As I asked around, however, it was easy to find people who disagreed with anything that resembled a mandate. Representative Paul Tonko of New York, though he lamented to me the slow adoption of buprenorphine, nonetheless suggested that a directive pushing hospitals and doctors to provide the opioid risked sparking a backlash. A much sounder approach, in his view, would be to remove the remaining barriers to the medicine’s full rollout. The D.E.A.’s monitoring of the drug has a chilling effect, he argued, making even pharmacies reluctant to stock too much of it, because they don’t want to attract the agency’s attention. To reduce this “fear factor,” Tonko recently was a sponsor of a bill that would temporarily exempt buprenorphine from the D.E.A.’s oversight.
Then, in November, with the election of Donald Trump and the Republicans’ return to power in Congress, the question of how best to respond to opioid-use disorder was confronted with new uncertainty. For the past decade, the push to expand access to treatment for opioid addiction has enjoyed bipartisan support. But during his campaign, Trump outlined a draconian vision to address the opioid problem, threatening drug dealers and smugglers with the death penalty and promising to “seal” the border. On Feb. 1, he signed an executive order to levy tariffs against China, Mexico and Canada, in part to pressure these countries to halt the flow of fentanyl into the United States. (Soon after, he gave 30-day reprieves to Canada and Mexico.)
Keith Humphreys, a professor of psychiatry and behavioral sciences at Stanford who studies the opioid crisis, says the idea that beefed-up border control could halt or greatly curtail the flow of fentanyl into the country is simply misguided. Fentanyl is so concentrated that the amount needed to supply the entire country’s demand for a year is at most 10 metric tons, he estimates. Law enforcement has to find those 10 tons — the weight of few cars — among the more than seven million trucks carrying goods that cross the border annually. To meaningfully impede the flow of fentanyl, he thinks, you would have to completely close the border, at which point the country would inflict massive economic harm on itself. And even with the border shut, drones, planes and tunnels can easily continue supplying the market. A birthday-card-size letter mailed from abroad could carry a week’s supply of the opioid for someone. “You can’t really keep fentanyl out of such a big country,” he says.
Trump’s expressed desire to slash government spending also worries proponents of medication-for-addiction treatment. Some Republicans are actively seeking ways to cut Medicaid, along with other federal programs. Trump may also try to undo or simply undermine the Affordable Care Act, a favorite target. Either development could be disastrous for the distribution of medication to treat opioid addiction, reversing the gains, however tenuous, made under the Biden administration. Medicaid covers an estimated 40 percent of non-elderly adults with opioid-use disorder in the United States, some two-thirds of whom receive treatment for their addiction through the program.
It’s also possible, however, that Trump will expand the public-health approach he embraced during his first term, which was furthered by the Biden administration, and continue to encourage efforts to roll out M.A.T. Trump signed a law during his first term that removed some requirements for doctors who wanted to prescribe buprenorphine, notes Kassandra Frederique, the executive director of Drug Policy Alliance, a nonprofit that advocates for less-punitive drug policy. And uniquely among Republican presidents, Trump supported the use of some harm-reduction practices like making clean syringes available, according to his first-term surgeon general. Frederique told me she hopes that the current administration will continue to build on the work Trump and others have done to expand access to treatment.
What’s important to remember is just how much evidence exists indicating that buprenorphine can help people with opioid addiction. Sarah Wakeman often points this out as she pushes back against what she sees as a pervasive sense of pessimism around the opioid crisis. The problem is that this medicine isn’t getting to the people who need it quickly enough. “Most people think this is a terribly recalcitrant, untreatable, insurmountable problem,” she says. “That couldn’t be further from the truth.”
