The fed­eral gov­ern­ment re­leased a re­port last week that came to a strik­ing con­clu­sion: More than 80 per­cent of the roughly 2 mil­lion peo­ple strug­gling with opi­oid ad­dic­tion in the United States are not be­ing treated with the med­i­ca­tions most likely to nudge them into re­mis­sion or pre­vent them from over­dos­ing. This de­nial of care is so per­va­sive and egre­gious, the re­port’s au­thors found, that it amounts to a se­ri­ous eth­i­cal breach on the part of both health care providers and the crim­i­nal jus­tice sys­tem.

The Food and Drug Ad­min­is­tra­tion has ap­proved three med­i­ca­tions to treat opi­oid-use dis­or­der — methadone, buprenor­phine and nal­trex­one. All of them work by bind­ing to the brain’s opi­ate re­cep­tors in a way that re­duces the crav­ings that peo­ple ad­dicted to drugs like OxyCon­tin and heroin ex­pe­ri­ence, but with­out caus­ing the same eu­phoric high as those drugs. Methadone and buprenor­phine have proved es­pe­cially ef­fec­tive. Pa­tients who take one of those med­i­ca­tions are half as likely to die from their ad­dic­tion; they are also more likely to stay in treat­ment, and they tend to have bet­ter long-term health out­comes.

Nei­ther drug is new or ex­per­i­men­tal — methadone was ap­proved to treat opi­oid ad­dic­tion in 1972 and buprenor­phine in 2002. Some coun­tries have shown that in­creas­ing ac­cess to them can sig­nif­i­cantly drive down the rate of over­dose deaths. In France, for ex­am­ple, poli­cies that en­abled more doc­tors to pre­scribe buprenor­phine helped lead to a ten­fold in­crease in the num­ber of peo­ple whose opi­oid use dis­or­der was be­ing treated and to a nearly 80 per­cent de­cline in over­dose deaths in just four years.

Yet, many drug courts and most res­i­den­tial treat­ment pro­grams in the United States pre­vent par­tic­i­pants from us­ing these med­i­ca­tions; and the re­ha­bil­i­ta­tion pro­grams that do of­fer them rarely of­fer all three op­tions. The treat­ments are not avail­able in most emer­gency rooms, as the Times has re­ported, even though stud­ies show that pa­tients given buprenor­phine in an ER are twice as likely to be in treat­ment a month later than those who are given an in­for­ma­tion pam­phlet. They are also not avail­able in most pris­ons, even though a sig­nif­i­cant por­tion of the fed­eral in­mate pop­u­la­tion suf­fers from opi­oid use dis­or­der. Opi­oid over­dose is a lead­ing cause of death among those who’ve been re­cently re­leased.

Part of the prob­lem is stigma and a pro­found lack of aware­ness. Methadone and buprenor­phine are opi­oids. They are weaker than drugs like OxyCon­tin, fen­tanyl and heroin that have fu­eled the cur­rent cri­sis, but many law en­force­ment and med­i­cal pro­fes­sion­als still see them as trad­ing one ad­dic­tion for an­other. Or they mis­tak­enly be­lieve that the med­i­ca­tions should be used only tem­po­rar­ily, to help wean pa­tients off stronger opi­oids. Or they see them as an op­tional com­ple­ment to be­hav­ioral in­ter­ven­tions in­stead of an es­sen­tial com­po­nent of opi­oid ad­dic­tion man­age­ment.

None of these per­cep­tions is sup­ported by the bal­ance of sci­en­tific ev­i­dence.
There’s also a lo­gis­ti­cal bar­rier to get­ting these drugs into the hands of peo­ple who need them. Doc­tors are al­lowed to give methadone only at spe­cial­ized clin­ics where pa­tients must re­port every day for their dose. Lines at such clin­ics are of­ten long, and ac­cord­ing to the fed­eral re­port, which came from the Na­tional Acad­e­mies of Sciences, En­gi­neer­ing and Medicine, Med­i­caid does not cover the treat­ment in at least 14 states.

Buprenor­phine is avail­able by pre­scrip­tion, but health care pro­fes­sion­als must ob­tain a spe­cial li­cense to write those pre­scrip­tions, a process that re­quires them to com­plete hours of ad­di­tional train­ing, grant the Drug En­force­ment Ad­min­is­tra­tion ac­cess to all of their pa­tient records and agree to strict lim­its on the num­ber of pa­tients they can treat with the med­i­ca­tion. In many states, would-be buprenor­phine pre­scribers also must sub­mit to strin­gent cri­te­ria for in­sur­ance re­im­burse­ment. These re­stric­tions also are not jus­ti­fied by sci­en­tific ev­i­dence. They are not em­ployed by other coun­tries, and they are not used to man­age the treat­ment of other chronic med­i­cal con­di­tions in the United States.

Pres­i­dent Don­ald Trump de­clared a pub­lic health emer­gency to re­spond to the opi­oid cri­sis in 2017, but so far that dec­la­ra­tion has led to very lit­tle mean­ing­ful ac­tion. Congress passed a suite of opi­oid bills in the fall, but that leg­is­la­tion con­tained al­most no fund­ing. And in most states, strate­gies that might truly mit­i­gate the dis­as­ter — from ev­i­dence-based ad­dic­tion treat­ments like methadone and buprenor­phine to proven harm-re­duc­tion ap­proaches like nee­dle ex­changes and safe in­jec­tion sites — re­main vastly un­der­uti­lized or out­right il­le­gal.

Pub­lic health fore­casts in­di­cate that the opi­oid over­dose epi­demic might claim an­other 500,000 lives in the next decade. Many of those deaths could be avoided — if ex­ist­ing tech­nolo­gies would just be put to use