Medical News

Few things in life are both cheaper and better, but for a long time, this was true of the chicken thigh. Its superiority was passed like a shibboleth among food connoisseurs: Thighs are juicier, tastier, are almost half the price—preferable in just about every way to the boneless, skinless, flavorless breasts that reign supreme in America.

Well, the secret’s out. On a recent trip to the grocery store, I picked up a pack of boneless thighs that cost, pound for pound, some 50 cents more than boneless breasts. In fact, the cost of thighs has crept steadily upward for years now, and surpassed that of breasts for much of last year. In recent months, breasts have gained in price again, but white meat’s continued dominance no longer seems assured. Home cooks have embraced the flavor and versatility of dark meat; fast-casual restaurants such as Chipotle and Sweetgreen have it all over their menus. After a decades-long run, America’s white-meat era may finally be ending.

That era began in the1980s, when the first plant dedicated to deboned breast meat opened in the United States. “Before that, deboned breast meat was very expensive and rare,” Paul Aho, a poultry-industry consultant, told me. Eating chicken used to mean getting whole chickens, skin and bones and all. But when processing plants started atomizing chicken into their parts, the popularity of boneless, skinless breasts exploded. Americans learned to love not only slabs of white meat but also nuggets, patties, and tenders—processed products made possible by the ubiquity of deboned breasts. In an era obsessed with low-fat, low-cholesterol diets, white meat was deemed the healthier option too. Demand for breasts drove the expansion of the entire American poultry industry, Aho said.

The billions of chickens being raised for breast meat of course also have billions of thighs, legs, wings, and organs, arguably by-products of breast production. U.S. producers learned to export minimally processed leg quarters—an entire thigh and leg with skin and bones—overseas, where consumers did not mind, or even preferred, dark meat. Russia was a major customer, then China, and then Mexico.

The boneless and skinless chicken thigh, however, did not exist as a widespread meat product in the United States until the 2000s. This is also partially a story of industrial innovation: Over time, the thigh-deboning process has become more automated, making boneless dark meat less labor-intensive to produce. The Baader 632 Thigh Filleting System, for example, boasts of processing 230 thighs a minute, by yanking the meat straight off the bone. Aho points out that automation tends to work better with thighs, which have only a single straight bone, than with breasts, which cling to multiple curved bones. Machines that debone breasts usually can’t get the muscle off as cleanly, leaving more meat behind.

With the rise of the boneless thigh, American chicken producers saw an opportunity to sell dark meat at home, at prices higher than intact thighs can get overseas. They started producing more deboned thighs. In 2019, the chicken producer Sanderson Farms told the Los Angeles Times that it would soon have thigh-deboning capacity at all seven of its plants for large birds, compared with just one or two a couple of years earlier.

If a fully intact thigh is unmistakably a thigh, the boneless, skinless version is more approachable for Americans raised on similarly processed breasts. Deboned thighs are just as easy to throw on a grill, put in a sandwich, shred, or chop into bite-size pieces for burritos. In fact, they’re easier to cook than breasts, because they’re less prone to drying out from being left in the pan for five minutes too long. Recipe developers optimizing for easy and quick can tout their “mass appeal.” “I certainly see a lot more praise of dark meat than there used to be,” J. Kenji López-Alt, the food writer and cookbook author, told me. (He personally prefers a perfectly cooked chicken breast, but said it’s hard to get right.)

Matt Busardo, who heads up North American poultry for the market-intelligence firm Expana, points to two other reasons for the popularity of thighs: the diversification of the American palate, thanks to the popularity of Asian and Latin American cuisines that prize dark meat, and the rise of fast-casual restaurants, which considered thighs a tastier, more forgiving, and until recently cheaper cut. Chicken breasts are still popular; their sales have been rising this whole time, too. But “thigh meat has kind of overshot that by leaps and bounds,” Busardo told me. Sales of chicken breast by volume are up 3.9 percent in the past three years, but sales of thighs are up 15.9 percent, according to the marketing-research firm Circana.

