The Washington PostDemocracy Dies in Darkness

Opinion We have a way to end the opioid epidemic, but not the will

First responders work to revive a 32-year-old man who was found unresponsive and not breathing after an opioid overdose on a sidewalk in the Boston suburb of Everett, Mass., in 2017. (Brian Snyder/Reuters)

Beth Macy is the author of “Dopesick” and, most recently, “Raising Lazarus: Hope, Justice, and the Future of America’s Overdose Crisis.”

I knew when I was giving a talk about the opioid epidemic to the Indiana Sheriffs’ Association in 2020 that it wasn’t going well. When I suggested that law enforcement officers divert arrestees with substance use disorders to treatment centers instead of jail, the sheriffs looked more disgusted than interested. When I proposed that prisoners be offered medications such as methadone or buprenorphine on-site to treat their opioid dependence — the gold standard of care — one sheriff hissed, “They’re clean when they leave my jail.”

Perhaps, but not for long: People leaving jail are up to 40 times more likely to overdose and die during the first few weeks after release. Suffice it to say that when my talk ended, it was met by the sound of a solitary audience member slow-clapping. I got the message.

But the United States isn’t getting the message that the overdose crisis — the killer of more than 1 million Americans since the OxyContin plague began in the mid-1990s — is far from over. According to provisional data from the Centers for Disease Control and Prevention, over 107,000 Americans died in 2021 from drug overdose, with opioids the primary driver.

What fueled the epidemic is well known: pharmaceutical companies’ greed, abetted by the politicians and lobbyists they paid to whittle away regulatory guardrails. That, plus the persistence of a decades-old “war on drugs” mind-set that handles addicted people like criminals instead of human beings with a treatable medical condition.

Even though ending the crisis sometimes seems like a hopeless cause, the solution is strikingly simple: Make treatment easier to obtain than the dope itself.

In other words, offer free treatment on demand for people who can’t afford it. Congress did that for those with HIV/AIDS in 1990, making antiretroviral medicines available at a scale that matched the scale of the crisis. Patients’ newfound ability to manage their illness not only saved millions of lives but also lessened the stigma surrounding the disease.

Methadone and buprenorphine are the antiretrovirals of the overdose crisis. They curb cravings and stave off withdrawal, making individuals 82 percent less likely to die than those not on the medications.

But these medicines are scandalously difficult to obtain; only 5 percent of people with opioid use disorder managed to get them in 2020, the nation’s drug czar, Rahul Gupta, told me recently.

In an era of cheap, high-potency fentanyl, methadone is particularly effective, but it is restricted by policies that were devised half a century ago, after the Nixon administration launched the “war on drugs.” The rules required people addicted to opiates to go to methadone clinics most mornings for their dose. Such regulations were stigmatizing and cumbersome — traveling in the predawn, before work — and yet that approach persists.

Unlike methadone, buprenorphine (often called “bupe”) can be prescribed on an outpatient basis. But since 2000, bupe providers have been required to receive extra training to get a mandated “X-waiver” from the Drug Enforcement Administration. Because of these and other restrictions, only about 6 percent of physicians have become waivered, creating critical access gaps, particularly for rural and Black Americans.

To the degree that waivered providers exist, they are most often found in urban centers. Some rural treatment activists have been forced to take their waivers on the road, to places where ready access to buprenorphine doesn’t exist — under bridges, in McDonald’s parking lots, in homeless encampments.

A striking sign of hope in the struggle to get treatment to those who need it can be found in The Post’s backyard. Sheriff Stacey Ann Kincaid of Fairfax County has instituted policies that are succeeding in helping addicted people who are booked into the county jail. The policies include screening new inmates for addiction, and both buprenorphine and counseling are offered to those who need it. This, at a time when most jailers tend to regard treating inmates with buprenorphine as “hug-a-thug” coddling.

Kincaid has also opened her doors to vital treatment providers, including peer support specialists whose help includes picking up inmates at the moment of release, when they’re most vulnerable to relapse and a possibly fatal overdose.

More than 7 million Americans now suffer the tortures of opioid addiction, taking an untold toll on their family members. Unless policymakers, law enforcement and others take decisive action, the country stands to lose another million Americans to drug overdoses in the next eight years.

An immediate step that Congress could take: Pass the Mainstreaming Addiction Act, removing the X-waiver requirement to prescribe buprenorphine. President Biden could also help by calling for an end to the ban on federal funding of syringes; that would aid harm-reductionists, who provide everything from the overdose reversal drug, naloxone, to clean needles to stem the spread of disease and critical connections to care.

Such front-line heroes fighting the overdose crisis understand that you can’t recover if you’re dead.