Washington, D.C. has the second-highest opioid overdose death rate in the country, behind only West Virginia. Its pharmacies have on the shelves one of the most effective treatments for the condition killing its residents. Buprenorphine has been approved, safe, and stocked for decades.

Across the 50 states and the nation’s capital, the hardest-hit places tend to dispense the most buprenorphine, a medication that binds to opioid receptors in the brain to alleviate withdrawal symptoms while avoiding the dangerous effects of heroin, fentanyl, and other opioids.

Washington, D.C. breaks the pattern. 

It dispenses the drug to patients at a rate far below what the city’s overdose burden would predict, a clear statistical outlier, even though the medication reaches its pharmacies at ordinary rates. 

In other words, the medication to treat opioid disorder seems to be there, but it is not reaching people.

Stronger public health messaging to dismantle the stigma against people with opioid use disorder throughout the District’s communities can help bring buprenorphine and supportive services directly to the places they’re needed.

We spent a year trying to figure out why by pairing an analysis of state dispensing data with 19 interviews of the people who work on the problem: physicians and nurses, a pharmacist, a peer recovery coach, harm-reduction staff, lawyers, and policy experts. 

Our research helps unpack conspicuous gaps in understanding what’s amiss. For example, the 2023 removal of the federal X-waiver required to prescribe opioid medication barely improved uptake because the barrier was never really the paperwork. 

Instead, we found that the distance between the shelf and patients is made of two things: the structural barriers that sit between people and care (including services and commodities), and the social stigma that reaches them first.

The Distance Is Structural

The gap is not evenly spread. In 2019, the opioid death rate among Black residents of the District was 11.3 times that of white residents, the widest disparity of any jurisdiction in the country. 

Deaths cluster east of the Anacostia River, in Wards 7 and 8; the city’s behavioral health clinics, shelters, and community support organizations, on the other hand, cluster to the west. Wards 7 and 8 share three grocery stores between them; Ward 3 alone has sixteen. Only one of the District’s seven full-service hospitals is east of the river. 

“Everything costs money,” a harm-reduction worker told us. “Waterfront has a tax base that can afford this team. Ward 8 doesn’t. We need to subsidize the wards that need it most.”

For people the system never sees, care has to travel. 

Beneath the map are the ordinary barriers that keep treatment from reaching those who need it. 

“Housing has to come first,” one worker said. Seeking, initiating, and completing treatment is “much harder when you have to sleep on the ground.” 

Transportation is the second, and even more prohibitive for taking an opioid medication like methadone that requires daily clinic visits. Moreover, when federal funding for rides was cut, some patients were stranded.

The District also carries one barrier no state does. Since it does not have a state legislature, the city must submit its budget to Congress to approve — even down to how it spends the taxes it raises itself. Federal legislators often even attach riders that dictate or forbid narrow spending measures. 

For nearly a decade, one such rider barred the District from using its own local dollars on syringe safety programs, a restriction no state faced. 

Similarly, when federal priorities swung from harm reduction toward abstinence, a District organization reported that its programs collapsed: supplies rationed, low-barrier access to buprenorphine curtailed, drop-in centers closed. 

None of that was a change in the medicine. It was a change in the political weather, and in the District the weather is federal.

Trading One Myth for Another

The barriers are not only material. Long before patients reach a pharmacy counter, cultural stigma touches them. Public bias reflected in internalized blame effectively buries their struggles in silence, which precludes every other step. 

A nurse practitioner described a patient who stopped her mid-sentence. “Why do you keep talking to me like that?” he said. She asked what he meant. “You’re talking to me all nice, and I can’t trust when people talk to me like that.”

That distrust is learned, and it is reinforced by a durable myth: that medication for addiction is just “substituting one high for another.” It is not. For a patient with a physiological opioid dependency, buprenorphine restores a state of normalcy, not euphoria. A patient stabilized on it is not high but healthy and safe. 

Stigma written into law does not deter use. It deters disclosure.

