapse before the medication has a chance to take effect. The right dose depends on how much opioid they have in their system, but that can be difficult to gauge: Not all patients know exactly what kinds of opioids they’ve consumed, and synthetic versions like fentanyl have a way of lingering in the body. As a result of such uncertainties, this process, buprenorphine induction, can take six hours or longer.
“We have to start with a very low dose,” Ms. Manasseh said. “Then we increase slowly while monitoring the patient very closely.” Blood pressure can spike during buprenorphine induction, dehydration is a concern, and waves of intense discomfort are common. Success is often as much a matter of the nurse’s empathy as it is of the medication’s effectiveness, the clinic’s chief psychiatrist, Dr. Joseph Squitieri, told me. It’s also a matter of timing. The window when a person with substance use disorder is willing and able to accept treatment can be vanishingly small, in part because withdrawal itself is often unbearable.
So it’s a problem that Community Healthcare Network has only two such nurses (Ms. Manasseh and a colleague) to cover 14 clinics across the city. “We have people walking in who want help,” she said. “And a lot of times, when we have to ask them to wait or to come back, we lose them.” The organization’s South Bronx clinic completes just three or four inductions per month, on average. The facility could certainly do more, Dr. Squitieri said. The surrounding community reports one of the highest overdose rates in the nation. Much of what Ms. Manasseh and her colleague do is not covered by health insurance, though; there is certainly no reimbursement code for walking a buprenorphine patient around the block. And the kind of grants that pay her salary are difficult to obtain.
For most of the modern medical era, substance use disorders have been among the few conditions whose treatment is heavily subsidized with state and federal grants instead of being primarily covered through health insurance. That distinction makes for a substantial difference. For all its shortcomings, health insurance is at least elastic: the amount of money that treatment providers are reimbursed grows with the number of patients they see and the amount of care they provide. Grants, by contrast, tend to be fixed and to come in lump sums. They can run out when demand surges, forcing providers into desperate scrambles and patients onto interminable wait lists.
Such unreliable funding makes doctors wary of entering addiction medicine and educators apathetic about teaching it to begin with. “It’s hard to build a program when you don’t know what money you’ll have from one grant cycle to the next,” said Dr. Humphreys. “And it’s very difficult to persuade young professionals to enter the field when you can’t offer competitive salaries.”
The Affordable Care Act has helped to change some of that. By requiring more health insurers to cover behavioral health the way they cover most other medical specialties — what policymakers refer to as parity — and by vastly expanding access to insurance itself, the law has made mental health care and addiction treatment available to more Americans than ever before. It has also triggered a broader shift. “By flooding the system with insurance money, it has helped turn addiction treatment from something that looked nothing like the rest of medicine to something that looks a lot more like the rest of medicine,” said Dr. Frank.
But enforcement of these parity laws has been weak, and insurers have been brazen about violating them. “They constantly deny and delay payments,” said Lauri Cole, executive director of the New York-based nonprofit Council for Community Behavioral Health Care. “They do it to such an extent that providers run into cash flow problems. Then those providers have to reduce services, which in turn creates wait lists.” In New York, she said, wait lists for behavioral health care abound.
Across the country, regulators have documented sweeping lapses in recent years: reimbursement rates that are far too low, co-payments that are way too high, claims and benefits that have been denied when they should have been approved and a whole suite of special requirements, including that a person remain abstinent or demonstrate specific progress to continue receiving treatment.
All of these practices run afoul of existing parity laws, and all of them are commonplace.
Behavioral health care networks are also much smaller than they can or should be. Insurers blame work force shortages, but that claim does not hold up to scrutiny. Such shortages are certainly dire, but many more addiction treatment providers say they would join insurance networks if only insurers would work with them on reimbursement and credentialing. “Ask insurers what they do when their network is short on cardiologists,” said Ali Khawar, a deputy assistant secretary in the Department of Labor’s Employee Benefits Security Administration. “We all know what the answer is. They pay more. They find cardiologists and solicit them. That’s not what you see with behavioral health.”
What you see instead are laws that exist on paper but not in reality, providers that are heavily reliant on grants and subject to all the limitations that come with them, and professionals who remain deeply and understandably reluctant to enter a field — addiction medicine — in which compensation remains egregiously low.