The historically single-minded focus on breeding chickens for white meat has, ironically, made it less appealing in some ways. Anecdotally, I’ve heard of shoppers put off by woody breast or spaghetti meat—muscle disorders that result from the breast growing too big too fast. Chicken breasts have nearly doubled in size since the 1950s, and these muscle irregularities became common enough to worry the industry about 20 years ago. Woody breast causes an unappetizing, almost crunchy texture; spaghetti meat comes out mushy and stringy. Tinkering with diets to slow growth or slaughtering birds at lower weights can mitigate woody breast, Casey Owens, a poultry scientist at the University of Arkansas, told me. But a small, slower-growing chicken is a less profitable chicken. Owens has also studied how to make woody breasts more palatable through extra processing. When ground up into patties, she said, the extra connective tissue found in woody breasts makes for a less dense, maybe even preferable, texture.  

If the demand for dark meat continues to rise, chickens selected for their big breasts may no longer be economically optimal. Could the industry start breeding birds with bigger thighs? “I’ve actually brought that up to breeding companies, and 10 or 15 years ago, they would just scoff at the idea,” Aho said. “Now they say, ‘We might need a more balanced bird.’”

Hong Kong Supermarket looked exactly as it always had. When I visited the store in Manhattan’s Chinatown last week, buckets of live crabs were stacked precariously next to bags of sweet-potato starch and shrink-wrapped boxes of dried shiitake mushrooms. The instant noodles took up two walls, where I quickly found my beloved and gloriously weird cheese-flavored kind. The aisles were packed with the usual staples: black vinegar, bags of vermicelli, sacks of jasmine rice big enough to body-slam a man.

But the product labels gave away that something was wrong: Product of China, many of them read in Mandarin. Almost everything at Hong Kong Supermarket is imported from China, and, because of tariffs, they could soon get more expensive. President Donald Trump’s 145 percent tax on goods imported from China affects everything from sofas to socks. Starting tomorrow, the fast-fashion giants Shein and Temu will hike their prices. And for some Americans, sticker shock from tariffs might mean skipping a new pair of jeans or squeezing a few more months out of a wheezing vacuum cleaner.

But the tariffs are especially tough on Chinese grocery stores and their customers. Unlike retailers that just happen to sell Chinese-made clothes and gadgets, stores like Hong Kong Supermarket are stocked with Chinese products because they are made in China. After all, I’ve yet to come across American brands that make my cheese-flavored noodles. Chinese grocery stores are a lifeline for millions of Americans like me. They’re where you can always count on basic ingredients that you’ll never find in Trader Joe’s or Whole Foods. In a world of tariffs, the Chinese grocery store has gone from a space of security to one of low, simmering dread: the kind that comes from watching the small constants of your life get a little more expensive, a little more distant.

At Hong Kong Supermarket, the prices haven’t gone up yet, but customers are bracing for hikes. There’s more pausing at price tags. More sighing. Aunties in quilted jackets crowd the produce bins, where their shopping carts tell the story of careful calculation: one bunch of scallions instead of two, a single pork bun where there might have been three, the occasional wistful glance toward the $13.99 fresh durian in the cardboard barrel. In the dried-snacks aisle, the shopper beside me stared wistfully at a jar of salted plums. Anna Chen, a slight 50-year-old woman holding an empty green shopping basket, told me that tariffs were on her mind. “I really hope the prices don’t get higher,” she said.

They will, Wille Wang, a manager at Hong Kong Supermarket, told me. The store hasn’t had to increase prices much at the moment, he said, but it’s only a matter of time if the tariffs remain in effect. “What can we do? It’s not our fault; we can’t control tariffs. Unless we sell at a loss, which isn’t sustainable.” He expects that cheap products might go up a little, but that the big jumps will be on premium goods and hyper-specific varieties. I thought of fermented bean curds, a hot-pot favorite; black-yolked century eggs, found in so many congees; and the sea cucumbers gifted to every grandparent. When existing inventory runs out, store owners will face hard choices: Eat the costs and risk going under. Raise prices and risk losing customers, as some businesses with Chinese suppliers are already doing. Seek alternative suppliers and risk altering the flavors that define their communities.

Everyone loses. Shoppers who frequent Chinese grocery stores may have few alternatives but to shell out more money for their food. You can’t swap out the Pixian bean paste for something generic from the “international” aisle for your mother’s mapo tofu and hope she won’t notice. You can’t trade out Shaoxing wine for dry sherry. Substitutions only go so far before the dish falls apart—one missing ingredient, and you’re eating a sad memory of something else. “Western grocery stores don’t have the groceries I need,” Chen said. “If prices keep going up, I can’t do anything about it.”