Stronger public health messaging to dismantle the stigma against people with opioid use disorder throughout the District’s communities can help bring buprenorphine and supportive services directly to the places they’re needed, rather than behind closed doors. It can make a world of difference when patients are met with compassion and conversation in their everyday lives, not just at the clinic. 

These cultural dynamics are accentuated during pregnancy. Becoming pregnant is, for many women on the margins, the strongest reason they have ever had to seek care. It is also, in 22 states and Washington, D.C., grounds for a child-welfare report, even when the opioid in question is buprenorphine. The same event that could pull a woman into treatment can cost her a child, so it teaches her to stay hidden. 

An obstetrician described the intergenerational effects of separation: “a traumatized parent, a child who’s lost their connection with their parent […] Early life disruption is an adverse childhood experience…and there’s a dose response for addiction.” 

Stigma written into law does not deter use. It deters disclosure.

What Actually Reaches People

“The opposite of addiction is not sobriety, it’s connection,” an epidemiologist told us. “What works is helping people reconnect to the people and the things that they love.” We found that connection was not a soft addition to treatment but rather the heart of OUD treatment. Connection includes both strengthened links between patients and their communities and streamlined links from crisis to care.  

Asked what works, the people we interviewed converged on a single principle: shorten the distance. The cleanest version is the medical home, a primary care model where the separate pieces of care sit in one place. 

An addiction physician described what changed when the pharmacy in his building started stocking the medication his patients needed. “Now patients don’t have to go someplace else after they see you,” he said. “The more we can consolidate services, the better.” 

For people the system never sees, care has to travel. 

Much of that service consolidation is within the District’s reach right now. The people we interviewed pointed to concrete, fundable steps.

Case managers and care navigators who book the next appointment and follow up, giving people a more tangible next step than a list of phone numbers. 

Peer recovery coaches who meet people the day they leave an emergency room or a jail cell. 

Transportation and housing support attached to treatment rather than treated as separate problems. 

Clinics that stock the medication and put the prescriber, the pharmacy, and a counselor under one roof. 

And established networks between hospitals and clinics facilitate the handoff to longer-term care, along with an interim buprenorphine prescription. 

None of these steps require an act of Congress. They require money spent on the connective tissue of addiction treatment, which is exactly what settlement dollars can buy.

Prevention, harm reduction, and long-term recovery each demand their own fight, and the settlement should fund all four buckets.

Other fixes would help but sit further from local hands, but it’s perhaps worth calling them out. One is paying providers fairly for the complex visits that opioid use disorder and its frequently co-occurring conditions demand. Models like Patient-Centered Opioid Addiction Treatment (P-COAT), which reimburses comprehensive care in a single bundled payment instead of piecemeal, have been projected to save money by preventing emergencies. 

Other strategies include enforcing the mental-health parity law already on the books and restoring the pandemic-era telehealth and Medicaid rules that briefly widened access. 

But these laws run through Congress, federal agencies, and insurers, the same machinery that, as we have seen, often turns on the District rather than for it. The lesson is not to wait for distracted politicians or cumbersome bureaucracies. It is to spend what the District controls on the parts of the problem it can actually reach.

This is not to suggest that DC can treat its way out of the crisis. Prevention, harm reduction, and long-term recovery each demand their own fight, and the settlement should fund all four buckets. 

But treatment is an area where the science is already settled and the medicine already made. The challenge there is delivery, not discovery, which makes it among the most solvable of the four areas. The pieces are already there; they just need to be connected.

The Last Few Feet

Increased spending doesn’t guarantee success. The District is set to receive a little over $100 million from opioid suppliers, distributors, and retailers. These funds are to be spent on prevention, harm reduction, treatment, and recovery, as part of an evidence-informed strategy. 

It is real money, but money is a mechanism, not a plan, and its first allocations went to outreach in Wards 5 and 6, not wards east of the river (Wards 7 and 8) hardest hit by the opioid crisis. 

Spent well, the settlement funds would go where the analysis points: to closing the distance between treatment availability and access. 

The medicine is already on the shelf. What the District still has to bridge, and can now afford to build, is the last few feet between the shelf and the person.