Jeffrey A. Singer
Next Tuesday, the Senate Committee on Health, Education, Labor, and Pensions (HELP) is scheduled to consider S.644, the Modernizing Opioid Treatment Access Act (MOTAA). The bill is sponsored by Senator Edward Markey (D‑MA) and co‐sponsored by Senators Rand Paul (R‑KY), Bernie Sanders (I‑VT), Mike Braun (R‑IN), Cory Booker (D‑NJ), and Maggie Hassan (D‑NH). It would expand access to methadone treatment for people with opioid use disorder (OUD) by allowing board‐certified addiction specialists to prescribe methadone to patients in their offices or clinics. This would provide people with an alternative option to the current system that segregates and stigmatizes people with OUD by making them queue up daily at government‐approved opioid treatment programs (OTPs).
As I wrote here, the bill doesn’t go far enough—there are not nearly enough board‐certified addiction specialists to meet the needs of people with OUD. However, as I wrote here:
The Modernizing Opioid Treatment Access Act is the first serious attempt in many years to remove unnecessary government barriers to methadone treatment. The bill also helps to destigmatize people with OUD by treating them as suffering from a medical condition.
As Sofia Hamilton and I explain in a recent Cato policy analysis, methadone has been proven as an effective treatment for addiction and dependency since the 1960s. Before Congress passed the Drug Abuse Prevention, Treatment, and Rehabilitation Act of 1972, primary care clinicians in the US would prescribe methadone, an opioid agonist, to patients and follow them in their office practices.
That all ended in 1972 when the federal government segregated people with opioid use disorder from people with other health conditions that doctors treat in their offices, requiring them to often travel miles each day to take a daily dose of methadone in front of OTP staff. In the UK, Canada, and Australia, primary care clinicians working with community pharmacies have always prescribed methadone, and people in those countries thus have much greater access to methadone treatment.
Ideally, Congress should allow primary care clinicians to prescribe methadone to people with OUD in the office setting, as they do in the countries above. Clinicians can already prescribe another opioid agonist medication, buprenorphine, in the office to treat OUD. And we doctors can legally prescribe methadone to treat patients’ pain in the office setting. There is no good reason for the government to apply different rules for prescribing methadone to treat OUD.
Most objections to allowing clinicians to prescribe methadone emanate from the operators of the OTPs. This comes as no surprise. It is reminiscent of the objections raised by the taxi cartels when Uber and Lyft emerged as competition. They argue that allowing clinicians to prescribe take‐home methadone—and pharmacists to fill the prescriptions—would result in methadone getting “diverted” to the black market for sale to non‐medical drug users. But the evidence doesn’t back up those claims.
Critics of allowing clinicians to prescribe buprenorphine raised similar concerns about diversion. But research in 2018 by Washington University’s Theodore Cicero and others shows:
The most common reasons for illicit buprenorphine use were consistent with therapeutic use: to prevent withdrawal (79%), maintain abstinence (67%), or self‐wean off drugs (53%)… Among respondents who had used diverted buprenorphine, 33% reported that they had issues finding a doctor or obtaining buprenorphine on their own. Most (81%) of these participants indicated they would prefer using prescribed buprenorphine, if available.
The researchers concluded, “Diversion was partially driven by barriers to access, and an unmet need for OUD treatment persists.”
In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) temporarily liberalized methadone take‐home rules for OTPs, allowing “stable” patients to take home up to a 28‐day supply. The program was such a success that SAMHSA has extended the rule and is “working toward a permanent solution.” Researchers at the Centers for Disease Control and Prevention and the National Institute on Drug Abuse evaluated the impact of the relaxed take‐home rules and wrote in JAMA Psychiatry in July 2022, “Monthly methadone‐involved overdose deaths remained stable after March 2020.”
The National Institutes of Health reported that same month that “the percentage of overdose deaths involving methadone declined between January 2019 and August 2021.”
Interestingly, the National Institute on Drug Abuse stated in December 2021:
Methadone diversion is primarily associated with methadone prescribed for the treatment of pain and not for the treatment of opioid use disorders. In one survey, giving methadone away was identified as the most common form of methadone diversion, which aligns with other findings that 80 percent of people who report diverting methadone did so to help others who misused substances. (Emphasis added.)
Keep in mind that the law has always permitted clinicians to prescribe methadone for the treatment of pain.
Thus, it appears that, as with buprenorphine, the majority of people who use diverted methadone are using it to avoid withdrawal as they attempt to taper off of an illicit opioid they’ve been using. This is because they cannot get access to the scarce number of methadone OTPs.
As I pointed out here, ”Expanding access to OUD treatment would reduce the number of people who seek drugs in the dangerous black market and, in turn, reduce the risk and incidence of overdose deaths.”
Last September, I moderated a policy forum at the Cato Institute examining ways to expand access to methadone treatment that featured Rep. Donald Norcross (D‑NJ), a sponsor of the House version of MOTAA. You can view it here.
As the Senate HELP Committee starts to mark up the bill, lawmakers should dismiss unsubstantiated concerns about diversion that incumbent OTP operators would like to raise. On the contrary, based on the data, one can argue that the most effective way to minimize methadone diversion is to increase access to methadone treatment.