At some point, a work-around becomes a compromise, and a compromise becomes a resignation. These stores are where people can keep up how they’ve always eaten. Many people go to them not for novelty, but for continuity. “I’m thinking of stockpiling things like soy sauce and condiments,” said Fred Wan, a shopper whom I approached near the fish department. He’s a 34-year-old who moved from Beijing to New York eight years ago; he and his wife recently moved closer to Chinatown partly to have better access to Chinese grocery stores. “I’m definitely worried.”

Chinese grocery stores are under pressure in more ways than one: Not only do they stock lots of products that are now subject to steep tariffs, but they already tend to run on thin margins. “Small, independent grocery stores—especially those catering to ethnic communities—are particularly vulnerable,” David Ortega, a food-economics professor at Michigan State University, told me. If Trump’s full slate of tariffs goes into effect in a few months, the pain won’t stop at Chinese grocers. Vietnam is facing some of the steepest proposed tariff hikes. South Asian grocers might see seasonal delicacies like Alphonso mangoes get more expensive, if they can get them at all. (“Crying in H Mart” may soon take on a new meaning.)

If the costs of cultural foods keep rising, we’ll all feel it. More and more non-Chinese shoppers frequent these stores because they’re the only places that carry ingredients now in many kitchens—chili crisp, black vinegar, dumpling wrappers—or at least sell them cheaply. Food media, emphasizing that authenticity is a virtue, have popularized the idea that a visit to H Mart or the corner Chinese grocer will help you cook better. Big retailers have picked up brands popularized by smaller Chinese stores, such as Kikkoman, Lee Kum Kee, and the pantry favorite Lao Gan Ma chili crisp. The irony is that even as Asian groceries have become more mainstream, more cross-cultural, more popular than ever, tariffs are casting doubt on Americans’ ability to actually buy them. Tariffs shape and reinforce what’s affordable, what’s available, and, ultimately, whose cultures get priced out of reach.

After leaving Hong Kong Supermarket, I headed to Po Wing Hong, the grocer down the street. The store smelled like herbs and floor cleaner. A little boy was crouched in front of a stack of Jin Jin lychee jellies, squeezing each one to figure out which had the most juice. I overheard two teens calculating how many instant-noodle packs they can buy. (Answer: fewer than they’d like.) I passed a big box of packaged nuts and grains slapped with a bright yellow sign. On it, prices had been crossed out and updated in black pen. Peeled mung beans: formerly $1.75 a bag, now $1.99. Dried chestnuts: formerly $9.99, now $11.55. On my way out of the store, I walked past a stack of discarded cardboard boxes, all still marked with Chinese shipping labels.

One of the most notable things about Robert F. Kennedy Jr.—the secretary of the Department of Health and Human Services, a federal agency tasked with “improving the health, safety, and well-being of America”—is how confidently he distorts the basics of health, safety, and well-being.

In his short stint as health secretary, Kennedy has touted cod-liver oil as a valid measles treatment (it’s not), said that Americans are being “poisoned” by seed oils (they’re not), and claimed that “many” vaccines are not adequately safety-tested (they are). And he has readily cherry-picked and exaggerated findings to suit his own needs: “There’s a scientist at Harvard now who is curing schizophrenia with a carnivore diet,” he said at a press conference in March (it’s not a carnivore diet, and it’s not a cure).

The secretary also seems to think he knows what causes autism, a topic that scientists have been looking into for decades without producing a simple, clear-cut result, M. Daniele Fallin, a genetic epidemiologist at Emory University, told me. Kennedy, however, is adamant that a series of new investigations by his department will reveal at least “some of the answers” by September. “And we will be able to eliminate those exposures,” he said at a recent Cabinet meeting.

Since its first days, the new Trump administration has clearly shown where it thinks scientific attention should not be focused: It has attempted to censor federal scientific data, cut billions in government spending on research, and compromised care for some of the world’s most at-risk populations. Now, as the nation’s leaders have begun to encourage inquiry into specific areas, they are signaling that they’re willing to not just slash and burn research that challenges their political ideology but to replace it with shoddy studies designed to support their goals, under the guise of scientific legitimacy.

