ON A sweltering morning, a motley crowd queues at the BAART Beverly clinic near downtown Los Angeles to receive methadone treatment for their heroin and prescription-opioid addictions. An older Latino man in a car-dealership uniform checks his Apple watch while a clinic worker measures his dose of pink liquid methadone into a plastic cup. He gulps the medicine down as one might take a tequila shot. As she leaves the clinic, a thin blue-haired woman wearing a sailor’s cap gushes to another patient about how taking methadone has allowed her to kick her heroin habit and save money. “I have a cellphone now. Do you have a cellphone?”

An increase in overdoses from prescription and illicit opioids, such as heroin and fentanyl, means that deaths caused by drugs exceed those from car accidents and firearms. Methadone, buprenorphine and naltrexone are the three medicines that are approved by the Food and Drug Administration (FDA) to treat opioid addiction. First synthesised in Germany and introduced after the second world war to treat pain, methadone was widely used in America after the Vietnam war, to treat soldiers who returned home addicted to heroin. Methadone is doled out in daily doses. Patients who consistently show up for daily treatment, attend counselling sessions and test negative for drug use are sometimes given larger doses of the medicine to take home.

Unlike methadone, which is dispensed in specialised clinics, any doctor with authorisation to do so can distribute buprenorphine. Whereas fewer studies have been conducted on naltrexone, experiments have proved buprenorphine and methadone to be effective at reducing hospital visits, curbing criminal behaviour and lowering mortality. A study by a Harvard Medical School doctor, published in 2015, showed that three-and-a-half years after treatment, only 10% of patients treated with buprenorphine met diagnostic criteria for opioid dependency.

Yet, even as the opioids kill someone nearly every 15 minutes, the share of opioid and heroin addicts who receive medical treatments remains small. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), among those admitted and discharged for opioid-use disorders in 2015, only 35% of people received medication as part of their treatment. This represents an increase on the years from 2011 to 2015, when only 23% received medication. But it still means the majority of opioid and heroin addicts are not receiving treatments that have been proved effective.

Several things account for this. One is money. Without insurance, the medicines used to manage opioid addiction can be expensive. A year’s course of buprenorphine can run to about $4,000-5,000, according to BupPractice.com, an educational website funded by the National Institute on Drug Abuse. Methadone generally costs between $2,600 and $5,200 a year.

For those on Medicaid, the cost burden is lower. At the BAART clinic, both methadone and counselling are fully covered by Medi-Cal, California’s Medicaid scheme. According to a June report from the Urban Institute, a think-tank, Medicaid spending on buprenorphine, naltrexone and naloxone, an opioid-blocker commonly used to reverse overdoses, increased by 136% between 2010 and 2016, but demand for such medicines still outstrips supply, says Lisa Clemans-Cope, one of the study’s authors. A recent report from Blue Cross Blue Shield, a private insurer, showed that whereas diagnoses of opioid-use disorders nearly quintupled between 2011 and 2016, medical treatment grew by only 65% in the same period. This is unfortunate: a paper published in 2015 in the Journal of Substance Abuse Treatment suggests that treating people with methadone and buprenorphine results in $153-223 less spending on health care per month than treating addicts without these medicines does. Addicts are less than half as likely to relapse when treated with methadone or buprenorphine than if they receive treatment without medication.

Another barrier is regulation. Doctors must apply and take an eight-hour training course to administer buprenorphine. That may not serve as much of a deterrent in itself, but even after fulfilling such requirements doctors are limited to 30, 100 or 275 buprenorphine prescriptions per month depending on their experience level. “It makes no sense,” says Molly Rutherford, a family doctor and addiction specialist in Crestwood, Kentucky. “I can write 1,000 prescriptions a day for Percocet and oxycodone [two widely abused opioid painkillers] if I want, but I can’t treat more than 275 patients a month for opioid addiction.”

Studies on the behaviour of doctors allowed to prescribe buprenorphine suggest other factors may be even more powerful deterrents than bureaucracy. Bradley Stein, a researcher at the RAND Corporation, recently found that even those doctors cleared to prescribe buprenorphine often seem reluctant to do so. One reason is that the drug is supposed to be combined with psychotherapy. In places where psychotherapy services are not readily available, doctors may be wary of prescribing it. Doctors may also think that their patients do not want to come into the waiting room and sit next to someone with an opioid-use disorder, says Mr Stein.

Swapping addictions

Such fears may not be misplaced. Up the block from the BAART clinic, the patron of a Mexican bodega complains that the clinic’s patients take up the whole pavement when they are waiting for treatment, making it hard for children to get to the elementary school round the corner. Once, she says angrily, a patient used her shop to sell their dose of methadone to someone else.

Given that the opioid epidemic sprang from abuse of prescription medicines, concern about abuse of medication for addicts is warranted. Buprenorphine and methadone are opioids themselves. The drugs limit cravings and withdrawal symptoms associated with opioid addiction (heroin addicts, by contrast, require ever-greater doses of the drug). But they are addictive. Naltrexone, by contrast, is an opioid antagonist, or blocker. Some addicts continue treatment for years or even decades. Methadone clinics are often referred to as “maintenance” facilities. Isaac (not his real name) has attended the BAART clinic for ten years to keep his old heroin habit at bay. He has a seven-year-old daughter now, and doesn’t want to risk relapsing.

Critics complain that when addicts give up heroin or prescription painkillers for methadone or buprenorphine they are just trading one addiction for another. But that is, in a way, the point. These drugs are still considerably safer than illicit opioids such as heroin and fentanyl, an increasingly common synthetic opioid that is 50 times as strong as heroin and sold mixed with it, or in pills that look like painkillers. The choice on offer here may not be between addiction and no addiction, so much as between addiction that proves fatal and addiction that does not. Even if they never get off the medication, people who take methadone or buprenorphine can hold down jobs and be decent parents.

Yet rather than increasing the use of such treatments, the health-care legislation before Congress would probably curb medical treatment for opioid addiction. A study published in April by researchers at the University of Kentucky found that the introduction of the Affordable Care Act, more widely known as Obamacare, and the accompanying expansion of Medicaid was associated with a 70% increase in buprenorphine prescriptions covered by Medicaid. One estimate suggests that the law resulted in coverage for an extra 220,000 addicts. The Republican health-care proposals promise to greatly reduce funding for Medicaid. After Republican senators from states that have been especially hard-hit by the opioid epidemic, such as Ohio and West Virginia, expressed concerns about such cuts, the authors of the Senate bill agreed to add $45bn for states to spend on treating opioid addiction over the next decade. But a calculation by Richard Frank, an economist at Harvard Medical School, suggests the amount needed is at least four times that.