It’s fair to ask why insurers should treat addiction medicine the same way that they treat cardiology or cancer care when the quality of addiction treatment is often so much lower. But insurance is the key to correcting that imbalance. Better coverage would draw more professionals to the field: With their purse string powers alone, insurers could hold would-be providers to a higher standard than any regulator could. And insurance companies have a crucial role to play in helping their customers sort good programs from bad ones.
The current administration seems to understand as much. The Department of Labor has stepped up enforcement of parity laws under President Biden, and the Department of Health and Human Services has proposed rules that would make those laws stronger. Insurers are resisting the changes, which will ultimately require them to pay more practitioners more money for behavioral health care.
They should rethink that stance. Better, more consistent treatment of addiction will reduce their costs in the long run. And lawmakers and health officials should consider additional measures that would also bolster behavioral health:
Repair reimbursement. Fifteen years after the first substantial behavioral health insurance parity laws were enacted, reimbursement rates remain far lower for mental health services than they are for most other forms of medicine. And when it comes to addiction, far too much of that care is not covered at all. Federal officials could help solve this problem (for Medicare and Medicaid, at least) by doing what they already do for most other forms of medicine and consult the experts. Unlike the professional societies representing cardiology, pediatrics and more than a dozen other medical specialties, the American Society of Addiction Medicine is not represented on the committee that directly advises the government on reimbursement rates. It should be.
Loop in Medicare. Very few of the 1.7 million or so Medicare participants who struggle with a substance use disorder are receiving adequate treatment, and at least part of the problem has to do with their health coverage. The premier insurer of older Americans is still exempt from the federal parity laws that bind most other health insurance plans.
As a result, Medicare plans are not required to provide the full scope of addiction and mental health benefits to their beneficiaries: They don’t have to cover inpatient rehab, for example, or many forms of outpatient care. They are also allowed to impose a range of arbitrary policies and practices — including treatment caps and prior authorization requirements — that impede access to care.
The Biden administration has made several commendable improvements to Medicare’s coverage of addiction treatment, but the only way to ensure that Medicare participants have full access to this kind of care is to pass a Medicare parity law. Congress should take up that cause quickly. The rate of fatal drug overdoses among Americans age 65 or older has quadrupled in the past two decades and is set to rise even further in the years ahead.
Use grants smartly. Faced with the worst overdose crisis in the nation’s history, federal officials have increased the amount of grant money on offer for addiction treatment providers. They should tweak that approach.
Providers need much more stability than can be provided by grants that have to be reapplied for every few years, but grants still have an important role to play in funding addiction treatment. “A smart system would use grants to do all the things that insurance can’t, like building clinics and programs in communities that don’t have them,” Dr. Frank said. “And then, once those places are established, health insurers should cover their operating costs.”
Of course, even these changes will have to be paired with broader ones. “People had expectations that insurance parity would also get you really good quality,” Dr. Frank said, “but insurance reform is not delivery system reform.” If you want to close the addiction treatment gap, you have to fix both.
Methadone is one of the oldest and most effective treatments for opioid addiction, and it is still more difficult for most Americans to obtain than a bag of heroin. The medication has been approved for the treatment of opioid use disorder since 1972, and studies consistently show that for people addicted to opioids, it can help cut the mortality rate in half. But doctors and pharmacies can prescribe and dispense methadone only to pain patients. People struggling with addiction must go instead to specialized clinics called opioid treatment programs.
There are not nearly enough of these clinics to meet demand, beyond a few metropolitan areas like New York City. Eighty percent of American counties don’t have any, according to the Congressional Research Service. There are only six in all of Nebraska and none in Wyoming. Wait lists tend to run long as a result. And patients can be forced to travel hours to reach the nearest clinic with an open spot. That’s a huge problem for anyone with a job or children (or hopes of having either) because patients are frequently required to report in person — every day — to receive their medication.
Counseling is also mandatory for methadone patients, as is routine urine testing. In fact, methadone is subject to several strictures that its sibling buprenorphine is not. On its face, this extra caution makes sense. Methadone is a stronger medication than buprenorphine. It can be deadly when misused, and health officials and policymakers have long maintained that the strictures are needed to protect people with opioid use disorder — presumably from themselves.
But that’s not always how it goes.
