The U.S. drug crisis is as bad as it’s ever been, and there are few signs things are getting better.
About 110,000 people died of drug overdoses in 2023, about the same as in previous years. Fentanyl, the powerful synthetic opioid that now dominates the illicit drug market, remained the main culprit. Xylazine, the veterinary sedative known as “tranq,” only became more common. And more and more Americans are using other drugs — namely methamphetamine and cocaine — alongside opioids.
Nonetheless, addiction medicine and drug policy hasn’t changed much in the past year. Despite strong rhetoric from President Biden and lawmakers on Capitol Hill about tackling the opioid epidemic, Washington didn’t pass any major reforms to the addiction treatment system. Not much changed at the local level, either, though money is finally flowing to communities from the multiple opioid settlements that were recently finalized between drug manufacturers, drug distributors, and pharmacies in the wake of overprescribing scandals in the early 2000s.
Still, change is happening — even if not all of it can be characterized as progress. Below, STAT breaks down the three addiction medicine stories to watch in 2024.
Will methadone access expand?
Arguably the biggest debate in addiction medicine is over methadone, a highly effective drug used to treat opioid addiction. Despite the medication’s impressive numbers when it comes to preventing overdose and death, it’s highly restricted — currently, patients seeking methadone treatment can get it only at a specialized clinic that typically requires them to show up in person each day for a single dose.
Methadone is tightly regulated in part because it is an opioid itself, and can cause overdose when misused or used in combination with other substances or medications.
But increasingly, patient advocates, addiction doctors, and even lawmakers and high-profile Biden administration officials have argued that intense methadone regulations are doing more harm than good.
Much of the current debate centers on the Modernizing Opioid Treatment Access Act, or MOTAA, a bill that would allow board-certified addiction doctors to prescribe methadone directly to patients. A Senate committee approved the legislation in mid-December, though it’s not likely to become law.
Still, the bill and shifting opinion on methadone has clearly concerned methadone clinics, which jointly launched a public relations blitz titled “Program, Not a Pill” meant to emphasize the other services they provide, like psychosocial counseling.
What to watch is whether the Biden administration will act of its own accord to make methadone more accessible. It’s also possible that more methadone clinics could take advantage of new Covid-era regulations and become more liberal with giving patients take-home doses.
Will there be a return to police-first drug policy?
As the drug overdose crisis has worsened, the U.S. has generally warmed to harm reduction, the philosophy of helping people who use drugs stay safe while acknowledging they may be unable to stop using altogether. Harm reduction services like needle exchange, fentanyl or xylazine test strips, or even supervised consumption — creating sanctioned spaces for drug use so that professionals could intervene in the event of an overdose — can help reduce rates of overdose, disease transmission, and death.
It’s possible, though, that Americans are losing their patience. Sen. Tom Cotton (R-Ark.) last year caused a firestorm when he accused the Department of Health and Human Services of providing federal funding to include sterile pipes — “crack pipes,” as he referred to them — within “safe smoking” kits, even though the Biden administration clarified it never planned to give away pipes and did not support federal funding for smoking implements. In recent years, state legislatures and local governments have moved to ban syringe exchange. The Biden administration hasn’t backed down from a lawsuit, initiated by the Trump administration, meant to prevent a Philadelphia nonprofit from operating a supervised consumption site. Democratic officials in California and Pennsylvania have also moved to oppose supervised consumption.
At the same time, the U.S. has seen a resurgence of advocacy for hardline, police-first tactics even in left-leaning cities that have historically argued their drug policy will favor compassion over punishment. In California, Gov. Gavin Newsom and San Francisco Mayor London Breed have stepped up drug-related arrests. In Oregon, polls show voters may soon reverse a 2022 measure that largely ended criminal penalties for low-level drug possession offenses. Meanwhile, former president and 2024 hopeful Donald Trump has advocated for executing drug dealers.
It’s hard to tell which direction drug policy will turn next year, and some communities are still working to expand harm-reduction offerings. But it’s clear at least some forms of harm reduction are facing significant resistance — and many of the communities hardest-hit by the overdose crisis are among those pivoting fastest to the police-based approach.
Will telehealth be given a role in recovery?
One of the biggest changes that Covid-19 brought to drug policy was an immediate, major expansion of access to addiction medicine via telehealth. In particular, the federal government in early 2020 made it far easier to access buprenorphine, another common medication used to treat opioid addiction. Addiction doctors celebrated the emergency measures as a win for access, and data collected since the changes largely shows that they helped people enter and remain in treatment without major unintended consequences.
As the pandemic wound down, however, the Drug Enforcement Administration moved to roll back some of those emergency measures. To many addiction doctors, the move represents a drastic rollback of access — all for the sake of preventing buprenorphine misuse, which they say is neither common nor dangerous.
After facing immense blowback from doctors, patient groups, telehealth companies, and Democratic lawmakers, the DEA formally delayed its final decision all the way until December 2024, meaning the Covid-era flexibilities remain in place for now.
But the agency and Congress will soon need to decide what the future of telehealth addiction medicine looks like long-term. One bill from a bipartisan group of senators would effectively preempt the DEA’s decision, allowing doctors to prescribe via telehealth on a permanent basis. Of course, it’s possible the DEA will reach the same decision on its own. Either way, until a decision is reached, numerous companies whose business model relies on telehealth buprenorphine — and more importantly, thousands of doctors who’ve prescribed and patients who’ve taken the medication without an in-person visit — remain in limbo.
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.