Methadone is a medication that can help reduce the harmful effects of opioid use by treating cravings and withdrawal symptoms. Research shows that people who receive methadone treatment are less likely to use drugs like heroin or fentanyl and it is a safer option than these drugs because it works for a long time and doesn't make people feel high. Studies have also shown that people who take methadone are much less likely to die from an overdose or contract infections like HIV or Hepatitis C. Plus, because methadone can help control their cravings and withdrawal symptoms, people taking methadone are more likely to have a better life and more stability--they can find and keep jobs, have better relationships with loved ones, and reach their goals.
Why do we need to make methadone more available?
Methadone is a medication that can save lives, but it's not easy to get in the United States. You can only get methadone from special clinics called “Opioid Treatment Programs” that are licensed to treat opioid use disorder. Many places in the US don't have these methadone clinics, and even in places that do, people often are required to go to the clinic every day to get their medicine. This makes it hard for people who live far away or don't have much money to get the help they need. In fact, less than 20% of people in the US with opioid use disorder access methadone, even though it’s one of the best medications we have. If we make it easier to get methadone, we can save lives and help people who are struggling with chaotic opioid use to improve their health and well-being.
Why is the methadone clinic model the only way to get methadone for opioid use disorder in the US?
Methadone has been studied since the 1960s as a way to help people who use heroin. At the time, there was a heroin-related overdose crisis in major cities that was primarily associated with low-income Black communities even though white people were also dying. By 1972, the Food and Drug Administration (FDA) said it was safe and effective to use methadone to reduce the harms of heroin use. Normally, when the FDA says a medicine is okay, doctors can prescribe it like any other medicine. However, due to racism and drug user stigma, many were worried that methadone would be used the wrong way or sold to other people. They didn't think regular primary care doctors knew enough to use methadone. So, special Opioid Treatment Programs, or methadone clinics, were made just for giving methadone to people with opioid use disorder. There are a lot of rules about who can use methadone, where they can get it, how much they can have, and how long they can take it. These rules are still mostly the same today and keep methadone walled off from regular health care. Many of these rules also deter people from seeking care because they do not want to be subjected to so many requirements and surveillance in order to receive their medication. In many other parts of the world, methadone is treated like any other medication and dispensed at community pharmacies.
Does everyone on methadone also need therapy?
While therapy can be helpful for many people, it is not necessary for everyone. Methadone can help manage cravings and withdrawal symptoms, and for some individuals, this alone may be enough to achieve successful recovery. In fact, requiring counseling for people on methadone has not been shown to improve outcomes over methadone alone. For some, behavioral therapy can be a valuable tool in addressing the underlying issues that contribute to chaotic opioid use and developing coping strategies to avoid relapse, but it should not be required. Furthermore, mandated counseling is largely ineffective because it does not leverage a patient’s internal motivations and goals. The decision to include behavioral therapy as part of methadone treatment should be based on individual needs and circumstances.
Can we treat methadone like other medications prescribed in American healthcare today and have it available in primary care clinics?
Absolutely. Although methadone has been restricted to methadone clinics for the past 50 years, it doesn’t have to be this way. In fact, methadone is available in primary care offices and can be dispensed in regular community pharmacies in countries like Canada, Australia, the United Kingdom, and many other nations. Expanding methadone treatment into primary care and regular pharmacies would increase access for millions of people by removing barriers that prevent many individuals from accessing treatment. By integrating methadone treatment into primary care clinics, people struggling with opioids can receive treatment in a familiar environment, which may increase their willingness to seek help. Additionally, primary care providers are often the first point of contact for people seeking medical care, and can play a crucial role in identifying and treating opioid use disorder. Allowing community pharmacies to dispense methadone would help reduce the stigma associated with opioid treatment, as it would integrate it with the regular healthcare system, rather than creating a separate system of healthcare for people who use drugs. By increasing access to methadone treatment through primary care and regular pharmacies, millions of individuals could receive the care they need and improve their overall health and well-being.
What happened to methadone regulations during the COVID-19 public health emergency?