Policies and practices, not to mention quality of care, can vary greatly from one opioid treatment program to the next. The best offer comprehensive support and services (including a choice of methadone, buprenorphine or another medication called naltrexone) and tailor their treatment plans to the needs of individual patients. The worst are punitive and arbitrary. They employ one-size-fits-all strategies like requiring all patients to abstain from all drugs, including alcohol and marijuana. Or they skimp on treatment: One study found that more than 40 percent of methadone patients receive doses that are too low to be effective. Another found that nearly one-fifth of opioid treatment programs don’t offer buprenorphine.
For people with opioid use disorder, these vagaries can turn basic milestones like moving and changing jobs — and thus health insurance plans — into matters of life or death. The resulting conundrums are so common that opioid users have a name for them: liquid handcuffs (because methadone is commonly administered as a liquid).
David Frank, a medical sociologist at New York University who has taken methadone for years to manage his opioid use, remembers one friend who had to change methadone clinics when he moved out of state for a new job. “He had been off heroin and on methadone for years, without any issues,” Dr. Frank said. “But the new clinic would not give him take-home doses because he still smoked pot. He couldn’t get there every day because of the job, and he was terrified of going into withdrawal.” Dr. Frank and others wrote to the new clinic on his behalf, but their plea went unheeded, and a few months after moving, his friend died of an accidental overdose. “It was not a relapse,” Dr. Frank said. “He was just trying to avoid withdrawal, because the clinic wouldn’t help him.”
As numerous studies and reports have indicated, only about 20 percent of those whose lives might be saved by medications for opioid use disorder are likely to receive them. It’s common to blame that tremendous gap on the reluctance of people with addictions to get help, but a great deal of it comes down to access, which in methadone’s case is impeded by archaic and counterproductive regulations. It is well past time to update those regulations and to reimagine methadone treatment with the current opioid crisis in mind.
Opioid withdrawal is a brutal physiological process. When the body is repeatedly flooded with chemicals like heroin, fentanyl and OxyContin, it stops making its own endorphins and quickly comes to rely on those external sources to feel normal. By cutting that supply off, people subject themselves to severe cravings and excruciating pain. (Those who have been through withdrawal often describe it as many times worse than the most miserable flu imaginable.)
In the 1960s it became clear that methadone, a medication that was already being used to treat chronic pain, could alleviate the symptoms of withdrawal. Health officials began promoting it as a way to address the nation’s simmering heroin crisis. For political reasons, they focused on the medication’s potential to help curb drug-related crime. That framing might have persuaded President Richard Nixon to invest heavily in what are now known as opioid treatment programs. But it also created the impression that all people addicted to heroin were criminals, that methadone was a pseudomedicine at best and that both needed to be closely monitored and tightly controlled.
The result has been a grim cascade: Stigma deters many doctors and nurses from working in addiction treatment and spurs many communities to prohibit or otherwise reject methadone clinics. Opioid treatment programs tend to be understaffed as a result and to be overconcentrated in marginalized communities. They also tend to attract drug dealers — who come searching for potential clients — partly because of how isolated they are from other health facilities.
“It’s tough for people who are just starting to grapple with recovery to go into that environment every single day,” said Lori Hooley, a registered nurse and addiction specialist at Mass General Brigham’s Charlestown HealthCare Center. “They’re trying their hardest, but how do you stay sober when it’s in your face like that?”
As opioid fatalities soar, some communities are working to untie these knots. Mark Raymond, the clinic director at Farnham Family Services, an opioid treatment program with several clinics in rural New York, remembers a time not long ago when some wait lists stretched to 500, when people frequently died while waiting for care and when many of his program participants came from hours away. Today Raymond’s wait list is at zero, a shift he attributed to state health officials who he said have persuaded many more health clinics in his area to open methadone programs.
But Farnham’s experience may be the exception. In some parts of New York, and in too many other states, zoning restrictions, arbitrary licensing requirements and onerous approval processes have made methadone expansion all but impossible. In West Virginia, new opioid treatment programs have been prohibited outright. In Boston, the process is daunting enough to deter even large hospital systems like Mass General Brigham.
“You have to get a federal license and a state license,” said Dr. Wakeman. “You have to actually remodel the space because there’s requirements around separate entrances and medication storage. There’s also requirements around counseling. And there’s a bunch of logistics within each of those pieces that are incredibly opaque. We are fully capable of treating opioid use disorder with this medication, but the regulations make it really hard, even for a well-resourced, highly motivated system like ours.”