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Just last week, in a press conference discussing a new CDC report that described a continued rise in the prevalence of autism, Kennedy pledged to “follow the science no matter what it says.” And in an email, Kush Desai, a White House spokesperson, told me that the administration’s intention is “to leave no stone unturned to get to the bottom of America’s epidemic of chronic diseases and conditions.” But those statements seem at odds with Kennedy’s behavior.

Among scientists who study and treat autism, the consensus has long been that “there is no ‘one cause’” of autism, Neelkamal Soares, a developmental and behavioral pediatrician in Michigan, told me. Genetics are likely to play a role; researchers have also explored the possible contributions of factors such as parental age; labor and delivery conditions; and exposures to certain chemicals, medications, or infections during pregnancy. Experts also generally agree that much of the growing prevalence of autism can be attributed to increased awareness and diagnosis—an explanation that the CDC, an agency Kennedy oversees, cited in its report.

But at last week’s press conference, Kennedy dismissed that explanation as “a canard of epidemic denial.” He instead claimed, without citing any data, that autism rates soared after “industry” contaminated Americans with a “toxin,” and called genetics a “dead end” for future research. “Somebody made a profit by putting that environmental toxin into our air, our water, our medicines, our food,” he said. And he appears to be trying to bolster that viewpoint with what will now count as official government research—“a series of new studies,” he said, “to identify precisely what the environmental toxins are that are causing it.”

Kennedy did promise to look at all possible environmental factors “agnostically.” But several experts told me they’re worried that the secretary has at least one particular exposure in mind. For years, Kennedy has championed the debunked idea that childhood vaccinations cause autism. And in March, he reportedly tapped David Geier, a discredited health analyst who has long promoted the notion that vaccine ingredients cause autism, to lead an HHS study to once again search for a link between immunizations and the neurodevelopmental condition. Kennedy didn’t evoke vaccines when describing this new research, and since his confirmation as HHS secretary, he has been more sanguine—albeit inconsistently—about the benefits of shots. But vaccines have, for years, stood out in his rhetoric as “a very clear preconceived hypothesis,” Megan Pesch, a developmental and behavioral pediatrician at the University of Michigan, told me.

Kennedy, who has no scientific or medical training himself, also seems confused about what a scientifically rigorous investigation would entail—and how long it might take. During this month’s Cabinet meeting, he said that by September, HHS would complete “a massive research and testing effort involving hundreds of scientists from around the world.” At last week’s press conference, however, his comments suggested that HHS might rely heavily on AI and electronic-health-record data, which aren’t gathered uniformly, can depend on self-reporting, and cover only populations that interact with the health-care system. And Jay Bhattacharya, the new, Trump-appointed director of NIH, recently gave a presentation detailing the administration’s plans to source data for these investigations from hospitals, pharmacies, wearable devices, and other private sources with limited reach.

That approach, experts told me, can’t provide enough evidence to definitively pinpoint autism’s cause, much less guide policy to eliminate it. “The chances of getting garbage are so high,” Catherine Lord, a clinical psychologist at UCLA’s Semel Institute for Neuroscience and Human Behavior, told me. Desai said that Kennedy had promised “an exhaustive examination of the underlying causes of autism,” which “naturally would include use of data points such as electronic health records, among other data sets,” and noted that the secretary is focused on fulfilling President Donald Trump’s directives “with the Gold Standard of Science.”

No matter which methodologies Kennedy chooses, his September deadline “is ridiculous,” Lord said. Even the job of assembling the expert task force to initiate such a project could go past September. And Bhattacharya has already suggested getting results could take longer. (When asked about the practicality of this timeline, Desai replied, “Would the preference be vague timelines and no commitments to address a matter of utmost concern for millions of Americans?”) One way to rigorously gather more data on autism’s causes would involve following a large, representative sample of the American population over time, tracking participants’ exposures, taking into account their genetic and health history, and monitoring whether any of them develop autism. The process would take years—and still may not yield causes as clear-cut or easy to “eliminate” as Kennedy seems to expect. But an administration that already knows the answers it wants doesn’t need years to find them.  

