Jeffrey A. Singer
In a Cato Institute policy analysis, Sofia Hamilton and I highlighted that people with opioid use disorder (OUD) in Australia, Canada, and the UK have been able to access methadone treatment through their primary care clinicians for over 50 years. Patients in the US could access treatment from their primary care clinicians before 1972, when the implementation of the Controlled Substance Act (CSA) resulted in the current system, which treats patients with OUD as if they were outcasts and requires them to line up at Drug Enforcement Administration-regulated opioid treatment programs (OTPs) to receive methadone under supervision and oversight.
When COVID-19 hit in March 2020, and daily trips to federally licensed methadone clinics became more difficult for people with OUD, the Substance Abuse and Mental Health Services Administration (SAMHSA) relaxed the rules. It allowed OTPs to provide “stable” patients with up to a 28-day take-home supply and enabled buprenorphine visits to occur via telehealth, rather than requiring in-person appointments. The program was a success. Follow-up studies found the policy improved patient compliance and did not cause buprenorphine or methadone diversion into the black market.
The reforms were compelling enough that SAMHSA eventually made them permanent. Follow-up studies by the Centers for Disease Control and Prevention (CDC) and National Institute on Drug Abuse (NIDA) researchers, published in JAMA Psychiatry in July 2022, showed that methadone-related overdose deaths did not rise after the policy change. The National Institutes of Health (NIH) reached a similar conclusion that month, noting that the proportion of overdose deaths involving methadone actually decreased from early 2019 to August 2021.
It often surprises people that the DEA permits any clinician with a standard narcotics license to prescribe methadone for pain, yet bans them from prescribing it for addiction treatment. According to the National Institute on Drug Abuse, “Methadone diversion is primarily associated with methadone prescribed for the treatment of pain and not for the treatment of opioid use disorders. In one survey, giving methadone away was identified as the most common form of methadone diversion, which aligns with other findings that 80 percent of people who report diverting methadone did so to help others who misused substances.” (emphasis added)
Our policy analysis cited federal pilot programs that have already shown that when primary care clinicians are permitted to prescribe methadone for opioid use disorder, the results in the US are as strong as those long observed in Australia, Canada, and the UK. One such program, overseen by researchers at Yale University, randomly assigned 47 patients to six primary care clinicians and followed them for six months. It concluded:
Our results support the feasibility and efficacy of transferring stable opioid-dependent patients receiving methadone maintenance to primary care physicians’ offices for continuing treatment and suggest guidelines for identifying patients and clinical monitoring.
Today, a new study funded by NIDA was published in the Annals of Internal Medicine, providing even more substantial evidence that allowing primary care clinicians to treat OUD patients with methadone is safe and effective. Yale researchers conducted a randomized controlled trial involving 1,459 adults (905 in the intervention group and 509 in the control group), who received methadone treatment from primary care clinicians supported by telemonitoring across 13 cities in Ukraine. The control group received “standard specialty clinic care.”
The primary outcome they assessed was an overall quality-of-care score at 24 months, based on whether patients received 17 recommended services across primary and specialty care. They also analyzed each category separately—“domain scores,” which show how patients performed within specific areas of care—and several indicators related to methadone treatment.
Patients treated in primary care did better across the board. After two years, they scored about nine points higher on the overall quality-of-care measure than those treated in traditional methadone clinics. The advantage appeared in both primary and specialty care services. When it came to staying on methadone, new patients in primary care were slightly more likely to stay in treatment at 24 months—67 percent versus about 65 percent in specialty programs. Their conclusion:
Integrating methadone treatment into primary care settings improves adherence to guideline-concordant health care without compromising methadone retention and treatment quality.
The research keeps pointing in one direction: patients benefit when methadone is available in primary care.
One week from today, the Cato Institute will host a screening of the award-winning documentary “Shuffle.” Filmmaker Ben Flaherty demonstrates how federal rules—especially those embedded in the Affordable Care Act and Medicaid—have unintentionally allowed predatory rehab operators to profit from the suffering of people with substance use disorder, who deserve care, not exploitation. Instead of reducing harm, these mandates might be supporting—and even expanding—the very problems they were intended to resolve.
In our policy analysis, Hamilton and I argued that letting primary care clinicians prescribe methadone would expand access to effective treatment, reduce overdose deaths, and help more people with OUD reclaim their lives. After seeing in the film how predatory rehab clinics exploit vulnerable patients and siphon off health-care dollars, there’s another clear advantage: expanding office-based methadone would shrink the pool of people these operators can target.
(You can register for the film screening here. The screening will be in-person only, but the panel discussion that follows it will be livestreamed.)