Program, not a pill

Opioid Treatment Programs: Get the Facts

Overview

Program, not a pill, a campaign to support expanded access to patient-centered, evidence-based treatments for opioid addiction, is grateful for the increased attention around the opioid epidemic. There is a  need to increase access to medication-assisted treatment (MAT) while addressing the stigma that has led to harmful discrimination and policies against people with opioid use disorder (OUD). The problem of accessibility is complex, and even well-intentioned individuals may have misguided assumptions about MAT, OUD and barriers to access to treatment.

We provide an evidence-based perspective on these common misconceptions.

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WHAT IS MAT?
Medication-assisted treatment (MAT) is more than just medicine—it involves a comprehensive program of services individualized for each patient, which includes counseling and behavioral therapies.

WHAT IS METHADONE?
Methadone is a long-acting opioid agonist medication approved by the Food and Drug Administration (FDA) to treat Opioid Use Disorder (OUD) as part of MAT. Methadone reduces opioid craving and withdrawal and blunts or blocks the effects of opioids.  When used in a supervised setting, methadone is safe and effective. Structured methadone treatment helps individuals achieve and sustain recovery and to reclaim active and meaningful lives. Methadone is just one component of a comprehensive treatment plan, which includes counseling and other behavioral health therapies to provide patients with a whole-person approach.

Accessibility

MYTH: Many people with opioid use disorder (OUD) do not receive medication-assisted treatment (MAT) because they don’t have access to opioid treatment programs (OTPs).

Over the last 5 years, access to OTPs has increased dramatically, with investments in opening new facilities, expanded mobile clinics and greater use of telehealth. Nearly 87% of U.S. adults live within 30 miles or a 40-minute drive of an OTP, which is the network adequacy standards for outpatient behavioral health established by the Affordable Care Act.1 As of June 2023, there are over 2,000 OTPs in the United States, providing care to over 650,000 patients.

In the darkest days of the pandemic, 86% of OTPs continued to accept new patients in treatment with an average of just 3.5 days until admission, demonstrating OTPs’ dedication to patient access.3 During the first two years of the pandemic, patients receiving medication-assisted treatment (MAT) at OTPs increased by 32% to more than 500,000 patients.4

Even with this progress, OTP providers recognize that the structure of OTPs can be limiting for patients and disruptive to their daily lives and have been working with regulators for years to modify the rules to allow patients additional flexibilities. Thankfully, new expanded flexibilities enabled by SAMHSA’s modernization rule going into effect on April 2, 2024 will help accelerate accessibility. Under this rule, patients may receive up to 28 days’ worth of methadone when engaged with the OTP’s multi-disciplinary team (as codified by SAMHSA), patients can receive comprehensive OTP services at mobile clinics, and patients can be admitted to treatment and receive counseling via telehealth.5 SAMHSA also eliminated the requirement for patients to have had a year-long history of OUD to be eligible for treatment.6

1. https://dpt2.samhsa.gov/treatment/; accessed list March 2023
2. https://www.federalregister.gov/documents/2024/02/02/2024-01693/medications-for-the-treatment-of-opioid-use-disorder
3. https://www.sciencedirect.com/science/article/pii/S037687162300039X#bib16
4. https://www.aatod.org/wp-content/uploads/2022/12/OTP-Patient-Census-Narrative-Final-for-Release.pdf
5. https://public-inspection.federalregister.gov/2022-27193.pdf
5. https://www.samhsa.gov/medications-substance-use-disorders/statutes-regulations-guidelines/42-cfr-part-8/faqs

MYTH: The Modernizing Opioid Treatment Access Act (MOTAA) will expand access to methadone treatment by allowing addiction-certified office-based physicians to prescribe methadone for pick-up at pharmacies.

