When Marni S. quit using heroin last year, it wasn’t her first time—but it was the first time she did so using medication. Over the years, the Colorado resident tried quitting cold turkey, but the pain proved unbearable.
Marni asked to be identified by her first name and last initial, given the stigma that can be attached to opioid use disorder (OUD).
In January 2022, her cousin recommended she visit an opioid treatment program (OTP). These are the only facilities licensed to provide methadone, a medication that helps people who want to stop using heroin, fentanyl, and other powerful opioids without suffering the most agonizing symptoms of withdrawal.
“It was easier than going to my drug connection,” Marni said of her first visit to the clinic in eastern Colorado. “Everyone knew what I was going through. They took care of me. It was a good experience.”
Unfortunately, that is not always the case for people seeking treatment for OUD. Decades-old federal and state policies limit access to medication, particularly methadone, which supports treatment and recovery and reduces the transmission of infectious diseases. It also curbs fatal opioid overdoses, which claimed 80,816 lives nationwide in 2021, including 1,258 in Colorado.
But experts in the field say the onerous requirements are starting to change, and Colorado has taken positive steps to help more people get treatment.
“Societal views, laws, and rules toward opioid use disorder and its treatments have historically demonstrated stigma that is driven by a lack of understanding,” said Ryan Mueller, Colorado’s state opioid treatment authority, the primary official overseeing OTPs within the state’s Behavioral Health Administration. “I would implore people to follow the data. The evidence tells us that methadone is a gold standard for treating opioid use disorder, particularly when fentanyl is in the drug supply.”
To boost access to treatment, Colorado policymakers in February 2022 eliminated some regulations that were more restrictive than federal rules. For example, the state no longer requires that OTPs maintain a ratio of one counselor per 50 patients and that their medical director must be on site 40% of the time. This was especially critical for facilities in rural areas where health care staffing shortages are challenging.
Under the old rules, “some clinics stopped accepting patients because they were exceeding that ratio,” said Mueller.
“I know of two, if not three, OTPs that were on track to close,” said Angela Bonaguidi, president of Colorado’s chapter of the American Association for the Treatment of Opioid Dependence. “As a result of the policy changes, OTPs were able to stay open.”
Mueller noted that five new OTPs are expected to open throughout Colorado in 2023.
Another state policy shift allows the treatment programs to dispense take-home methadone without prior approval from state authorities. When patients initiate treatment, they must visit an OTP daily to receive a single dose of methadone. If they meet certain criteria, they can receive more medication per visit—ultimately, up to a month’s worth after two years in treatment and eight consecutive negative toxicology screens.
As Marni was starting treatment, she got up at 3:30 a.m. every day, drove more than an hour to her OTP, waited in line for one dose of medication, and rushed to her job at 6 a.m., praying that she would be spared bad weather or a flat tire. Now, she is getting ready to receive a week’s worth of methadone at a time.
“Imagine the gas I’m going to save, the travel time,” Marni said. “I’ll be able to have breakfast with my daughter, drop her off at school, see my horse, play with my dog.”
Colorado policymakers also withdrew the mandate that patients must receive an hour of counseling each month regardless of how long they have been in treatment or whether it is clinically appropriate. Evidence shows that people benefit from treatment with methadone even in the absence of counseling.
“You could have patients that benefited from counseling for one or two years, and now they no longer need it,” said Steve Young, medical director of Colorado Treatment Services, which operates three OTPs. “But when you have rigid rules, they still have to come in—and that can interfere with patients’ work schedules, especially because very few OTPs offer those services on the weekends.”
According to research from The Pew Charitable Trusts, as of June 2021, 23 states still imposed counseling schedules, a one-size-fits-all approach that runs counter to individualized, person-centered care.
The Substance Abuse and Mental Health Services Administration (SAMHSA) is finalizing federal rules that would permanently allow patients to receive up to 28 days’ worth of take-home methadone earlier in treatment, even if they are not in counseling.
Despite concerns that these temporary flexibilities would increase misuse and overdoses during the COVID-19 pandemic, research shows that they did not. Better still, an analysis of 29 studies identified significant benefits: When people did not have to report as frequently to OTPs for medication, they had more time to manage responsibilities such as family, work, and education, and in interviews with researchers, some described “feelings of pride, accomplishment, and self-confidence” and “a stronger relationship with their providers,” which aided recovery.
Mueller said that the Colorado Behavioral Health Administration is examining SAMHSA’s rules and will prioritize any necessary change to state regulations. He noted that the agency had expanded its staff and leadership in the past year so that it can update policies more quickly and effectively.
“More states should follow Colorado’s lead and align their policies with federal rules,” said Frances McGaffey, an associate manager with Pew’s substance use prevention and treatment initiative. “Clinicians and their patients deserve a modern, evidence-based approach that destigmatizes methadone and lowers barriers to it.”
“Treatment puts the family back together,” Marni said. “I have a great job, good friends, I go to church, my son is getting ready to get married, my daughter is top in the state for athletics. Life is really good— and methadone has given me that.”
Josh Wenderoff works on The Pew Charitable Trusts’ health programs.