During the COVID-19 pandemic, regulations regarding methadone were relaxed to increase access for individuals with opioid use disorder. The Substance Abuse and Mental Health Services Administration (SAMHSA), one of the federal agencies that regulates methadone, issued guidance to allow for increased take-home doses of methadone, in order to reduce the number of required in-person clinic visits across the country. This was done to reduce the risk of COVID-19 spread in crowded clinic settings. In addition, telehealth (using phone or virtual video calls to provide medical care) also was allowed, and it became more common to use virtual counseling and telehealth to support people on methadone treatment. These regulatory changes were important to maintaining access to methadone during the pandemic.
In fact, several research studies have since come out saying that with relaxed regulations allowing people to have more access to take home methadone, people reported better quality of life, being more likely to stay in treatment longer, and were able to get jobs, go to school, and provide care to loved ones. Meanwhile, fears about people selling their methadone or increases in overdose deaths from methadone have not been proven. There were two studies that found methadone overdoses increased in 2020, though these early increases did not continue beyond the first few months of the pandemic, and methadone deaths actually decreased in 2021. These methadone-involved overdoses also pale in comparison to the vast increase of deaths related to fentanyl.
Because of this evidence, experts have advocated for the continuation of these relaxed regulations beyond the immediate crisis and broadening access to methadone. In fact, Dr. Nora Volkow, director of the National Institutes on Drug Abuse (the leading scientific organization in the United States on opioid use disorder), recently said, “Methadone is underutilized in part because it requires such stringent conditions in order to be prescribed. We have a pretty powerful health structure in the United States, and we should optimize it to maximize access to treatment for people with substance use disorders or other conditions. And that includes methadone.”
Why should we reduce our reliance on drug testing to make methadone decisions? Which other factors should we consider?
In traditional methadone clinics, patients are expected to comply with regular and random urine drug testing, meaning the clinic can request patients complete urine drug tests at any time without warning and can withhold one’s methadone medication until the urine test is completed. Also, if a patient submits a urine drug test that is positive for other drugs, clinics will sometimes reduce a patient’s methadone dose or not give them their dose at all, even if the only drug returning positive is cannabis. If a patient’s urine drug test returns positive for opioids because they’re using heroin or fentanyl, this is also usually a sign that their methadone dose isn’t high enough to treat their cravings and withdrawal, causing patients to use more opioids on the side. Therefore, clinics reducing or holding a patient’s methadone may be counterproductive. There is also no evidence showing that drug testing improves treatment outcomes.
Reducing our reliance on urine drug tests is important because these tests can create a culture of surveillance and punishment that may undermine the therapeutic relationship between patients and providers. While urine drug tests can be an important tool for assessing medication adherence and detecting potential drug misuse, their results should not be the measure of treatment success. Other factors, such as retention, quality of life, and improved well-being, are more meaningful indicators of recovery and should be prioritized. Methadone retention, for example, is a strong predictor of positive outcomes and is associated with reduced risk of overdose and other negative health outcomes. Focusing on factors beyond drug use, such as employment, housing, and social support, can also help promote meaningful recovery and improve overall quality of life for individuals struggling with opioids. By shifting our focus away from drug testing and toward these broader indicators of recovery, we can help to create a more patient-centered and holistic approach to methadone treatment.
How do we ensure patients take their methadone as prescribed if we increase access?
Most people who are prescribed methadone take it as prescribed. Diversion, which is selling or using a medication in a manner other than prescribed, is rare. In the few cases when methadone is diverted it is most often for friends or family who want treatment but are unable to access it, or to those who are in withdrawal and cannot obtain illegal opioids. If methadone were more widely available and easier to prescribe, methadone could dramatically reduce overdose deaths and save lives since we are now losing over 100,000 people a year to drug overdose. We should focus on the potential number of lives saved by increasing access to treatment than to focus on much less common cases of people taking methadone without a prescription. Any medication comes with potential risks that have to be weighed against its benefits. We are accustomed to accepting a certain amount of risk when it comes to any other medication that saves lives, and healthcare for people who use drugs shouldn’t be any different. The same measures that ensure proper use of other medications are equally effective with methadone. Ending the stigma that causes so many deaths each year will require treating people who use drugs the same as any other American who needs healthcare.
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