Methadone, approved by the Food and Drug Administration in the 1970s as a first-line treatment for opioid use disorder (OUD), is a proven, effective drug: It reduces overdose deaths and infectious disease transmission, and it supports treatment retention and recovery. But people seeking methadone for OUD can access it only from opioid treatment programs (OTPs)—facilities regulated at the state and federal levels that subject patients to punitive rules that aren’t reflective of evidence-based care. Amid the COVID-19 pandemic, however, the federal government eased regulations so that people could more safely access the medication.
This interview—with Dr. Rachel Simon, an assistant professor of psychiatry and medicine at the NYU Grossman School of Medicine who practices primary care and addiction medicine in Bellevue Hospital’s opioid treatment program in New York City, and Abby Coulter, a special projects coordinator with the North Carolina Survivors Union and a methadone liaison with the Urban Survivors Union who has taken methadone for more than 20 years—has been edited for length and clarity.
Q: What has opioid treatment program care traditionally looked like?
Simon: OTPs were first established in the 1970s against the backdrop of the Nixon administration’s “war on drugs,” which disproportionately affects people of color. The focus of OTPs at the time was on reducing crime and methadone diversion, and as a result they were designed with control and security in mind, not as patient-centered health care facilities caring for those with addiction. To this day, these facilities have many restrictions. Most patients must travel to the facility every day to get medicated with methadone to treat their opioid use disorder, or OUD. These facilities can also be difficult to get to, even for people who live in an urban setting, where most of them are located. In rural areas, it’s even worse, as even fewer facilities exist, and I know patients who travel hours daily to get to their OTP. Wyoming has zero OTPs, for example, and South Dakota has only one. At the OTPs, there are often long medication lines in public spaces, a heavy security presence, and observed urine drug screens. And most OTPs require counseling, even though there’s no evidence that psychosocial treatments are essential components of care. Together, these factors make it nearly impossible for many people with OUD to get treated with methadone.
Coulter: I used to say the OTP system was broken, but the truth is, it works exactly the way it was designed. It caters to one specific group: folks who are compliant with and are able to follow these arbitrary rules around treatment. There are so many people who are just trying to survive the system.
Q: What’s changed since the pandemic?
Simon: In March 2020, the Substance Abuse and Mental Health Services Administration, or SAMHSA, loosened restrictions on take-home doses of methadone. Basically, the agency said that patients who met certain criteria could be classified as “stable” and could be eligible to take home either 14 or 28 days of medication.
Q: Rather than having to come to a clinic in person every day for a dose?
Coulter: Prior to COVID, methadone was almost taboo—people did not want to talk about it as a treatment option, and some people still don’t. But I think the pandemic has changed that somewhat. We’re in the midst of this huge overdose epidemic and we have this tool—methadone—that’s not being widely used by patients with OUD who would clearly benefit. And I hate to say it, but had COVID not happened, we wouldn’t be talking about making methadone easier to access. The federal regulations governing OTPs and how patients get methadone haven’t changed in years.
Q: So since the pandemic began OTPs have been able to send more patients home with take-home methadone doses. Did all OTPs do so?
Simon: Some OTPs provided increased take-homes. But only a minority were providing 14 or 28 days’ worth of medication.
Coulter: Some clinics have already rescinded take-homes, even though SAMHSA said OTPs can continue to offer these flexibilities to patients. These clinics aren’t going back and offering take-home doses to patients again just because SAMHSA said they could continue. And that’s the problem with guidance versus a mandate: Treatment availability can vary from clinic to clinic.
Q: Have we learned anything from allowing more patients to take this medication home?
Simon: There’s always been much resistance to increased take-home doses, but the sky didn’t fall once programs started sending patients home with 14- or 28-day doses. Data shows that methadone diversion didn't increase, nor did overdose from methadone—which critics argued would happen.
Not only do we see the absence of harm from take-home doses, we’re also seeing benefits. Patients love the increased autonomy, and said it’s helped them feel like a normal person—less shackled to the OTP. You have to realize, the unrelenting burden of planning your day around getting medicated at an OTP—your activities, your work, your child care— is really intense. We are also seeing data that increasing take-homes increases treatment retention, which in the field of addiction medicine is one of the most concrete markers of treatment success—because keeping people in treatment keeps people alive.
