— One-size-fits-all treatment approaches sometimes fail
America's drug overdose crisis has escalated in the past few years due to several factors, including disruptions caused by the COVID-19 pandemic, driving an unprecedented rise overdose fatalities. Fentanyl, stimulants and, more recently, sedatives like xylazine in the unregulated drug supply continue to drive the worst overdose crisis in American history. We cannot effectively address this crisis without updating policies that narrow the persistent addiction treatment gap acknowledge the reality of polysubstance use, and equip addiction specialists with every tool science has to offer.
While we saw important policy changes during the pandemic, one essential policy issue still lags behind: broadening access to methadone treatment.
Background on Opioid Use Disorder Treatment
As an addiction specialist physician, I served on the front line of this overdose crisis during the pandemic. My patients experienced lonely COVID-19 quarantines during inpatient and residential addiction treatment. Staff working in outpatient programs were pushed to deliver care remotely, including medical clinicians learning to initiate lifesaving addiction medications via telehealth.
In-person requirements to receive addiction treatment were modified, and addiction treatment systems quickly adapted. We learned that remote delivery of addiction medications could be managed safely and enhanced patient access to care. New policies were enacted, like those facilitating telehealth prescribing of controlled medications. Greater flexibilities with respect to take-home methadone supplies for opioid use disorder (OUD) treatment swept the nation.
Last year, federal policymakers further transformed the landscape when they passed a law ensuring that clinicians who prescribe controlled medications receive education on treating patients with substance use disorders, and eliminated antiquated restrictions on the prescribing of buprenorphine for OUD. Buprenorphine will continue to play a critical role in OUD treatment, but in the context of this unprecedented overdose crisis, we need access to additional options. One limitation of buprenorphine is that it can precipitate opioid withdrawal if a patient is actively using other opioids.
In a recently published document reviewing clinical considerations surrounding the use of buprenorphine in the age of high-potency, we come to better understand synthetic opioids. As part of an effort to increase successful buprenorphine treatment of OUD, the document's authors describe emerging buprenorphine-related strategies in the age of fentanyl. For example, higher doses of buprenorphine may be required for stabilizing some patients. For other patients, the use of long-acting, injectable buprenorphine may be the best option. Still, for others, initiating buprenorphine at low doses, while continuing full agonist opioids (such as methadone) during buprenorphine escalation may be warranted.
However, there's a major catch when it comes to this latter strategy: U.S. federal law is currently understood to prohibit an outpatient prescription of a full agonist opioid for the treatment of OUD. This means that some patients may continue to use illegally obtained opioids while initiating buprenorphine to avoid withdrawal. With such a strategy, it is outdated federal policy, not drug potency, that exacerbates an unnecessary patient risk.
This document should prompt every American policymaker to rethink how we can modernize our policies to save more lives. In the age of fentanyl, one-size-fits-all protocols for buprenorphine sometimes fail.
Options for Updating Methadone Policy
Methadone remains the only full agonist opioid approved in the U.S. for OUD treatment, and current federal law largely restricts outpatient access to methadone for OUD to approximately 2,000 clinics called opioid treatment programs (OTPs). These methadone regulations create an often-insurmountable challenge for many Americans. For example, in rural America, a patient may spend a good part of each day driving to their OTP -- if their county has one, that is.
Some health professionals have expressed concerns that a big increase in access to methadone could lead to new safety issues, such as low-quality care or harmful use of methadone itself. However, when methadone is managed by trained physicians who arrange for dispensing by community pharmacies, it can be handled in a medically appropriate manner. Inaction is a much greater threat to patient safety than the risk of responsibly updating decades-old policies to expand patient access to methadone when it is managed by addiction specialist physicians.
The U.S. Senate should take up the Modernizing Opioid Treatment Access Act (MOTAA), as the U.S. House advances other legislation to bolster the nation's addiction treatment infrastructure. MOTAA would finally allow addiction specialist physicians, like me, to use our clinical expertise to treat OUD with methadone dispensed by a local pharmacy. MOTAA would mean the chance for more Americans with OUD to reach remission and recovery; at full scale, it could man a giant step forward to ending this human crisis.
In honor of Overdose Awareness Day, Congress should pass MOTAA -- an essential policy change needed to save lives.