Congress Deleted Doctors' Paperwork Excuse for Treating Addiction. Most Kept the Stigma Anyway.

The drink cart rolled by. The flight attendant asked if he’d like a bloody mary. “Hmm. Sure,” Hunter Biden said — and that was the end of another stretch of sobriety, one relapse among many in a life he has now spent seven years rebuilding. He told NPR what came after: “You’re ashamed that you somehow failed because you’ve just relapsed. You don’t want to get honest with yourself about it.” He also told them the thing that damaged him worst wasn’t the crack cocaine the tabloids fixated on. “The most dangerous thing, however, that I ever ingested in terms of what it did to my physical body and my mental state, completely obliterating any judgment in me, was alcohol.”

Biden got a private plane, a father who took his calls, a ghostwriter, and access to some of the most expensive treatment real estate in the country. Here is the sentence that matters more than any of that:

A doctor who would never let a patient walk out untreated for high cholesterol will, every single day, let a patient walk out untreated for a substance use disorder — and call it a judgment call, not malpractice.

Most people relapsing in an airplane bathroom, an ER bed, or their own kitchen get none of what Hunter Biden got. What they get, according to an NPR investigation published August 6, is a doctor, nurse, or physician assistant who won’t offer them medication for addiction at all — not because the medicine doesn’t work, and not, anymore, because the law forbids it. NPR interviewed more than a dozen doctors, scientists, federal officials, and activists and found a healthcare system that treats every other chronic disease with medication and mostly declines to treat this one.

The stigma has a name, and doctors will say it to your face

Alcohol and street drugs kill more than 250,000 Americans a year, according to the federal data NPR cites. In 2025, more than 80% of people who met criteria for a substance use disorder received no treatment for it. Not inadequate treatment — none.

“There are too few physicians that are treating substance use disorder and too few patients that kind of receive that evidence-based treatment,” Dr. Bobby Mukkamala of the American Medical Association told NPR. “Evidence-based treatment” here has a specific, boring, unglamorous meaning: buprenorphine, methadone, and naltrexone — three FDA-approved medications, none of them experimental, all of them older than most residents currently in training — that treat opioid use disorder the same functional way insulin treats diabetes. They reduce craving and withdrawal so a person’s brain and body stop being in a 24-hour emergency, which is what makes it possible to hold a job, show up for a kid, or simply stay alive long enough to keep working on the rest of it.

Robert DeForde of the advocacy group Shatterproof named the actual obstacle without softening it: “Persistent stigma, right? They don’t want these people around them. They don’t think that the drugs that we have that are FDA-approved medications are really going to actually help the patient. That is what I would say is a fatal flaw in our system.” Not a funding gap. Not a workforce shortage, though that’s real too. A belief, held by trained clinicians, that the medicine doesn’t work and the patient doesn’t deserve the office visit.

Dr. Judy Chertok, an addiction researcher and clinician at the University of Pennsylvania, sees the size of what’s being left on the table: “I do think the impact would be transformative. We have tremendous opportunities to intervene.” Transformative and untapped are doing a lot of work in that sentence. It means the tools already exist. It means the failure is not technical.

Congress erased the paperwork excuse in 2023. Prescribing barely moved.

For most of the last quarter century, American medicine’s excuse for this was, at least, a legal one. Any doctor could prescribe an opioid painkiller with a standard DEA registration. To prescribe buprenorphine — the medication that treats opioid addiction — a doctor needed a separate federal permission slip called the X-waiver, which required extra training, a special application, and a cap on how many patients they could treat. It was, structurally, harder to get licensed to treat opioid addiction than to cause it.

Any doctor could prescribe an opioid painkiller with a standard DEA registration.

That barrier is gone. The Mainstreaming Addiction Treatment (MAT) Act, signed into law December 29, 2022 as part of that year’s federal spending bill, eliminated the X-waiver entirely. Any practitioner with a standard DEA registration covering Schedule III drugs can now prescribe buprenorphine for opioid use disorder, no special waiver, no patient cap. STAT News called it, correctly, a genuinely big deal — the kind of policy win addiction medicine had wanted for two decades.

If you’re the prescriber reading this: the only federal requirement left standing is the one from the MAT Act’s companion law, the MATE Act — eight hours of substance-use-disorder training, satisfiable through an asynchronous online course most state boards already accept, required once at DEA registration or renewal. That is shorter than a single on-call shift. It is also, for a lot of practices, the entire remaining distance between “we don’t do that here” and writing the prescription for the next patient who asks.