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Government-funded science has, to some extent, always been subject to the political priorities of leadership: The National Institutes of Health, for instance, is run by a political appointee. Trump and his allies, however, have already demonstrated that they are willing not just to set priorities, but to engage in science theater, with even more broad-reaching interference in the field of trans health.

From the start, the new administration’s views on transgender health have been clear. Since January, Trump has issued executive orders denying the existence of gender and describing hormone therapy and gender-affirming surgery for children as “maiming,” “sterilizing,” and “mutilation.” One order announced that the administration would not “fund, sponsor, promote, assist, or support the so-called ‘transition’ of a child from one sex to another” and instructed federal agencies to end such procedures at government-funded institutions, leading hospitals and clinics across the country to pause gender-affirming care for young people. Through the NIH, the administration has also slashed funding from more than a hundred research grants involving trans people.

In place of this research, HHS is pursuing a pointed agenda to confirm the president’s statements. Last month, Matthew Memoli, the acting director of the NIH at the time, sent top agency officials a memo with instructions to urgently “fund research” into “regret and detransition following social transition as well as chemical and surgical mutilation of children and adults.” (In his email, Desai described the memo’s stipulations as “realigning taxpayer-funded research to align with the priorities of the American people.”) “This is very important to the President and the Secretary,” the memo read.

The outcomes of gender-affirming care do need further study across the age spectrum, experts told me. Scientists still don’t have a full sense of the long-term outcomes of transition on mental and physical health, or how to best tailor interventions to patients. (Extended use of certain hormones, for instance, could raise people’s risk of some cancers or cardiovascular complications.) More research is needed, in particular, on how best to support gender-diverse youth, a growing sector of the population. But the kinds of research that the Trump administration is pursuing won’t help clarify or alleviate those concerns. And of all the scientific questions that could be asked about trans health, “regret and detransition aren’t the major problems,” Arjee Restar, a social epidemiologist at Yale, told me: Studies have found that adults and adolescents are generally very satisfied with the outcomes of hormone therapy and gender-affirming surgeries, and that rates of regret following surgeries are about just 1 percent.  

NIH officials found the memo’s directives appalling. “This is not how we do science, ever,” one of them, who requested anonymity out of concern for professional retribution, told me. “This is politicized research, exactly what we were always told we would never do.” In his memo, Memoli specified that studies into the outcomes of gender-affirming care should deploy “methods that don’t themselves subsidize or incentivize such practices as previous NIH studies have done.” (Desai pointed to a case in which an NIH-funded researcher cited politics to help explain her hesitation to publish a study with unfavorable results about puberty blockers.) But previous NIH studies have never “subsidized or incentivized” gender-affirming care, the NIH official told me. Rather, they followed the recipients of that care over time, and observed the results.

In contrast, Memoli’s memo unabashedly advertised the conclusion that the administration is pushing for: that gender-affirming care is harmful and regrettable. The directive also implicitly solicits researchers who “are following the administration’s example,” Logan S. Casey, the director of policy research for the Movement Advancement Project, an equality-focused think tank, told me—and potentially, for participants who might share those viewpoints as well. That makes it all the more likely that those projects will produce the skewed results the administration wants to see.

This is consistent with everything Trump and his allies have revealed about their views on science since January: that it is not a means to better understand objective reality, but a political weapon that they must guard against, or deploy themselves. In recent months, Kennedy has accused the expert committee that counsels the CDC on its nationwide vaccine recommendations of being in the pocket of vaccine manufacturers; the administration has also fired from HHS several scientists who were prominent leaders in the COVID-19 response, including a few closely affiliated with Anthony Fauci, whom Trump has ridiculed as a “disaster” and an idiot and Desai derided as one of many “demonstrably fallible ‘experts.’” Last week, administration officials also redirected two federal websites, once used to share information on COVID-19 tests, treatments, and vaccines, to a page promoting the idea that the coronavirus pandemic began as a lab leak, rather than Fauci’s “preferred narrative that COVID-19 originated in nature.”

