Opinion: One of the Best Tools to Manage the Opioid Crisis Already Exists

In the years since a family member of mine started taking methadone, a drug that helps him avoid the excruciating withdrawal symptoms and intense cravings that come with an opioid use disorder, he’s attended the funerals of three of his closest friends with whom he used to use drugs. The number of acquaintances he’s lost is in the double digits.

Methadone might have saved them — if only they could have picked it up from their local pharmacy.

Like heroin or oxycodone, methadone stimulates the opioid receptors in the brain. The difference is that while heroin rapidly floods these receptors leading to an intense high, the effect of methadone is more gradual and long-lasting. At the appropriate dose, my family member (whom I’m not naming due to the continued stigma surrounding opioids) and other patients can get full days of relief from pain, withdrawal, and cravings, without the intoxication. But methadone is tightly regulated. Rather than pick it up from the local pharmacy, patients have to visit a specialized clinic — often daily — to get each individual dose.

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In March 2020, concerns about Covid-19 led the Substance Abuse and Mental Health Services Administration, or SAMHSA, to relax those restrictions. The agency announced that states could request an exception allowing clinics to offer a greater amount of take-home doses— up to 28 days — for patients the clinical team believed were stable and could safely handle the medication. Some clinics embraced the opportunity. In a multistate survey of 170 opioid treatment programs, about half followed the relaxed SAMHSA guidelines for newly enrolled or less stable patients. And two-thirds of the clinics surveyed offered their stable patients a full four weeks of take-home doses.

The pandemic provided the natural experiment to demonstrate that loosening regulations on methadone in the U.S. was safe for both patients and communities. More than two years later, on July 13, researchers at the National Institute on Drug Abuse and the National Center for Injury Prevention and Control published some of the most powerful results of that experiment. While deadly overdoses involving opioids rose to staggering heights in the U.S. during the first year of the pandemic, the percentage of overdose deaths involving methadone decreased.

Some were concerned that allowing patients more take-home doses would raise the likelihood they would take multiple doses at once and overdose, but new research found that wasn’t the case. In fact, another 2022 study shows that when two clinics in Oregon offered additional take-home doses for patients who’d been in treatment for 180 days or more, treatment success actually improved. More people continued treatment and fewer relapsed. The patients said the increased take-home doses made them feel trusted and provided them with more time to dedicate to their careers and families.

In November 2021, SAMHSA announced that it would extend the loosened regulations for another year. Meanwhile, lawmakers have introduced a bill that would reform methadone care. But many clinics chose not to expand take-home doses despite the option to do so. Loosening state regulations on existing methadone clinics isn’t enough. If SAMHSA and the federal government hope to save lives, they should release methadone from the siloed clinics that make using it incredibly burdensome to patients.

We already know methadone works. Allowing people to pick up a week’s or month’s supply at their local pharmacies will make it work better and for more people. And methadone not only helps people maintain sobriety — it saves lives. A February 2020 study, for instance, compared patients who were prescribed methadone or buprenorphine, a similar, but less potent, medication used to treat opioid use disorder, with patients who had undergone other treatment pathways, such as residential treatment and behavioral therapies. Only treatment with either medication was associated with a reduced risk of overdose —76 percent within 3 months and 59 percent within a year. A 2015 study from England found similar results: Patients who received psychological therapy alone were twice as likely to die from an overdose than those who received methadone or buprenorphine.

In part because buprenorphine may have a lower risk of overdose than methadone, it has fewer restrictions. The drug has long been a controlled substance, but, unlike methadone, patients can obtain buprenorphine from a pharmacy and take it at home. While buprenorphine is as effective as methadone at higher doses, studies show that when patients were given the lower doses of buprenorphine most commonly prescribed, they were much less likely to continue treatment than patients who were treated with methadone. That was the case for my family member. Before methadone, he tried buprenorphine, in part because it was easier to access, but he never felt stable on it. “I always felt like I was about to fall off a cliff,” he said. One day he’d seem perfectly fine. The next day he’d slur his speech a little. Another day, I’d get a call that he needed to be bailed out of jail.

That’s why he chose methadone, despite the layers of regulations enacted in the 1970s that meant that rather than picking up a monthly supply at his local pharmacy, he’d need to go to the opioid treatment center day after day, so a nurse can watch him place the liquid into his mouth and swallow.

Eventually, after proving their reliability to their counselor, a patient may earn individual doses to take home. That same counselor also has the authority to withhold that patient’s dose for any reason, from a positive drug test to subjectively inappropriate behavior at the clinic to possession of an out-of-date bottle cap. This makes treatment inconsistent and unpredictable.

In a small qualitative survey published in 2021 in Harm Reduction Journal, patients repeatedly said that daily clinic visits interfered with their ability to maintain steady employment. It’s not just picking up medicine. Patients often attend mandatory counseling sessions and produce urine samples on-site (with supervision) to prove they’re taking the medicine and haven’t relapsed. Some of these services are inconvenient. Some are humiliating. Most also drive up the cost of care (and profits at the many for-profit facilities). At any time, my family member pointed out, a patient with take-home methadone doses can be called in for a bottle recall, in which case they have a few hours to retrieve any used and unused take home doses and bring them to the clinic before it closes.

Health researchers and policy analysts have long lamented these regulations, and often called for them to be overhauled. Other countries, such as Canada, Australia, and the United Kingdom, have allowed methadone to be picked up from regular pharmacies since the 1960s and ’70s. But stigma, racism, and the distrust of patients have prevented the U.S. from doing the same.

While the July data shows that patients were just as safe, if not safer, when offered more take-home doses during the pandemic, the North Carolina survey suggested the community remained safe as well. Only six out of 87 patients surveyed sold or shared their doses in the summer of 2020, often with the stated goal of helping a friend who needed methadone.  

There are a lot of ways the U.S. can improve its treatment of people who use drugs, such as opening safe consumption sites, distributing the overdose-reversing drug naloxone, and making it easier for doctors to prescribe buprenorphine. But one of the simplest and most effective is right in front of us: pry methadone from the clinics that shackle those who need it. The U.S. is currently considering ways to reform opioid treatment centers, but with overdoses growing more frequent and more deadly, now is the time to recognize that one of the best tools to prevent overdoses has been here all along, if only we could forget the opioid treatment centers and pick it up from the pharmacy.

Emma Yasinski is a science journalist whose work has appeared in The New York Times, National Geographic, The Atlantic, and other publications.