When Kyle Solsberg was injured in a car crash, his doctor prescribed a high dose of opioids for back pain, precipitating a decade-long struggle against addiction that cost him his job, health and nearly his life.
But unlike most Americans suffering from opioid use disorder, the former bank employee managed to access medication to treat his condition, which together with counselling helped him stop using illegal opioids.
“One of the biggest hurdles I faced was getting treatment initially. But I was fortunate and found a doctor who put me on a new injectable treatment,” said Solsberg, 35, from Kansas City.
“I’m at a place now where I never thought I would be,” he added.
Facing an overdose crisis that killed a record 107,000 people last year US authorities are planning to massively expand access to medications tackling opioid addiction such as methadone, buprenorphine and naltrexone.
It comes as pharmaceutical groups, distributors and drugstore chains finalise tens of billions of dollars in legal settlements linked to their roles in fuelling an epidemic of overprescription of painkillers.
But despite growing awareness of the problem, federal and state authorities face a battle to overcome a complex web of societal, legal and financial barriers that restrict access to medicines to between 5 to 15 per cent of the estimated 8mn Americans misusing opioids.
Initially fuelled by improper marketing of highly addictive legal painkillers by pharmaceutical companies and distributors, the US opioid epidemic has in recent years taken an even more deadly path. Almost two-thirds of overdose deaths last year were linked to fentanyl, a highly addictive and potent synthetic opioid that is sold illegally and has become a common contaminant in other street drugs.
The rising death toll is contributing to a decline in US life expectancy, which at 76 years is at its lowest level in a quarter of a century. It is also prompting US authorities to rethink their half century-long focus on law enforcement to tackle drug abuse and embrace previously taboo policies such as promoting medicines for addiction.
“More than 40mn Americans have a substance use disorder and only one out of 20 people can access care,” said Dr Rahul Gupta, the White House drug tsar who is leading the new approach.
“That is why President Biden has called for removing unnecessary regulatory regimes that prevent Americans from getting treatment and why he has set a goal for universal access to treatment by 2025.”
Research suggests the most effective treatments for opioid use disorder is medications that relieves withdrawal symptoms and drug cravings. As well as helping people quit and avoid relapses, one study found patients using medication were 80 per cent less likely to die of an overdose than those who did not.
But providing universal access to medications requires sweeping reforms to remove barriers at the patient, clinician and system level, according to health experts. Stigma, a lack of addiction treatment infrastructure and structural challenges in providing and financing treatment options all play a role in preventing people accessing the care they need.
“There is enormous stigma around the use of these [medication] drugs,” said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence.
Many opioid users only seek treatment as a last resort when they face being thrown out of their home or arrest. They see it as an admission of failure and worry that if their employer finds out they will lose their job or they won’t be able to access life or health insurance, Parrino said.
Doctors have also been slow to embrace medication for treating opioid use disorder, with many promoting abstinence instead.
“I would call it almost a Hollywood myth that the way to get off of an addiction to an opioid would be to kind of go to some retreat, do some meditation and go cold turkey,” said Allegra Schorr, president of the Coalition of Medication-Assisted Providers and Advocates.
Clinicians who do promote medication face tough rules aimed at preventing misdirection of the drugs. To prescribe buprenorphine, one of the most effective medications, they must apply for waivers that require them to undertake training. Methadone is typically administered in person at specialist opioid treatment centres, which are regulated by federal authorities including the Drug Enforcement Agency.
Experts say these rules and a lack of funding restrict access to medication, particularly in rural areas. In most states there are wait-lists to access medication and counselling, which increases the risk of relapse and overdoses.
“Walk-in care is really not available for . . . medications,” said Jeanmarie Perrone, professor of emergency medicine at the University of Pennsylvania Hospital. “People have to jump through hoops and potentially wait weeks for treatment while still using fentanyl that could kill them.”
Paying for treatment is another hurdle. About 26mn Americans or 8 per cent of the population do not have health insurance. And there are gaps in access for those on Medicaid, a joint state and federal insurance scheme that provides free or less expensive cover to low-income families.
Meanwhile, Medicare, the government-funded health programme for seniors, effectively excludes coverage for substance use disorder (SUD) treatment in “intensive outpatient, partial hospitalisation, speciality addiction outpatient clinics and residential addiction programmes, as well as by licensed professional counsellors”, concluded a report published in August by The Legal Action Center, a not-for-profit group.
The cost of adding SUD coverage to Medicare would be $1.9bn. But this is a fraction of the estimated $1.5tn cost to the economy in terms of healthcare and lost productivity because of the opioid epidemic in 2020, according to a report by the US Congress Joint Economic Committee.
Some of the more recently developed medications to treat opioid use disorder are less likely to be abused than methadone and are long acting, in that they only have to be taken once a month rather than daily.
Solsberg was prescribed a monthly injection of Sublocade, a form of buprenorphine developed by UK-listed company Indivior to help him recover. The drug reduces cravings and withdrawal symptoms without producing the type of euphoria that oxycodone or heroin does.
Christian Heidbreder, chief science officer at Indivior, said Sublocade removed the peaks and troughs of cravings experienced by patients using daily medications and was less susceptible to misuse because it is administered by a physician
“You protect your patients in a better way but at the same time you can prevent diversion and misuse,” he said.
The momentum for change is building. Last month the federal government announced $1.5bn to fund medication access. States and local government areas are also starting to receive some of the $26bn in funds extracted in settlements with Johnson & Johnson, Cardinal Health, McKesson, and AmerisourceBergen for their role in the opioids crisis. These funds are earmarked for use in programmes tackling opioid use disorder.
Gupta, the first medical doctor to hold the post of director of the Office of National Drug Control Policy, is proposing a swath of reforms to boost access to medication. These including greater use of telemedicine, removing legal barriers such as the waiver required by doctors to prescribe buprenorphine and educational efforts to challenge stigma.
For those who have battled addiction, such as Solsberg, boosting access to medication is an easy decision.
“From the moment I woke up until I went to be bed I used to be chasing [drugs],’ he said. “I’m happy to say I just got my 40th monthly injection . . . now I don’t think about it until the doctor calls me and schedules my appointment.”