The causes of autism, the outcomes of gender-affirming care, and the origins of SARS-CoV-2 are all topics worthy of scientific investigation. But how questions are asked can influence the answers they yield—and directly affect the populations they’re asked about. The language in the NIH memo is “alarming and inflammatory,” Camie Nitzel, a psychologist who specializes in transgender and gender-diverse people, told me: It shows that the administration is pursuing these studies not from a place of genuine inquiry, but from prejudice. Disdain is coded into the administration’s methodology on autism, too: In his briefings on HHS’s new pursuits, Kennedy has repeatedly described autism as a scourge worse than COVID-19 that “destroys” families and children, and insinuated that it should be purged from the population. But the implication of both the administration’s statements and its proposed studies is that neither trans people nor autistic people should visibly exist in America. Science is now yet another tool that the government is using to disappear anyone it deems undesirable.

Mallory Berry was ready to give up. It was 2019, and her addiction—prescription opioids had led her to heroin—had left her bedridden. An infection had eaten through parts of her pelvic bones, stomach muscles, and vertebrae, causing a pain so excruciating that she was afraid to move. Her partner, Randy, placed buckets under her body when she needed to use the bathroom. Bathed her and fed her. Before long, Mallory stopped eating entirely, subsisting on sweet tea and water, wasting away.

Four years later, Mallory would recount this memory to me over the phone from her house—a five-bedroom, three-bathroom colonial with a walk-in closet and a two-car garage—that she paid for with her earnings as a manager at a mortgage company, where she oversaw 10 direct reports.

When I spoke with her in March last year, she largely credited this remarkable turnaround not to her own willpower, or the grace of God, but to a widely available medication called buprenorphine.

The world of opioid addiction is one of morbid statistics. People struggling with opioid addiction have a mortality rate 10 times higher than the general population in the United States. The relapse rate for those in recovery is as high as 70 percent. As one doctor, an addiction specialist named Stephen Martin, put it to me, “The natural history of opioid-use disorder is: People die.”

Which is why the numbers describing buprenorphine’s impact stand out. Buprenorphine can stop cravings for opioids, and people who use it are 38 percent less likely to die of an overdose. After buprenorphine was adopted at scale in the midst of France’s opioid crisis in the 1980s and ’90s, overdose deaths dropped by 79 percent.

About a year ago, when I began reporting this story as part of an Atlantic podcast series, I asked Mallory how important this treatment was to her recovery. She, too, reached for a number. “If you want a percentage,” she told me, “75 percent.” Yet being on buprenorphine at all made Mallory an outlier. As of 2021, about one in five patients struggling with opioid-use disorder is taking this or other medications for treating addiction. One of the most effective tools for defusing a crisis that in recent years has killed more than 80,000 people annually is going unused.

Underpinning this failure is a quiet conviction among doctors and patients alike that taking buprenorphine doesn’t count as success—that people who use drugs to recover from drug use are still addicts, the sobriety they achieve is fake, and the drugs saving their lives could spark the next wave of the opioid epidemic. At the same time, the drugs that have made addiction even more deadly—synthetic opioids such as fentanyl—are making buprenorphine more complicated to use. As a result, the window in the U.S. for this treatment to fulfill its greatest promise is nearly closed.

When buprenorphine arrived in the U.S. in 2002, the country was immersed in what would later be categorized as the first wave of the opioid epidemic. That year, 11,920 people died from opioid overdoses, which at the time sounded alarms in the medical community. (The annual death toll would increase sevenfold over the next two decades.)

The triumph in France was already well known to addiction specialists. Many believed that once more of their colleagues in health care understood the silver bullet they’d been handed, the treatment would find its way into primary care, Martin told me. The crisis could be stopped in its tracks.

But buprenorphine’s strength as a treatment is also a weakness. Buprenorphine is an opioid. Like methadone, the tightly regulated treatment for opioid addiction used in America since the 1950s, it acts on receptors in the brain to satisfy cravings.

Compared with methadone, buprenorphine is more difficult to overdose on and easier to access. It also has a stronger affinity for opioid receptors than opioids such as heroin or fentanyl, which can protect patients against overdose if they relapse. In a brain flooded simultaneously with buprenorphine and another opioid—the brain of a buprenorphine patient relapsing on fentanyl, for example—buprenorphine has dibs on the relevant receptors. Without available receptors, both the high and the harm of an opioid such as heroin or fentanyl are greatly reduced or eliminated. This is why buprenorphine can be a powerful medication. It strikes at the root of addiction, and protects patients when they slip up.

