Lindsay Atkins, 38, was introduced to heroin by her boyfriend when she was just 18 years old.

“Over nine months, I became a full-on heroin addict,” she said.

Atkins moved to Texas for a fresh start, but two years later her disease caught up with her, resulting in repeated stints in rehab and scattered periods of sobriety that inevitably ended with yet another return to the drug. It wasn’t until she began receiving methadone — coupled with therapy, 12-step meetings and other help — that she was finally able to escape heroin for good in 2009.

“I haven’t touched opioids since then,” she said.

Atkins was fortunate. She had access to the evidence-based addiction treatment that research has shown is the best way to conquer the opioid epidemic roiling this country.

It’s treatment that most Americans addicted to opioids don’t receive, despite numerous studies showing medication-assisted treatment (MAT) helps people kick their illicit opioid habits and go back to living productive, law-abiding lives.

Buprenorphine, commonly sold under the brand name Suboxone, is a synthetic opioid that reduces a patient’s craving for opioids like heroin, fentanyl or OxyContin without giving them a high.

It also keeps users out of the torturous hell of physical withdrawal, often the downfall of many addicts’ attempts to get clean and sober.

Buprenorphine, approved for use in opioid addiction for two decades, has been shown to lower overdose deaths, reduce illicit drug use, slow the transmission of diseases like HIV and Hepatitis C, prevent relapse and help people stay in treatment.

Methadone, which has been around even longer, is a long-acting opioid “agonist” that is used to control withdrawal safely. Another drug, naltrexone, blocks the high from opioids, helping deter future use.

But these life-saving and life-transforming medications are vastly underused in the United States, condemning untold numbers of people to lives of degradation and preventable deaths.

Meanwhile, tens of thousands of Americans continue to die of drug overdoses, which in 2022 once again topped 100,000 deaths, about 75% from opioids.

I was drawn to this issue after reading a recent op-ed in the Washington Post by two physicians decrying the lack of access to buprenorphine and other forms of MAT. They wrote that these medicines are prescribed to fewer than 1 in 6 people who would benefit from them.

They placed a big part of the blame on the fact that most U.S. medical schools and residency programs don’t provide enough training to young physicians regarding the treatment of addiction, including opioid use disorder.

One reason: Addiction medicine, they wrote, has been long neglected because of stigma — drug addicts are considered a challenging patient population, known for lying and manipulation — as well as other issues.

I reached out to two psychiatrists who direct the largest medication-assisted treatment program in Bexar County to see if this national-level critique applies to facts on the ground here.

“It’s totally spot-on,” said Dr. Rene Olvera, chief medical officer with the Center for Health Care Services.

The center’s mostly state-funded ambulatory clinics (2023 budget: $5.3 million) provide buprenorphine and other MAT to some 600 patients at any one time, most of whom lack health insurance. This is just a fraction of the people who could benefit from the treatment, he said.

(There are also a number of for-profit MAT clinics and programs in San Antonio, which typically cater to those with insurance or cash to pay for their treatment.)

Olvera said that when he started medical school in 1986, addiction treatment was a relatively new field. Over the last 30 years, it’s been highly regulated, with opioid addiction medications categorized as Schedule 2 drugs, which means doctors have had to mount prescribing hurdles and maintain prodigious record-keeping.

“It was onerous and a lot of physicians didn’t want to bother with it,” he said.

Olvera’s colleague Dr. Christopher Healey, who oversees the center’s MAT program, said doctors have had to apply for a special waiver to prescribe MAT and go through specialized training.

“And because of the regulations, you could only treat a certain number of patients at any time, to guard against doctors overprescribing or creating ‘pill mills,’” he said.

Both physicians agreed with the op-ed that there hasn’t been adequate training in medical schools, but there are other roadblocks that keep people from accessing the medicine that could save them.

Namely, the expense: Buprenorphine can cost as much as about $300 a month, placing it out of reach for those who lack insurance or work a low-wage job. Even patients who have insurance may find the treatment not covered.

“For many patients in this population, that amount of money is a real challenge,” said Healey.

The stigma against treating addicts has lessened in recent years, said Olvera, as those in the medical community — and the public at large — have grown to see addiction as a chronic disease, not some moral failing or matter of personal “choice.”

