The U.S. is experiencing its deadliest drug crisis ever, and there’s no end in sight. And even as nearly 108,000 Americans die of drug overdose every 12 months, the federal government hasn’t changed much about its approach to drug use and addiction.
With Republicans and Democrats each set to control one chamber of Congress, most advocates aren’t expecting Capitol Hill to suddenly step in.
But some drug policy groups and major medical associations haven’t given up. Instead, they’ve continued to call for major overhauls — including several that the Biden administration, and potentially individual states, could pursue without help from Congress.
Almost any change to U.S. drug policy is prone to controversy, however, and these are no exception.
Below, STAT lays out the three debates likely to dominate the drug policy and addiction medicine landscape in 2023.
In the fight against drug deaths, there’s no tool more effective than methadone. Patients taking the medication are 59% less likely to die of an opioid overdose.
But methadone itself is a powerful opioid sometimes used to treat pain, and current regulations can make the medication extremely difficult to access. Currently, it’s only available at certified opioid treatment programs, or OTPs, that require patients to participate in frequent counseling and drug testing, and in some cases to show up in person every day to receive a single dose.
Many addiction doctors want to dramatically deregulate the drug, allowing physicians to prescribe it directly to patients who can pick it up at a pharmacy.
Sen. Ed Markey (D-Mass.) has taken up the cause, and the American Society of Addiction Medicine has also called for doctors to be allowed to prescribe methadone directly.
The American Association for the Treatment of Opioid Dependence, which lobbies on behalf of methadone clinics, has called the proposal wrongheaded. Despite low rates of methadone overdose, they warn that increasing access to methadone could exacerbate the opioid crisis, and cite statistics showing that patients taking methadone are more likely to stay in treatment when they receive the medication through an OTP.
While Congress seems unlikely to change methadone regulations, one recent report from George Washington University argues that the Biden administration could act of its own accord. It’s not clear whether the White House shares that opinion — but with over 80,000 opioid overdose deaths occurring each year, it’s a sure bet that methadone will be among the most contentious addiction debates of 2023.
There’s perhaps no drug policy proposal more controversial than supervised injection — the practice of allowing people who use drugs to do so under medical supervision. While some studies show that the sites are helpful in reducing drug overdose deaths, only a handful are currently operating in foreign countries.
There are only two supervised injection sites currently operating in the U.S., both operated in New York by the same nonprofit. But a separate organization seeking to open a site in Philadelphia is embroiled in a years-long legal battle with the federal government that has sweeping implications.
Currently, supervised injection sites are considered illegal, thanks to the so-called “crack house statute” of 1986, which outlaws any space maintained for the express purpose of facilitating drug use. The Trump administration used that law in the 2019 suit that has kept Safehouse, the nonprofit, from opening its proposed site in Philadelphia. (One of the bill’s co-sponsors, incidentally, was Joe Biden, then a third-term senator representing Delaware.)
It’s not clear, however, whether the current White House shares the view of the Trump-era Department of Justice. The current administration faces a deadline of Jan. 9 to respond to Safehouse and, in effect, decide whether to continue enforcing the ban on supervised injection sites.
It’s also unclear whether other states will attempt to open supervised injection sites, and whether the federal government would turn a blind eye, as it has in New York. California’s legislature, for instance, passed a bill in 2022 that would have allowed several pilot sites to open. Gov. Gavin Newsom, a Democrat, vetoed the proposal, citing potential “unintended consequences.”
Regardless of what happens in Philadelphia, the debate is far from over. Harm-reduction advocates, lawmakers, and even a small group of public health officials will certainly push to make 2023 the year supervised injection becomes a widely used overdose-prevention tactic.
In a way, addiction doctors’ lives became easier during the Covid-19 pandemic. As part of the broader public health emergency, the federal government extended unprecedented flexibilities for prescribers and patients — in particular with respect to telehealth.
For the first time, doctors could prescribe buprenorphine, a common medication for opioid addiction, without an in-person visit. It also became easier to give patients weeks’ worth of take-home methadone doses.
The changes have been broadly popular among doctors, advocacy groups, and patients. The federal government recently moved to make them permanent.
But some concerns, like quality of care or patient privacy, still remain. In all likelihood, the regulations are only half the battle — whether the health care system will continue to embrace them is another question altogether.
As the country’s post-Covid recovery continues, it’s unclear whether doctors will keep using the telehealth flexibilities; whether insurers will keep reimbursing for telehealth services; and whether pharmacies will keep filling prescriptions written in the absence of an in-person visit.
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