What to Know About Buprenorphine, Which Could Help Fight Opioid Crisis?

When President Trump announced plans to impose tariffs on Mexico and Canada, one of his stated rationales was to force those countries to curb the flow of fentanyl into the United States. In fiscal year 2024, United States Customs and Border Protection seized nearly 22,000 pounds of pills, powders and other products containing fentanyl, down from 27,000 pounds in the previous fiscal year. More than 105,000 people died from overdoses, three-quarters of them from fentanyl and other opioids, in 2023. It doesn’t take much illicit fentanyl — said to be about 50 times as powerful as heroin and 100 times as powerful as morphine — to cause a fatal overdose.

In my article for the magazine, I note that one of the many tragedies of the opioid epidemic is that a proven treatment for opioid addiction, a drug called buprenorphine, has been available in the United States for more than two decades yet has been drastically underprescribed. Tens of thousands of lives might have been saved if it had been more widely used earlier. In his actions and rhetoric, Trump seems to emphasize the reduction of supply as the answer to the fentanyl crisis. But Mexico’s president, Claudia Sheinbaum, has pointed to American demand as a driver of the problem. Indeed, if enough opioid users in the United States ended up receiving buprenorphine and other effective medication-based treatments, perhaps that demand for illicit opioids like fentanyl could be reduced.

Comparing buprenorphine and abstinence-based treatments for opioid-use disorder.

A wealth of evidence suggests that a medication-based approach using buprenorphine — itself a type of opioid — is much more effective at preventing overdose deaths than abstinence-based approaches. (Methadone, a slightly more powerful opioid, is also effective as treatment.) That greater success stems in part from the fact that by engaging the same receptors stimulated by fentanyl and other illicit opioids, buprenorphine (and methadone) can greatly blunt cravings and withdrawal symptoms. Several studies indicate that people exiting abstinence-based programs actually face a greater danger of overdosing than they did when chronically using illicit opioids. After abstaining for a long period, former users lose their tolerance to opioids; doses that were previously fine can become deadly. This is one reason many addiction experts think that a medication like buprenorphine is more effective as a treatment for opioid-use disorder than stopping cold turkey. It greatly reduces the cravings and misery that could provoke a relapse.

Where buprenorphine has reduced deaths.

Although the United States government partly funded buprenorphine’s development as a treatment for opioid addiction, France was one of the first countries to most fully exploit its potential. In the 1990s, French health authorities began allowing all doctors to prescribe buprenorphine. By the early 2000s, overdose deaths there from heroin and other opioids had declined by nearly 80 percent. Other European countries, like Switzerland, that have made medication to treat opioid-use disorder easily accessible also have much lower overdose death rates than those seen in the United States.

Why fentanyl has been so hard to control in the United States.

Meaningfully impeding the flow of fentanyl into a country as vast as the United States is difficult. Very small amounts are needed to supply the entire American demand — only 10 metric tons, by one estimate. And those 10 metric tons, equal to the weight of just a few cars, have to be found among the more than seven million trucks that cross the southern border every year.

How fentanyl flooded into the illicit opioid market in the United States.

Unlike heroin, which is derived from the opium poppy, fentanyl is entirely synthesized in labs. With no agriculture required, its production does not depend on land, sun, water, fertilizer or extensive labor; the right chemicals, a competent chemist and a lab are all that’s needed. Fentanyl producers — like those who make methamphetamines, the sedative xylazine, the stimulant captagon and other concoctions from what has been called the “synthetic drug revolution” — are thus much less vulnerable to the types of law-enforcement efforts directed against, for example, coca growers in South America. And they can bounce back from setbacks much more quickly: When a drug shipment is seized, they don’t have to wait for a new crop to grow; if they have the precursor chemicals, they can immediately fabricate more drugs.