In the meantime, Dr. Wakeman, a board-certified addiction specialist working in one of the nation’s top health care systems, cannot prescribe methadone to any of her patients except during hospital stays — a stricture that would be comical were it not so frequently dire. “I have had to send new mothers, just a day or so after they deliver their babies, on four-hour round trips to receive methadone, because I can’t prescribe it for them once they’re discharged,” she said. “Their newborns are here in the hospital with us, and they have to go all the way out to Weymouth and come all the way back every day, which is crazy.”
So far, the boldest plan for changing those rules is a bipartisan bill, the Modernizing Opioid Treatment Access Act, that would finally allow board-certified addiction doctors to prescribe methadone for opioid use disorder — and pharmacies to dispense it.
Clinic operators have opposed the law, warning that among other things, such drastic changes would destabilize existing treatment infrastructure, creating real risks for patients and very little benefit. “Doctors and pharmacies are in no way prepared to dispense methadone to people with addiction,” said Allegra Schorr, the president of the Coalition of Medication-Assisted Treatment Providers and Advocates. “What I’m worried you’ll see instead are mills.”
Those concerns are not unwarranted. Methadone comes with real risks, and people with opioid use disorder can be complicated to treat. The opioid treatment industry has sounded similar alarms, though. When buprenorphine was approved in 2002, methadone providers fought vigorously to restrict its use, arguing that making it too widely available would lead only to diversion and death. Today many experts say that those worries were overblown.
Methadone may be riskier than buprenorphine, but it’s safer than other medications that are already widely available, and the challenges of offering it through regular doctors and pharmacies are not insurmountable. Plenty of other countries, including Canada and Britain, have been doing as much for decades without catastrophe. Studies going back to at least the early 2000s suggest that the United States can do the same, especially for patients who have been stabilized and are doing well.
The Modernizing Opioid Treatment Access Act is hardly perfect. It would constrain methadone prescribing to addiction specialists instead of opening it up to all qualified clinicians, including regular primary care doctors and nurse practitioners. That would do little to help rural communities, where the need for more methadone treatment is often greatest and where few such specialists are available. But the act would be a crucial first step toward making methadone more available to the people whose lives it could save. Congress should work to pass it (or something like it) as quickly as possible.
That should not mean the end of specialized methadone clinics. Some patients, especially those who are unhoused or who suffer from serious mental illness, will still need (and in many cases prefer) the daily check-ins and closer monitoring that opioid treatment programs can provide. However, those clinics — and the lawmakers and health officials that govern their practices — would do well to consider some changes:
Lower obvious barriers. State and federal officials loosened several methadone restrictions during the Covid pandemic: enabling opioid treatment programs to treat patients in mobile clinics instead of restricting them to brick-and-mortar facilities, permitting many more patients to take up to 28 days’ worth of medication home with them and enabling more doctors and patients to connect via telehealth. Those changes have not led to an uptick in methadone misuse or overdose, according to health officials. More clinics should take advantage of them. Policymakers could help by ensuring that treatment providers don’t lose money for seeing patients less often or in nontraditional settings.
Loosen other strictures. Counseling and drug screening should be based on the needs of individual patients and the discretion of the clinicians who know them best, not on outdated policies that subject everyone to the same requirements. Opioid treatment programs should provide their own patient identification cards instead of requiring prospective participants to present driver’s licenses, birth certificates or other forms of government identification that many of them, especially the unhoused, struggle to obtain.
“Too many opioid treatment programs have interpreted the regulations far too rigidly,” said Dr. Jonathan Giftos, a former assistant health commissioner in New York City’s Department of Health and Mental Hygiene. “They’re missing opportunities to treat patients as individuals as a result and often end up running inaccessible or unattractive treatment programs.”
Integrate. One way to expand methadone treatment without overturning current Food and Drug Administration regulations is for opioid treatment programs to coordinate with or incorporate themselves into existing health care facilities, including other addiction treatment programs, primary care practices and community health and behavioral health centers.
This, too, would require policy change: Licensing requirements would have to be modified and payment models adapted so that providers could be reimbursed for coordinating care and, ideally, for the parts of treatment that go beyond providing medication. Those changes might be less politically fraught than a wholesale abandonment of the current rules and thus easier to execute.
