Safer Solutions: Why is it easier to get illegal drugs than medicine to treat addiction?

In America, it’s easier to get illegal opioids than to access proven medications to treat opioid addiction.

Nearly 8 million people in the United States misuse opioids in a given year. Illicit opioids can be purchased 24/7, rain or shine, via the internet or in person, and the seller will often come to the buyer. What’s in these drugs is unknown and inconsistent, with some containing enough fentanyl to cause a deadly overdose.

On the other hand, medications for opioid use disorder (MOUD) are harder to get. Although these medications offer better health and social outcomes than non-medication-assisted recovery pathways, only 17 percent of people with opioid use disorder (about 816,000) received them in 2024. The two most effective MOUD—buprenorphine and methadone—are hardest to get because of how each drug is regulated.

Our friends at Broken No More recently introduced us to two moms, Sara and Kathleen, who shared what it can look like when illicit drugs are available on demand while proven medications are difficult or impossible to access.

Buprenorphine: A medication too often out of reach

Sara describes her son Aiden as a passionate, creative young man with a quick mind; endless energy; and a love of reading, his siblings, and winning at anything competitive. When Aiden developed opioid addiction as a teenager, he worked hard at trying to get well. None of the treatment facilities he went to offered MOUD, even when he requested it. At the time, doctors had to jump through many regulatory hoops—including patient limits, additional mandatory training, and a special waiver from the Drug Enforcement Administration (DEA)—to be able to prescribe buprenorphine. These requirements created shortages that made finding a provider extremely challenging. When Aiden finally found a prescribing doctor, he faced a three-month wait for an appointment. He died of an overdose a month before that appointment. Three weeks later, in December 2022, President Joe Biden signed legislation removing the waiver requirement.

“Aiden spent a year and a half trying to dig himself out of the darkness,” Sara told us. “There was medication that he was begging for, and we just couldn’t get it. But it was very easy for him to get [fake] Percocet pills that had fentanyl in them.”

Barriers to buprenorphine persist:

• In 2023, fewer than 40 percent of U.S. pharmacies regularly dispensed buprenorphine.
• Patients without insurance may find the medication cost-prohibitive.
• Many pharmacies are hesitant to stock buprenorphine due to stigma around addiction or out of concern they might trigger a DEA investigation or run afoul of state regulations (some of which exceed federal requirements).

Methadone: Lifesaving treatment under lock and key

Kathleen describes her daughter Molly as resilient, bright, loving, compassionate, stubborn, and “genuinely LOL funny.” She told us it was “consistently easier” for Molly to access fentanyl and other illicit drugs than evidence-based medication. “Our systems make individualized, sustainable treatment so difficult for families to access and maintain,” she said.

Molly’s opioid misuse started after she was prescribed oxycontin following tooth surgery. For 20 years, Molly—like Aiden—worked hard at recovery. Of the 20 different rehabs she tried, none offered MOUD. She eventually started methadone treatment via a two-hour round-trip daily commute to an opioid treatment program (OTP).

Molly had to make that trip because methadone is subject to uniquely strict regulations in the United States, under which patients can only access it through an OTP. Some must appear in person up to six days a week to take their medication. Nationwide, the average commute to an OTP is 45 minutes each way. Some patients can “earn” take-home doses for a week or more, but they must return to the OTP for refills.

Molly did well while taking methadone and eventually earned take-home doses. Then the OTP called her for a random “bottle check,” a process in which patients have “mere hours” to get to the OTP to present their take-home bottles to prove they aren’t misusing their medication. Molly missed the call, and the clinic revoked her take-homes. This meant a return to daily trips to the OTP, located in an area where drugs were sold. That environment felt overwhelming and unsafe to Molly, so she switched to buprenorphine.

Kathleen explained that Molly was doing “fairly well” on buprenorphine until her father’s unexpected death, which was profoundly destabilizing. During that time, “the buprenorphine did not adequately suppress her cravings or block continued [drug] use.” Molly returned to using illicit opioids, ultimately living on the street for more than a year.

“This is a reality the public often does not understand,” Kathleen said. “While buprenorphine is lifesaving for many people, some individuals respond better to methadone. A one-medication approach does not fit everyone.” This is true for any health condition, as different medications work better for different patients at different times in their lives. Today, Kathleen proudly told us, Molly is doing well— but it has been a long road.

What needs to change?

In 2024, the deputy director of the National Institute on Drug Abuse decried MOUD access in the United States: “[P]eople are dying of a drug overdose … while safe and effective medicines to treat opioid use disorder are sitting on the shelf unused.”

R Street has argued that:

• Methadone should be prescribable outside of OTPs, with state regulations that facilitate better access.
• All treatment facilities should offer MOUD. (Fewer than 50 percent currently do so.)
• The DEA should clarify its policies so that its oversight doesn’t unduly flag pharmacists for dispensing buprenorphine.
• Medicaid and Medicare coverage should be comprehensive, provide transparent and sufficient reimbursement for MOUD, and streamline reporting requirements.

If the goal is to help people recover from addiction and lead healthy, stable lives, then it’s imperative that the best treatment options are more accessible than the illicit drugs themselves. Thoughtful policymaking and regulation should help us move toward this reality.

Note from the authors: There is no way to capture the full, vibrant, beautiful lives of the people profiled here in this limited space. They are so much more than the stories of how their lives have been impacted by opioid use disorder and the systems that prevent people from accessing treatment. We are grateful for the permission to share a small part of their stories here.