On the flip side, we’ve also seen some patients say they like going to an OTP each day for daily dosing. And that’s fine! That doesn’t negate the benefits of take-home doses; it just tells me that we need person-centered, individualized treatment.
Q: Are more patients coming to OTPs as a result of the loosened restrictions?
Coulter: No, because methadone is still so difficult to access. Some folks are opting for buprenorphine—which can just be picked up at the pharmacy—to treat their OUD. And they’re doing this even though they say it doesn’t work as well for them, because they just can’t go to an OTP for methadone every day. They’re essentially white-knuckling it—using a medication that isn’t as effective for them personally just because it’s easier to get.
Q: Can you explain how accessing methadone differs from accessing buprenorphine?
Simon: Absolutely. Clinicians can prescribe buprenorphine to patients in office-based medical settings, and those patients can pick up their medication at a pharmacy just like any other drug. Even methadone if prescribed for pain can be prescribed by any licensed clinical provider and picked up at a pharmacy. Methadone for opioid use disorder, however, is only available at OTPs, and patients have to earn the right to take home limited amounts of medication, at the discretion of those in charge.
Q: You’ve referenced some of the challenges you’ve seen in OTPs. Can you say more about that?
Coulter: Sadly, OTP counselors are more like probation officers. And most OTPs don’t provide any trauma-informed care.
A patient I know struggled with her take-home dosing during COVID and was going to run out of medication before the end of the month. She went to her clinic and asked for help. What did they do? They handed her a suicide hotline card and said, “See you next month.” This was a compliant patient who was struggling with a divorce and a daughter who had attempted suicide. Can you imagine the difference it would make if people like her could access effective counseling services?
Personally, I lost my monthly take-homes as a result of one positive drug screen. I was stripped back down to daily dosing. Clinic patients often feel that at any given moment, our lifesaving medication can be yanked from us.
Q: How would you change methadone treatment?
Simon: Methadone should be available via office-based care and people should be able to pick it up at a pharmacy, just like patients do for any other medical condition. This has already been implemented successfully in the U.K., Australia, and Canada. And I want prescribing flexibility, like I have with buprenorphine. I want to sit with my patients and find out what’s going to keep them safe and healthy and in treatment.
Coulter: In a perfect world, there would be no OTPs. I could go to my doctor for a drug I need, just like anybody else goes to their doctor for the medications they need. But OTPs aren’t going away, so parity between methadone and buprenorphine is the goal.
Q: Parity how? In terms of how they’re dispensed?
Coulter: Yes. Pharmacy dispensing of methadone would have saved me from dragging my newborn out into the snow and driving more than two hours in bad weather to get dosed. It would have saved me from telling my son on Christmas morning that he had to wait to open presents until Mommy got back from the clinic.
Q: What other benefits would there be of pharmacy-based dispensing?
Simon: It would change lives. It would increase access to care by reducing long commutes and transportation costs to treatment, especially for people living in rural areas. It would also reduce stigma, because office-based treatment would increase patient privacy, compared with the communal setting of an OTP. And it would address issues of racial equity, because Black and Latinx people with OUD are disproportionally harmed by oppressive methadone regulations.
Coulter: It would give patients back our dignity—and the autonomy we deserve.
Q: Any final thoughts?
Simon: Methadone is an incredible treatment for OUD. During COVID, we’ve seen lots of overdoses. But not one patient of mine who is stable on methadone has died from an overdose. That’s remarkable.
We need to frame methadone as not simply an OUD treatment, but as an invaluable tool for overdose prevention. We need to put methadone treatment for opioid use disorder back in the hands of health care providers and do so in a way that allows methadone treatment to be accessible, equitable, and patient-centered.
Coulter: I always say, I’m my most optimal self when I have an opiate on board—that is, when I have the drug in my system—and methadone is the safest option I have. It helps with my mental health issues. It’s a miracle medication.