Laws requiring all insurers to include opioid treatment programs in their networks and all opioid treatment programs to accept Medicare and Medicaid would also help. The key to making methadone more accessible is getting more clinics to offer it and more communities to accept it. The best way to do that is to make it more like what it can and should be: an ordinary part of modern health care.
In November 2018, Sonya Mosey was presented with an impossible choice: stop taking the buprenorphine her doctor had prescribed for her opioid use disorder or have her probation revoked and be sent to prison. Such medications are widely recognized as the gold standard of addiction treatment, but a Pennsylvania state judge had issued an order prohibiting their use among drug court participants and people on probation. Ms. Mosey tried to taper off but quickly went into withdrawal. Terrified of relapse and incarceration, she sought legal help.
In some ways, resolution came swiftly. The nonprofit Legal Action Center pointed out that the judge’s ban violated several laws, the Department of Justice opened a federal investigation, and the judge rescinded his order before the year was over. Ms. Mosey was able to resume taking her medication and completed her probation without relapsing.
The Pennsylvania court system has not amended its policies to prevent additional violations, however, and as a result is being sued by the Department of Justice. The case is not an isolated one. The Department of Justice has taken similar steps in Massachusetts and elsewhere, and the Legal Action Center said it has heard from people all over the country facing situations just like Ms. Mosey’s.
The criminal justice system represents the single biggest missed opportunity to turn the tide of addiction in America. Roughly half of those who wind up in criminal court, and roughly half of those in jail or prison, struggle with a substance use disorder of some kind. (Approximately 15 percent of the nation’s inmates have opioid use disorder, specifically.) Not only are most of them not getting treatment for these conditions, but many are being actively denied the care that doctors say is most likely to stabilize them.
Drug courts frequently fail to refer people with opioid use disorder to programs that offer standard medications for the condition, even though courts that receive federal funds are required to. Few jails or prisons provide those medications — or any other addiction treatments — even though legal precedents make clear that not doing so violates laws against cruel and unusual punishment. And few facilities link inmates to care when they are released, even though the risk of death by overdose is inordinately high when a person first comes out of jail or prison — a fact that officials have long been well aware of.
The barriers to improving this system are painfully familiar: stigma against people with substance use disorder, fear that medications for opioid addiction will be diverted from treatment and seed epidemics of their own, a lack of resources for new programs, and the same deep silos that afflict the rest of addiction treatment. “Health officials and prison officials do not generally speak the same language,” said Paul Samuels, president of the Legal Action Center in New York. “And that makes it very difficult for them to work together.”
It would be foolish to think that anything as unwieldy and dysfunctional as the American prison system could be remade easily. Better laws and policies can be difficult to enact, even when they are easy to identify, and changes in custom and culture are often glacial. But meaningful improvement is not impossible. In fact, glimmers of hope and road maps for repair have been emerging quietly across the country for years.
Considering that the nation spends roughly five times as much money prosecuting and incarcerating people with substance use disorder as it would cost to treat them and that newly released inmates are among the most likely to die from drug overdoses, ferreting out those successes and finding ways to replicate and expand on them ought to be a national priority.
So far, it has not been.
Jails and prisons are uniquely terrible places for people struggling with behavioral health conditions like addiction. They tend to be underfunded, overcrowded and violent — and to bend sharply away from any notion of rehabilitation or treatment. “We kind of gave up on that in the ’70s,” said Marie Waldron, a California state assemblywoman who has worked on jail and prison reform. “It was partly because of this feeling that nothing worked and partly because prisons in particular became so enormous that the cost of making them humane would have been backbreaking.”
When it comes to substance use disorder, a different mentality has prevailed in most of the nation’s jails and prisons. Incarceration itself is seen as the only treatment needed. Locking people away should be more than enough to break the chains of addiction, the thinking goes. And if it is not, it’s the addicted person’s fault, anyway. “There is a huge amount of stigma among the staff of most correctional facilities,” said Linda Hurley, the president of Community Organization for Drug Abuse Control, the opioid treatment provider that runs Rhode Island’s inmate program. “There’s a lot of: ‘Well, they got themselves into this. So what if they get sick with withdrawal, or die of an overdose? That’s on them.’”
