Imagine you need a daily dose of medicine to control a life-threatening condition. Now imagine that to get that dose — on weekdays, weekends, Thanksgiving, Christmas — you must travel an hour each way to a clinic that is only open during certain daytime hours. You also have to attend counseling. Could you hold a job and take care of your children?
“I have a car, live safely in a house, have more than a couple of dollars in my pocket, and I couldn’t get to a methadone clinic every day,” said Deirdre Calvert, director of the state Department of Public Health’s Bureau of Substance Addiction Services. “Yet we make the most disadvantaged, disenfranchised humans get to a clinic every day.”
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Methadone is one of three medications approved to treat opioid use disorder, and for some patients it is the only effective option. Yet methadone is the only federally approved drug dispensed outside the traditional medical system.
People who need methadone must get it from a federally approved opioid treatment program, a clinic with strict, onerous rules. This system stigmatizes use of the medication and leads to pockets of drug use as people with addiction and those in recovery crowd around areas like Mass. and Cass, which has multiple methadone clinics.
New flexibilities instituted during the COVID-19 pandemic let patients take more doses home, and those flexibilities should be made permanent. But to truly make methadone accessible, Congress should pass the Modernizing Opioid Treatment Access Act, a bill sponsored by Senator Ed Markey of Massachusetts with bipartisan support — and support from the American Medical Association and more than 100 other groups — that would let doctors prescribe methadone and pharmacies dispense it.
“Methadone should be used to help people maintain recovery and not to make their lives more difficult,” Markey said in an interview with the Globe editorial board. “There’s a lot of stigma that attaches to accessing methadone and addiction treatment more generally and this is a way of helping reduce that.”
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In Massachusetts, there are 54 methadone clinics treating 24,000 people, according to the Bureau of Substance Addiction Services. Dr. Ruth Potee, medical director for addiction services at Behavioral Health Network, which runs four methadone clinics in Western Massachusetts, said her agency has clients in rural areas who drive an hour to a clinic.
Since methadone was approved in the 1970s, the US Substance Abuse and Mental Health Services Administration has maintained strict rules that require most people using methadone to treat substance use disorder to visit a clinic in person daily, though take-home doses were allowed under narrow circumstances. When COVID hit in March 2020, SAMHSA allowed states to request blanket permission for people who are stable on methadone to receive up to 28 take-home doses and those who are less stable to receive up to 14 doses. SAMHSA also allowed telehealth counseling. Almost all states adopted these flexibilities, although implementation was uneven and varied by clinic.
Studies suggest the policy was successful. There were not more instances of people diverting or overdosing on methadone, patients and providers were generally happier, and there was some evidence that more people remained in treatment. In Massachusetts, Calvert said there were zero reports of methadone overdoses under the flexibilities, fewer than 10 reports of diversion, better retention in treatment, and improved client satisfaction. SAMHSA has since extended the flexibilities until May 2024 for states that accept them — which Massachusetts has — and the agency is expected to write new rules making them permanent. The Biden administration should adopt these flexibilities permanently. But it is not enough.
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Last year in Massachusetts, 2,357 people died of opioid overdoses. Fentanyl is becoming prevalent in the drug supply, and clinicians say the other commonly prescribed addiction medication, buprenorphine, is less effective and can cause withdrawal symptoms for fentanyl users.
The best way to expand methadone access is by letting physicians and pharmacists prescribe and dispense it, just as they do other potentially dangerous drugs.
There would still be room for methadone clinics, and some patients would still need daily visits. Potee said at her clinics, even with the COVID-era flexibilities, around one-third of patients come in daily because they need the structure, are not yet stable, lack a safe place to store methadone, use other substances that put them at risk of overdosing, or previously took home methadone and sold it.
But expanding the number of people who can prescribe and dispense methadone and moving it into traditional medical settings would lessen transportation challenges and reduce stigma. Dr. Jessica Taylor, medical director at Boston Medical Center’s urgent care clinic for people with substance use disorder, said policy makers need to make methadone more accessible. Now, Taylor said, “It’s a system that fails our patients. … The experience of going to a methadone clinic is an incredible barrier.”
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Implementation details would need to be worked out. Physicians would need training and would have to abide by prescribing rules set by the federal government. But that is not insurmountable, and some physicians already prescribe methadone to treat chronic pain or at clinics like Taylor’s, which may dispense up to 72 hours’ worth of methadone.
Pharmacies would likely have to purchase the expensive machines used to dose liquid methadone, since the only pills manufactured tend to be much smaller than the doses people take to treat addiction.
A new policy would not result in an immediate sea change. When the federal government made it easier to prescribe buprenorphine, clinicians reported other barriers like concerns about treating patients with addiction or insurance approval processes.
But other countries have done it successfully. Canada, the United Kingdom, and Australia all let physicians prescribe and pharmacies dispense methadone, and daily in-person dosing can be done in pharmacies.
Most opposition to change has come from the opioid treatment programs, which could lose money if they lose patients. The American Association for the Treatment of Opioid Dependence opposes letting physicians prescribe methadone, though it is open to letting pharmacists dispense it. At the recent STAT Summit in Boston, association president Mark Parrino raised concerns about increases in methadone overdoses, diversion, and whether a solo physician could take a holistic approach of requiring counseling and medication.
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These are legitimate concerns. But the potential benefits of a policy shift outweigh the risks. If Congress does nothing, people will continue to die of drug overdoses simply because getting treatment is too hard.
Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion.