Yet it requires prescribers, regulators, and patients to accept that a person can be sober while taking an opioid every day. That idea cuts against the narrow definition of sobriety that America’s addiction model was—and to a large extent still is—built on. Whereas many European countries have successfully implemented coordinated, low-barrier access to treatments like methadone and buprenorphine, abstinence-based opioid addiction treatment is alive and well in America. In many Narcotics Anonymous meetings, for instance, attendees taking buprenorphine are treated the same as those in active addiction: They can listen, but not speak. In many sober houses, the first stop after rehab, residents are not permitted to take buprenorphine. “There’s a particular path to treatment and recovery” in those settings, Erin Madden, a professor at Wayne State University who studies stigma and addiction, told me, and “medications can’t be a part of it.” Asking people whose lives were destroyed by opioid dependence to depend on a different opioid is already a hard sell. Asking them to accept this dependence in a culture of abstinence is nearly impossible.

Fear that buprenorphine would be abused also worked against its broad adoption. In the early days of the crisis, prescription opioids such as oxycodone were driving a sharp rise in deaths. The DEA, for one, was skeptical that another prescription opioid could be the solution to widespread abuse of prescription opioids in part because the Department of Justice reported some evidence of buprenorphine abuse, particularly in the Northeast, as early as 2004. And opioid-addiction treatments do have a history of abuse: Heroin, for example, was once considered an effective treatment for codeine and morphine addiction. The year buprenorphine was approved, the DEA restricted its dispensation. Buprenorphine was moved from a Schedule V controlled substance (like codeine) to Schedule III (like ketamine). Physicians had to complete special training to prescribe the drug, and could prescribe to a pool of only 30 patients.

After its approval, buprenorphine never came close to achieving the scale needed to slow down the crisis. By some estimates, for every patient who received the drug, four more might have benefited from it.

Mallory’s younger brother, Quincie, had, like her, started with pills. Then he began using intravenous drugs; he showed her how to shoot up. Before long, he was overdosing regularly, sometimes twice a day, and depending on Narcan, the overdose-reversal drug, to revive him. Quincie was caught in a terrible loop: overdose; Narcan; emergency room. Overdose; Narcan; emergency room.

Then one day an outreach specialist approached Quincie at the emergency room and handed him her card. Call me when you’re ready, she said. He did, and eventually found his way into rehab and onto a buprenorphine product called Suboxone. As I reported in the podcast, he told his mom, Jennifer Hornak, “This keeps me from going off the deep end. I can work. I can live a real life on this medication.”

For a time, Quincie and Mallory were on roughly the same path. But in 2020, the paths split. Mallory finished rehab and entered a halfway house, while still on Suboxone. She was lucky, in a way: Many sober houses operate on the principle that an opioid is still an opioid, and for that reason won’t accept people on buprenorphine. And Quincie ran into exactly that problem at the sober houses near him. Because he needed a place to live, he saw little choice but to stop taking Suboxone. When Jennifer asked, “Are you sure you can do that?” he told her, “I think I can.”

About a month later, Jennifer was having a pool party at her house when Mallory told her that she saw a Facebook post that read “Rest in peace Quincie.” He had died of an overdose.

Quincie was caught between two approaches to addiction treatment. Inside rehab, his recovery was built around medication, not willpower. But outside, the infrastructure available to him was built on abstinence.

When Quincie died, Mallory’s family expected her to relapse. She’d been sober for only a few months, and her little brother’s death was a major blow—but she didn’t. She didn’t relapse when her grandfather died the next year. She didn’t relapse when Randy, who had cared for her when she couldn’t walk, died the year after that.

One day, Mallory got busy at work. Before she knew it, she ran out of time to make it to her doctor’s appointment to refill her Suboxone prescription. The withdrawal symptoms—vomiting, diarrhea—started quickly. For Mallory, missing her dose felt like going through heroin withdrawal—“like I’m dying,” she told me. She could go to her sober network for a few spare doses, but she feared their judgment. Asking for pills was addict behavior.