The key to overcoming such obstacles, Ms. Hurley and others said, is for correctional facilities, treatment providers and policymakers to work together, closely and consistently. “You have to sit everyone down at the same table,” she said. “And then you have to listen to each other. You have to respect each group’s separate mission, whether it’s safety, treatment or budget management. And you have to build relationships at the very outset, not at the end of things.” She ought to know. In 2016 her state became the first in the nation to offer comprehensive treatment for opioid addiction — including buprenorphine, methadone and naltrexone — to every inmate who wants and needs it.
This was no small feat. It required buy-in from lawmakers, treatment providers and prison staff members, not to mention inmates themselves. It took a $2 million investment from the state and extensive negotiations with a raft of labor unions. It also necessitated a major education initiative: Hardly anyone without training knows the difference between addictive drugs like fentanyl and addiction medications like methadone. In the end, though, it worked. More inmates participated in treatment in the first few years after the program began. Many of them continued that treatment after release, and before long, overdose rates in the state’s inmate population fell by 60 percent.
In 2021, New York passed a law requiring all jails and prisons in the state to make all medications for opioid use disorder available to all inmates who need it. So far, though, it is one of only a few of states working to replicate Rhode Island’s success. More states need to try. For all the many challenges, studies indicate that treating opioid addiction in jails and prisons can reduce substance use during incarceration and lower the risks of overdose fatality after release.
The boldest, most imaginative programs may accomplish even more than that. In Kentucky, Virginia, Ohio and elsewhere, sheriffs are turning some jails into full-time addiction treatment programs. Early reports indicate that at least some of these facilities have less violence, less contraband and lower health care costs. Policymakers at every level should be watching them closely for lessons about how to move forward.
The South Bay House of Correction in Boston sits just a few blocks from an open-air drug market known as Methadone Mile or, more recently, Mass and Cass. Lovelee Harvey, a recovery coach, likes to say that a former inmate’s chances of success depend heavily on which way he turns after he steps through the exit. “If you go left toward Mass and Cass, you back up in the mix,” he told me recently. “If you go right, you have a fighting chance.”
Mr. Harvey spends a lot of his time positioning South Bay’s residents to go right. He visits with them well before discharge and connects them with all manner of resources. (A lifelong resident of Boston and a former inmate, Mr. Harvey maintains a grand mental Rolodex of programs and personal contacts.) And when the fateful day finally arrives, he meets them at the door.
“You can’t just give people a pamphlet or a phone number and say, ‘Good luck,’” Mr. Harvey said. “A lot of people are walking out that door with nothing. You have to be physically present.” Treatment providers and advocates call this a warm handoff. It can be trickier than it sounds: Inmates are often reluctant to admit that they need help, especially for addiction. But it can also make the difference between life and death. The risk of fatal overdose is greatest in the two weeks after a person is released from jail or prison.
The reason is obvious — tolerance for drugs like heroin and fentanyl wanes during a long stretch without them — but the magnitude of that risk is still striking. In 2007 a seminal study in The New England Journal of Medicine put it at 129 times that of the general public. Similar studies have since corroborated that finding. So far, the most widely employed solution to this avoidable crisis has been a terrible one: Instead of treating people for addiction while they’re incarcerated or connecting them with care when they’re released, many facilities have opted to inject inmates with naltrexone instead.
Naltrexone (also known by its brand name, Vivitrol) has been approved by the Food and Drug Administration to treat opioid use disorder. It works differently from methadone and buprenorphine and has less evidence behind it, but it has benefited from an aggressive and deeply skewed marketing campaign targeting court and prison officials. The drug’s makers have emphasized their product’s most incarceration-friendly features (the medication is unlikely to be diverted or abused, in part because it does not trigger any euphoria) and have vastly understated its risks. When naltrexone wears off (usually after a month), it leaves people far more sensitive to even low doses of opioids and much more vulnerable to overdose.
A better option would be for correctional facilities to provide methadone and buprenorphine to inmates who need it and to create more warm handoff programs for when they are released. But so far, outreach workers like Mr. Harvey are a rare sight in most jails and prisons, and securing treatment after incarceration remains tricky. “I get calls sometimes asking if I can dose them in the emergency department so that they don’t end up going into withdrawal or overdosing on the streets,” said Dr. Gail D’Onofrio, an addiction specialist and professor at the Yale School of Medicine. “And of course I do it, but that’s a very flimsy solution.”
