Providers of methadone treatment say a big increase in access could backfire

BALTIMORE — Providers of methadone for addiction treatment have a message for advocates seeking a giant expansion in access: Be careful what you wish for. 

Methadone, they acknowledge, is a highly effective medication for opioid addiction. But allowing doctors to prescribe it directly to patients could backfire, they argue, by leading to an increase in low-quality care or even overdoses on methadone itself. 

“There’s a lot of demand to do something curative to address the opioid crisis,” said Christine Martin, a member of the board of directors for the American Association for the Treatment of Opioid Dependence, speaking during a panel at the organization’s annual conference. “But it’s really important that in our zeal to improve the accessibility of treatment and help more people get well, we don’t implement change at the expense of safety.” 

Methadone is one of just three medications currently approved in the U.S. to treat opioid use disorder. By the standard of most epidemics, it is extraordinarily effective: One 2018 study showed patients receiving methadone were 59% less likely to die of an overdose than those not receiving medication.  

Currently, however, methadone can only be prescribed to treat addiction in the context of an opioid treatment program, or OTP. To access the drug, most patients must undergo frequent drug tests, participate in counseling sessions, demonstrate that they’ve experienced opioid addiction for at least a year, and show up in person at a methadone clinic each day to receive a single dose. 

With overdose deaths hovering around an all-time high, many addiction treatment advocates have shown a willingness to try aggressive new solutions. Methadone, in particular, has emerged as a flashpoint in the broader debate about how quickly the U.S. should expand access to addiction treatment and harm reduction services. 

Advocates for methadone expansion say the overdose crisis has reached such extreme levels that making the medication more widely available could save thousands of lives, despite its risks. There are roughly 1,800 OTPs across the U.S., according to a 2021 estimate, which collectively serve just over 400,000 patients. Moreover, they argue, any licensed doctor, physician assistant, or nurse practitioner can prescribe methadone as a treatment for chronic pain — the tight regulations surrounding the drugs only kick in when it’s used to treat addiction. 

Opponents argue that methadone treatment should be accompanied by regular counseling and other services that OTPs are uniquely equipped to provide. They also cite statistics showing that methadone overdoses remain a concern: Over 3% of opioid overdoses involve methadone, according to a recent estimate from the National Institute on Drug Abuse. 

Methadone-involved deaths, however, have declined in recent years — even after federal officials lifted major restrictions on the drug in response to the Covid-19 pandemic, allowing patients deemed “stable” to take home weeks’ worth of doses in lieu of daily clinic visits. 

Members of Congress have taken notice.

One bill introduced this year by Sens. Ed Markey (D-Mass.) and Rand Paul (R-Ky.) would allow patients to receive methadone at a pharmacy, rather than traveling to an OTP. A separate proposal from Rep. Don Norcross (D-N.J.) would allow certain health professionals to prescribe up to one month’s supply of methadone directly to patients, who could pick up the medication at a pharmacy. 

Other experts and advocacy organizations, including researchers at George Washington University and the Pew Charitable Trusts, have also voiced support for deregulating methadone, and urged the White House to take action itself instead of waiting for Congress.  

Methadone providers, however, are increasingly vocal in their opposition to such proposals. While many support calls to loosen methadone regulations more incrementally, such as allowing take-home doses, they argued that attempting to integrate methadone treatment into primary care could pose a threat to patient safety. 

Some speakers also noted their opposition to an expansion of access to another common addiction-treatment medicine, buprenorphine. Currently, prescribers must notify federal regulators if they intend to treat patients using buprenorphine, and must undergo at least eight hours of specialized training if they plan to treat more than 30 patients. Norcross’ bill would also eliminate those requirements. 

“In an age of increasing fentanyl use, combined with methamphetamine and other drugs, and also lots of comorbidities that patients bring to treatment, I think it’s important to say that we need trained practitioners,” Mark Parrino, AATOD’s founder and CEO, said during the conference’s opening session.

AATOD, the trade organization that represents opioid treatment programs across the country, devoted a 90-minute session at its annual conference to educating members on different proposals to dramatically expand methadone access. One centerpiece of the campaign, emphasizing the view that addiction treatment is more than just prescribing addiction-treatment drugs, came complete with a Twitter hashtag: #morethanmedicine. 

“There were 5,500 to 6,000 methadone-specific deaths from 1999 to 2015,” Parrino said. “We do not want to exacerbate the problem we’ve already got.” 

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