But compounding the problem is a shortage of psychiatrists, in Texas and elsewhere, which means there are not enough providers to do the prescribing.

“Some psychiatrists may feel they have enough to do dealing with patients who struggle with bipolar disorder, depression or other mental illnesses,” said Olvera. “They don’t want to do the special training to treat this population. They would rather just refer to someone else, although the reality is people without insurance are not going to be referred in the first place.”

Things are slowly changing, the two physicians said.

For example, a one-year addiction training fellowship at UT Health San Antonio, which had lain fallow, is now drawing more applicants, said Healey, as doctors in training realize they’ll be able to get jobs in addiction treatment once they’re out of school.

(It’s a sort of paradoxical silver lining to the opioid epidemic, he said: The tidal wave of people suffering and dying is drawing more healers to the field.)

Psychiatrists have become more open to non-psychiatrists prescribing MAT, broadening the level of access to the medications, said Olvera. And doctors are coming to understand that substance use disorder and mental illness are intricately interwoven diseases, to be treated concurrently, not as a “chicken or egg” situation, he said.

Perhaps most important, this year President Joe Biden signed into law legislation that, among other things, will make buprenorphine more readily available to those seeking treatment.

Now, physicians no longer will be required to get the special waiver to prescribe Suboxone and will be able to offer it to patients like any other medication.

Also, Congress has required all doctors to receive eight hours of education on substance use disorders before prescribing controlled substances. (It’s still not enough training, said the op-ed authors.)

Progress has happened locally, too, with programs like Be Well Texas through UT Health San Antonio, which started receiving funding in 2015.

In addition to conducting research in addiction treatment, providing training modules for physicians and distributing funding to community-based treatment organizations, the Be Well Texas Clinic offers comprehensive care, including MAT, to those seeking treatment, regardless of their ability to pay, via both in-person office visits and through virtual telehealth.

It’s about time that attitudes are changing.

Treatment with buprenorphine and methadone has been found to cut opioid overdose deaths in half when compared to behavioral therapy alone. MAT for opioid use disorder, especially when paired with therapy and other support, is far and away more effective than traditional programs based on abstinence.

Providing recovering addicts with MAT on an outpatient basis is both more effective and cheaper than adding inpatient beds at rehabilitation centers, other research shows.

Still, resistance to evidence-based MAT remains. Outdated beliefs that such treatment entails “just trading one addiction for another” persist in the wider culture.

Many residential or outpatient drug treatment centers in Texas and elsewhere don’t offer it, despite its being available for decades. The folks who run many programs may view such medication as a “crutch,” despite studies that show MAT is more successful at keeping people in treatment than abstinence-based approaches.

Some folks in 12-step programs like Narcotics Anonymous may look down their noses at recovered addicts who use these medicines, going so far as to say they’re not truly sober, because they’re not 100% abstinent. Some sober-living homes and work programs reportedly have rejected people on methadone or other MAT, saying they aren’t “recovered.”

These mindsets are absurd, bordering on the criminal.

Thanks to stubborn stigmas, one study showed it’s far easier to get access to the drugs that started the U.S. opioid epidemic than it is to get help.

No, MAT isn’t a complete magic pill. Some people relapse on it. It’s not enough by itself: Recovering addicts on MAT need therapy, fellowship and other support to combat the isolation and disconnection that is so much a part of addiction.

And, yes, some patients may be on MAT for the rest of their lives. But isn’t that better than dying in an alley, with a needle stuck in your arm?

Last month, Gov. Greg Abbott signed into law measures to combat the fentanyl crisis, including increased penalties for producing and selling it, greater access to the anti-overdose medication Narcan and new programs to increase awareness about the drug’s dangers.

That’s all well and good, but until we can increase access to the medications that stop people from using illicit opioids in the first place, residents of this state will continue to die.

Atkins, today a human resources manager in San Antonio and single mother to her 15-year-old son, no longer takes methadone. She stays sober by immersing herself in her recovery community. But without MAT, her story could have ended far differently.

“I’m pretty sure I would have kept doing heroin,” she said. “I probably wouldn’t be alive today.”