The problem, Dr. D’Onofrio and others said, is funding. The vast majority of people who are both incarcerated and addicted to opioids are eligible for Medicaid, according to health economists, but a provision of the Social Security Act known as the Medicaid inmate exclusion prohibits almost any federal health coverage for inmates of jails, prisons or detention centers. This is a counterproductive law whose time has passed. “Add up everything it costs us to kick people off Medicaid and to provide medical care by other means during incarceration, and then to deal with all the fallout from people slipping through the cracks,” Ms. Waldron said. “It would probably cost us less to just keep them on Medicaid.” But so far, efforts to repeal or modify the exclusion have failed in Congress.
The Centers for Medicare and Medicaid Services took a crucial step forward this year when it created a waiver program that enables participating states to cover at least some inmate medical care, including for addiction, through Medicaid. California and Washington State have already had their waivers approved, and more than a dozen other states have proposals pending with the agency. Health officials should approve those applications as quickly as possible, lawmakers should consider repealing the inmate exclusion act altogether, and treatment providers and prison officials should find ways to work together.
Tens of thousands of lives and many millions of dollars depend on it.
When the Linkage Center in San Francisco’s Tenderloin district first opened in January 2022, it looked like a comprehensive sticks-and-carrots solution to the deeply intractable problem of open-air drug markets and the addictions that fuel them. It would offer people who use drugs access to safe supplies, including clean needles and overdose reversal kits; it would connect them to programs that offer addiction treatment and other support, such as food and housing; and it would combine all of those offerings with stepped-up law enforcement efforts in the surrounding area.
In practice, critics say, almost none of these things came to pass. “It was called the Tenderloin Linkage Site, and it didn’t have any linkages,” said Matt Haney, a State Assembly member who represents the Tenderloin district. “The harm reduction teams reversed a lot of overdoses, but not many people found their way to treatment.” Instead, the site quickly became known as a hub of drug dealing and use. Harm reductionists disputed that characterization, insisting that drug use at the site was contained and that many people were indeed connected to care, but those arguments fell flat.
The Tenderloin split quickly into the same factions that have long divided the city’s response to addiction and overdose. “One group didn’t care at all about the people using drugs,” said Dr. Humphreys. “Another group didn’t seem to care much about how the rest of the community felt about open drug use.” Some people blamed the police for not doing enough to protect the community, while others blamed them for doing far too much to target drug users.
Less than a year after it opened, the center was shuttered by the same officials who had once championed it. “We needed a comprehensive, all-hands response to the drug problem,” Mr. Haney said. “Instead we’re back to just the police, forcing dealers to move from one corner to another, which of course accomplishes nothing.”
America is on the cusp of a potentially great transformation. but a thousand practical hurdles are holding us back. Many of those hurdles are structural, and plenty are the result of stigma — but not all of them.
Harm reduction proponents are wary of law enforcement, which they see as the vestige of a failed and fading drug war. Those in the recovery movement tend to be wary of harm reduction because it feels to them like giving up. Proponents of the 12-step approach reject medication because it looks too much like addiction, and those who champion medication often question the value of 12-step programs, which can be ideological and lack evidence.
“These seem like simple fights,” Dr. Humphreys said. “But they are real barriers to progress because they take people who should be on the same team and pit them against one another.” If we want to gain ground against addiction, this infighting will have to stop.
A robust addiction treatment apparatus requires several sturdy components to work in harmony: not only treatment options that are available, affordable and effective but also harm reduction programs to help those who aren’t ready for recovery and law enforcement that’s prepared to deploy public health solutions when confronted with drug- or addiction-related crises.
Too often, however, one of those components is too anemic to do its part, or another becomes so flush — or so suddenly popular — that it displaces all the others.
Greg Davis, the founding director of the Boston-based recovery group Metro Boston Alive, knows these imbalances all too well. He has been around long enough to remember how George W. Bush’s administration first enabled faith-based charities to receive federal social service funding: A lot of that money went to churches, he said, and very little to addiction treatment. Next came the needle exchanges, he said. He begged health officials to pair those programs with ones that offered treatment, to little avail. Now, he said, harm reduction is all the rage.
“When you have a marginalized community, other people like to come in and tell you what you need and then give it to you in an overconcentrated way,” he told me recently. “Then they say, ‘Look! We fixed it!’ right before they disappear.” Mr. Davis has been wary of harm reduction, especially as he sees these new programs displace older ones with deep roots in the community. “It’s good to meet people where they are,” he said, echoing a popular harm reductionist mantra. “But you can’t just leave them where you meet them. You have to offer them something more.”