Eventually a friend gave her a pill, which she broke into pieces to last until she could refill her prescription. But the experience scared her. “What if something like this happens again?” she asked herself. “Do I want to be on a medication where if I don’t have it, I feel like I’m dying?” She realized that she didn’t want to be on Suboxone for the rest of her life. She was also tired of telling doctors she was taking the drug, which she felt led them to treat her differently than they would other patients.

And she wanted to keep the six teeth she has left. (Buprenorphine has been connected with tooth decay, according to an FDA warning.) For Mallory, her dentures represent some never-ending punishment for her years spent in active addiction, a permanent reminder of her past.

Jennifer begged Mallory to stay on Suboxone. “I pray that she’ll stay on it, I really do,” she told me in April 2024. “I just really can’t bear the thought of losing another child.”

Mallory came off Suboxone. In July—the last time I was able to reach her directly—she said she was feeling fine. More recently, whenever I tried to get in touch, she didn’t respond to me. In October, Jennifer told me via text that Mallory had not relapsed, but was dealing with what Jennifer described as “mental and physical health issues.”

Quincie’s death, and Mallory’s story, reflect a stark truth about buprenorphine’s limits, at least in America. Staying on the medication over the long term requires resolve, with limited support and against persistent stigma. Stopping presents its own risks. Diminished tolerance, paired with an ever more potent drug supply, can make buprenorphine cessation deadly if a person starts using drugs again. It might also shatter the fragile stability the medication can provide, as a salve for the mental-health issues that so often underlie addiction. But America’s fractured approach to recovery makes buprenorphine hard to live with, and impossible to live without.

On paper, getting buprenorphine to as many people as possible should be easier now than ever before. Today, patients can get a prescription through telehealth or even a phone call. Special training requirements for would-be prescribers have been eliminated. The widespread buprenorphine abuse feared in the early aughts never came to pass; although some buprenorphine has been sold illicitly, most buyers seem to be people who are using it as a medication, rather than abusing it. The DEA, after decades of strict enforcement, now urges pharmacists to maintain an “adequate and uninterrupted supply” of buprenorphine and similar medications. The regulatory barriers between patients and this medication have never been lower.

But usage rates are relatively flat. In 2022, they fell. According to Rachel Haroz, who leads Cooper University’s Center for Healing, and other experts I spoke with for this story, the stagnant rates can be blamed on stigma, a lack of infrastructure within primary care, and fear of DEA repercussions.

Buprenorphine’s uptake numbers in the past five years also have to do with the synthetic opioids it’s now up against. In earlier waves of the opioid epidemic, clinicians would wait for opioids such as painkillers or heroin to leave those receptors in the brain naturally, and then, at the onset of withdrawal symptoms, they would begin patients on buprenorphine. The drug would reduce cravings and eliminate the need for a protracted, painful withdrawal.

This process can break down if the patient has been using fentanyl, which stays in the body longer than heroin or pain pills. When buprenorphine displaces fentanyl from opioid receptors, it can trigger an instant reaction called precipitated withdrawal, marked by vomiting, diarrhea, and chills. Patients, who already live in constant fear of withdrawal, are reluctant to seek a treatment that triggers its symptoms. And doctors, reluctant to cause such acute pain, are hesitant to start patients on buprenorphine.

So addiction specialists are improvising. When Haroz’s EMS teams revive a patient with Narcan, a drug that reverses overdoses by clearing fentanyl from opioid receptors, they start them on buprenorphine immediately, which can help avert precipitated withdrawal symptoms. Boulder Care, an addiction network in Oregon, is piloting a new approach in which fentanyl users take a dose of Narcan without having overdosed, intentionally triggering a withdrawal before starting on buprenorphine. Lucinda Grande, a professor at the University of Washington School of Medicine, has trialed using ketamine, a dissociative drug, to ease symptoms while her patients transition from fentanyl to buprenorphine.

Introducing buprenorphine is a much easier task for people who use, say, heroin. But today, fentanyl—with all the side effects that accompany its interaction with buprenorphine—has taken over the market for illicit opioids. Having missed the best window to get buprenorphine into patients, this is now what success looks like. And these creative approaches cannot yet be deployed at a scale that would meet the needs of the tens of thousands of Americans who lose their lives every year to overdose. The story of recovery in America is essentially the same as it was 20 years ago, and the barriers to changing that story are higher than ever.