It is worth sitting with how old this pattern is. Methadone, the first medication ever proven to treat opioid addiction, was boxed into a separate regulatory universe starting in the early 1970s — dispensed only through federally licensed “opioid treatment programs,” a category of clinic that exists nowhere else in American medicine, for no other disease. The message embedded in that architecture was that addiction medicine was too dangerous, or too morally fraught, to be trusted to ordinary doctors’ offices. Fifty years later, Congress finally took down one version of that fence for buprenorphine. The NPR investigation is what happens next: the fence is down, and most doctors haven’t walked through the gate. The barrier, it turns out, was never really the form. The form was just where the stigma had been hiding.

Arizona is what a stigma-shaped system produces at scale

If you want to see what an undertreated crisis looks like when you let it run for a few years, look at Arizona. The state just hit an all-time high of 43.5 overdose deaths per 100,000 residents and is now, according to a report covered by AZFamily, the only state in the country with drug deaths above its post-pandemic peak — surpassing even West Virginia’s former worst-in-the-nation rate. National overdose deaths have been falling since 2023. Arizona’s haven’t, and a system where fewer than 1 in 20 people with opioid use disorder ever get offered medication for it is a big part of why.

None of this is happening because the science on opioid use disorder is unsettled. A federal study of 137,000 Medicare beneficiaries who survived a nonfatal overdose found that methadone lowered the odds of a subsequent fatal overdose by 58%, and buprenorphine by 52% — cutting the risk of dying roughly in half, from two medications most doctors are now legally free to prescribe from any exam room in the country. If a cardiologist withheld a medication proven to cut a patient’s heart attack risk in half because they personally found the patient’s lifestyle distasteful, that cardiologist would not have a license by Friday. In addiction medicine, that withholding happens quietly, every day, and is called clinical discretion.

Medical school never taught them this was medicine

Part of why the stigma outlived the paperwork is that most doctors were never trained to see it any other way. NPR’s reporting found that most U.S. medical and nursing schools still don’t teach addiction care as a normalized, core part of practice — it’s an elective, a single lecture, a rotation students can skip, in a curriculum that gives cardiology and endocrinology entire semesters. A doctor who has never been taught to think of craving and withdrawal as a treatable brain state, rather than a character problem, walks into residency with exactly the instinct Robert DeForde described: this isn’t really my department, and honestly, I’m not sure it works.

Part of why the stigma outlived the paperwork is that most doctors were never trained to see it any other way.

That instinct isn’t just outdated — it’s specifically wrong about what craving is. Researchers publishing in Nature Mental Health this year found that craving doesn’t just make people want a substance more; it measurably changes how their brains process decisions in the moment, with different substances warping that decision-making in different directions. In plain terms: the thing your doctor may be reading as a lack of willpower is a brain running a different set of rules than it does when the craving isn’t active. You don’t out-willpower a rule change. You treat the state that’s producing it — which is precisely what buprenorphine, methadone, and naltrexone are designed to do.

What this means if you’re the one in the chair

If you have ever sat across a desk from a doctor and watched their face shift the moment you said “opioids” or “meth” or “how much I’ve been drinking,” none of this will surprise you. You already know the visit changes. The questions get shorter. The eye contact gets harder to hold. You leave with a pamphlet, maybe a referral to call a number that goes to voicemail, and nothing that touches the actual chemistry of what’s happening in your body at 3 a.m.

Here is what’s true tonight, regardless of what that doctor did or didn’t offer you: naloxone is available over the counter, in all 50 states, at your pharmacy counter, no prescription and no permission needed, and it can reverse an opioid overdose in the moment it’s happening. And the next time a doctor tells you they can’t prescribe buprenorphine, that is, as of 2023, not a legal fact — it is a choice. You are allowed to ask why, allowed to ask for a referral to someone who will say yes, and allowed to walk into Rize’s find-help tool and keep looking until someone does.

Hunter Biden’s message to people still in it was simple: “You are not alone.” He’s right, and it costs him nothing to say it — he had a family with the resources to keep proving it true. The rest of the system’s job is to make that sentence true for the person who doesn’t have a senator for a father: to build a healthcare system where the medicine proven to cut your risk of dying in half isn’t something you have to get lucky to receive. Congress already took down its half of the fence. Medicine is still deciding whether to walk through it.