What that something should look like, though, is another source of tension. Weaning people off addictive substances is tricky and can be idiosyncratic. The 12-step approach that Mr. Davis favors tends to reject the long-term use of medications like methadone and buprenorphine because, by that philosophy, there is no difference between being dependent on a medication like methadone and being addicted to a drug like heroin or fentanyl. Trading one addiction for another is what they call it.
This stance puts people who want both — meetings and medication — in a tough spot. “They go to meetings and get the message that they are not in recovery if they take Suboxone or methadone,” Ms. Mcmahan told me. “So they come off way too quickly and a lot of times end up relapsing. It happens all the time.” She remembers being proud and hopeful at her first 12-step meeting some 15 years ago. She’d been off heroin for 20 or so days by then, but when she told the group how much Suboxone, a medication containing buprenorphine, was helping her, she said she was quickly shunned. “They told me I wasn’t really in recovery and that I couldn’t collect chips,” she said. “Some of them even refused to sponsor me.”
That with-us-or-against-us mentality reflects a broader tendency. “Nonprofits like to say that the solution is 100 percent of what they do and zero percent of what the other group does and that the only reason they haven’t solved the problem yet is that their budget isn’t big enough,” Dr. Humphreys said. It can be tough to resist such zero-sum thinking, especially when resources are scarce, but setting differences aside may be the key to saving more lives.
Both the organization and the event, a rally for H.I.V. funding hosted by the nonprofit San Francisco AIDS Foundation, were ones that the community supervisor Matt Dorsey supported. But the flier the organization was distributing around the Tenderloin district to advertise that event was a problem. It included a scale of justice, poised over an image of City Hall, that equated clean needles and naloxone with life (fine) and cop cars with death (not fine). The organization was one of several groups pressing the city to establish a safe consumption site — a move he also very much supported but one that he knew would require buy-in from law enforcement to ever stand a chance. “Stuff like that, equating cops with death, makes it so much harder to advocate for the things that we all want,” he said.
It’s understandable that people would be deeply wary of law enforcement. Criminalization was the linchpin of our nation’s highly unsuccessful war on drugs. But law enforcement still has a crucial role to play in the way communities respond to addiction and overdose, especially now, when fentanyl is changing everything.
The drug has eclipsed heroin in many communities, in part because it is easier to produce and transport. It is also far more addictive and deadly. “With heroin, you had a good several hours between doses where you could function normally,” Mr. Haney said. “With fentanyl, people need to use it every few hours. That puts them out on the street far more frequently.” It also means that the drug is still profitable for dealers even if a lot of clients die, because clients use much more of it overall. There is no safe amount of fentanyl, and unlike with heroin, no long-term users.
In the Tenderloin district, residents have said that crime is worse than it’s ever been and that the police are understaffed and disempowered. “We had a guy in the market chewing his own arm off,” one local shop owner told me. “It took, like, eight officers to restrain him. Another guy robbed the laundromat with a machete, and another passed out under some lady’s car, and she accidentally ran him over pulling out of her driveway.” Insurers are fleeing the community, he said, and older residents who spent their lives there no longer feel safe.
In San Francisco, especially, reports of urban decline — or doom — tend to be exaggerated. The city’s fentanyl crisis is real, however. So are the safety concerns of people living in communities where drug use is open and drug dealing unchecked. If we want to end the first drug war instead of tumbling into a second one, we will have to take these concerns seriously. “Harm reduction is supposed to be about the entire community,” Dr. Humphreys said. “Not just people who use drugs but all the people who live with and around them. You wouldn’t have a hard time explaining that to someone in Amsterdam, but somehow, it’s been removed from the equation here.”
Restoring that balance does not have to mean locking up more drug users or people living with addiction, but it will require police officers, public health officials and harm reduction organizations to work together. This is already happening in New York City, where safe consumption sites work with the police to bring drug use indoors. It’s happening in New Jersey, where police officers do traditional harm reduction and outreach work, through initiatives like Hope One. It’s happening in cities like Boston and states like Virginia, where some police departments are using public health strategies to rein in drug dealers. There’s no reason it can’t also happen in the Tenderloin or anywhere else.
Or everywhere else.
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