How the pandemic spurred a push to expand methadone access

A bipartisan push to expand methadone access across America is picking up momentum after restrictions on the medication were relaxed during the pandemic.

Methadone is one of the most effective treatments available for opioid use disorder (OUD), however experts have long feared that easy access could backfire since methadone carries its own potential for abuse and unintentional overdose.

But the pandemic provided an opportunity to see the real-world impact of dispensing restrictions being relaxed, as patients and clinicians experienced a more open system. 

Under current federal law, methadone can only be dispensed at licensed and accredited opioid treatment programs (OTPs), where patients take the medication under the supervision of a practitioner, with the potential of taking doses home after some time under stable treatment.

When the pandemic began in 2020, however, the Substance Abuse and Mental Health Services Administration (SAMHSA) swiftly issued guidance allowing states to relax OTP requirements and permit patients to take home doses of methadone sooner than usual. 

“That gave us several years of experience in at least a somewhat more open-access system,” said Wilson Compton, deputy director of the National Institute on Drug Abuse.

“So there's been an opportunity to hear from patients, what they thought about it, to look at administrative data and even the overdose death data to see if there's evidence of potential harms from the relaxation of access to methadone in the opioid treatment programs.”

A 2022 study that Compton was a part of found that methadone-involved overdose deaths remained stable after the onset of the pandemic despite the take-home policy change, while the rate of non-methadone opioid overdoses rose.

The White House has signaled an eagerness to explore further options for expanding access to methadone. Rahul Gupta, director of the White House Office of National Drug Control Policy, said in an interview earlier this year that “all options are on the table” when it comes to increased methadone access.

SAMHSA issued proposed rules in December that would make the pandemic flexibilities permanent if adopted. 

A bipartisan coalition of lawmakers reintroduced legislation earlier this year that would build on these flexibilities. The Modernizing Opioid Treatment Access Act would allow more clinicians to prescribe methadone for the purpose of treating OUD as well as allow pharmacies to dispense the drug.

The bill has the support of Reps. Donald Norcross (D-N.J.), Don Bacon (R-Neb.) and Brian Fitzpatrick (R-Penn.) as well as Sens. Bernie Sanders (I-Vt.), Rand Paul (R-Ky.), Cory Booker (D-N.J.), Mike Braun (R-Ind.) and Maggie Hassan (D-N.H.).

Legislative efforts to expand methadone access have floated around for years, but the unique circumstances of the pandemic provided “quite a bit of emphasis” on this push, Compton noted.

Reintroduced in March, the bill has yet to have a committee hearing after being referred to both the Judiciary Committee and the Energy and Commerce Committee.

According to a Republican staffer in the House, supporters of the bill are looking to shore up even more bipartisan support, adding the chief obstacle to passing this bill — which failed to pass in the previous Congress — is making sure there is bandwidth for it among larger pieces of legislation.

Those familiar with addiction treatment say legislation like the Modernizing Opioid Treatment Access Act would go a long way towards getting more people treatments like methadone.

“One of the big issues with opiate treatment programs is they're not everywhere,” Brian Hurley, president-elect of the American Society of Addiction Medicine (ASAM) board of directors, told The Hill. There are just under 2,000 OTPs in the U.S.

“They are geographically clustered and not every community even has an opiate treatment program. Again, that limits methadone access,” said Hurley. 

“When patients go to OTPs, and there really is no other alternative, they're getting care in a system that is kind of universally regulated across the country without really full flexibility in being able to meet patients where they are.”

Much of the pushback against expanding who can prescribe and dispense methadone comes from those working in the OTP space, Hurley noted. Opponents argue that unsupervised methadone treatment could lead to increased rates of abuse and overdoses.

Methadone, first approved for treating opioid dependence in the '70s, can be prescribed for both pain management and addiction recovery. Out of the three available medication options for OUD — buprenorphine, methadone and naltrexone — methadone comes with more ease of use and is indicated for those with all levels of dependence.

Still, Mark Parrino, the founder and CEO of AATOD, the trade organization that represents opioid treatment programs across the country, pointed out at its annual conference that there were thousands of methadone-specific deaths from 1999 to 2015. 

“We do not want to exacerbate the problem we’ve already got,” he said, according to STAT. 

Hurley pushed back on those concerns, noting, “methadone overdoses are not zero but are vanishingly low and are almost always associated with methadone that's being used for pain.”