  1. Methadone medication is not synonymous with the evidence-based comprehensive methadone treatment patients receive from OTPs. OTPs’ patient-centric approach incorporates counseling to help patients identify underlying triggers and provides wraparound psychosocial supports. MOTAA has no requirements for counseling, support services and oversight which are critical components of the model’s success.
  2. As buprenorphine trends show, just because doctors can treat OUD with medication, does not mean they will. Many board-certified physicians are hesitant to treat OUD with medication. Many doctors have not increased prescribing of buprenorphine after the removal of X-waiver requirements, which had previously been cited as a barrier to treatment.1 And many pharmacies have not been adequately stocking buprenorphine.2 Given that addiction specialists are not required to have any hands-on methadone training and methadone is substantially more potent than buprenorphine, it is not likely that enough doctors would feel comfortable treating addiction with methadone.3
  3. Most non-elderly adults with OUD are on Medicaid or uninsured.4 For many OTPs, Medicaid is their largest payer. However, only 36% of addiction medicine physicians accept Medicaid and just 2% (n=85) practice outside of an OTP treatment area.5 Therefore, most patients with OUD would not have increased access to treatment if addiction medicine physicians were allowed to prescribe methadone.

    1. https://www.statnews.com/2023/07/21/opioid-addiction-buprenorphine-suboxone-x-waiver/
    2. https://www.fiercehealthcare.com/providers/many-pharmacies-dont-have-buprenorphine-stock-jama-study-finds
    3. https://apnews.com/article/cvs-walgreens-pharmacists-drug-shortages-c7a94430a2c9d11779a684c2bcfc4c2c
    4. https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in-facilitating-access-to-treatment/
    5. https://programnotapill.com/wp-content/uploads/2024/03/OTP-and-Addiction-Medicine-Physician-Maps-and-Analysis-1.pdf

Financial Incentives

MYTH: OTPs oppose deregulating methadone because they have a profit motive.

There is no evidence indicating methadone treatment outside of OTPs in U.S. is safe or effective. However,  the dangers of prescribing methadone without supervision have been corroborated in five federal reports throughout the 2000s, all finding that methadone prescriptions obtained in a physician’s office led to more overdose deaths.1,2,3 Data from other countries include similar insights and more — including one study that patients receiving methadone prescriptions at onsite pharmacies in clinics are more likely to stay in treatment than those who receive them at offsite community pharmacies.4 Regular interactions with patients as they stabilize on methadone are crucial to engagement and preventing relapse.

Many organizations, including non-profit OTPs and law enforcement agencies are concerned about how liberalizing methadone will impact patients and communities.

1. https://www.justice.gov/archive/ndic/pubs25/25930/index.htm
2. https://atforum.com/documents/CSAT-MAM_Final_rept.pdf
3. https://www.gao.gov/assets/gao-09-341.pdf
4. https://pubmed.ncbi.nlm.nih.gov/30064001/

Drawing Inaccurate Parallels

MYTH: Results in Europe show the just prescribing methadone for unsupervised use and without providing any psychosocial services.

Before instituting sweeping changes that risk worsening this epidemic, the government should take a more measured approach by investing in piloting approaches in the U.S. and studying the impact

MYTH: Methadone is comparable to other drugs. The fact that it is long-acting and that it is used to treat opioid addiction makes it unlikely that people will use it to get high and therefore indicates safety.

Daily interactions and patient engagement with a multidisciplinary care team help ensure long-term retention and recovery. When titrated correctly, methadone shouldn’t lead to intoxication, but it can cause drowsiness while hindering reaction time, attention span, peripheral vision and information processing.1

Methadone is metabolized differently within people’s systems, leading to inconsistent levels at the same dosage amount — a safe dosage for one person may lead to overdose for another, which some research has attributed to genetic makeup.2 Methadone is a long-acting opioid, which means that it can linger in the blood and interact with other substances. Large doses are required for a “high”, so if an individual does misuse or combine it with other substances, it can lead to dangerous toxicity in the liver over time if misused.

Currently, at OTPs, it is up to multidisciplinary care teams’ discretion, informed by regular interactions with patients, to determine which patients can safely receive larger amounts of take-home doses without risk of misuse. Removing this level of oversight puts patients and communities in danger.

1. https://americanaddictioncenters.org/methadone-addiction/high
2. https://source.wustl.edu/2015/10/methadone-side-effects-efficacy-may-be-linked-to-genetic-makeup/