Overregulation Hurts Competition Among Methadone Providers—and Harms Patients
Methadone is one of the most effective methods for treating opioid use disorder (OUD). People taking methadone use fewer illicit opioids and are far more likely to stay in treatment than people in non-medication treatment. Methadone can also help people build stability in their lives—for work, parenting, and more—making this treatment beneficial to both individuals and communities.
But in America, methadone is highly regulated and extremely difficult to access. The only way to get methadone for OUD is to travel up to six days a week to an opioid treatment program (OTP), often referred to as a “methadone clinic.” There are 77.5 million Americans who live in a county without an OTP, and in rural areas, the nearest OTP may be an hour or more away. The result of this scarcity is that in many areas of the country, the only organizations authorized by the federal government to provide methadone to people with OUD have no direct competition. This market concentration can make accessing methadone a hellish and sometimes untenable experience for people seeking an off-ramp from OUD. When there’s only one game in town (often for many towns over), there is little incentive to improve operating hours, wait times, quality of counseling (which patients are often required to get from the OTP), and patient-centered treatment decisions. As a result, OTPs vary widely in what they offer patients—as well as how they offer it.
We talked to Amber Frazier, a South Carolina-based peer support coordinator who has taken methadone since 2015. Frazier has attended two different OTPs in her nine years of methadone treatment and is familiar with many more OTPs through her work. In 2023, after eight years of taking methadone, Amber “earned” the ability to pick up 27 days’ worth of doses at a time (“take-homes” in methadone parlance) from her OTP.
What was it like to have to get to the OTP every day for so many years?
It was awful. I went daily from 2015 to 2019. It’s only open from 5 a.m. to 10 a.m., and you have to wait up to two hours for your dose. This made it hard to hold down a job. When I was working in construction, if I was late for work, I didn’t feel that I could tell my boss why. If you miss a day [of medication] because you get sick, or your car breaks down, you will feel awful all day, and some OTPs will punish you for it.
What does it mean for an OTP to “punish” a patient for missing a dose?
OTPs have all the power, because you don’t have a choice to go elsewhere. At many clinics in my state, if you miss a day or two, they’ll reduce your dose, even if it’s the dose that is medically necessary for you to stay stable.
What was the process to “earn” your take-homes?
From 2015 until 2019, I had been using some other illicit substances. When I was able to stop, I “earned” a week’s worth of take-homes of methadone. When COVID-19 happened in 2020, they moved me to two weeks of take-homes. I didn’t get monthly take-homes for three more years. It wasn’t offered to me; I had to proactively ask for it. I made my first request to phase up to a month of take-homes in 2022, and I was denied. I asked again a year later, and they finally phased me up.
What’s the counseling like at OTPs?
I’m sure counseling at some OTPs is good, but I’ve never had a legitimate session in nine years of taking methadone. The longest session I’ve had was 15 minutes. There’s no way the OTPs I have been to have the capacity to do individualized counseling, but they require that we use their counselors, and those costs are built into what we have to pay for methadone.
Note from Safer From Harm: A STAT News investigation reviewed Medicare and Medicaid payments to OTPs and found that Medicare pays OTPs $259.80 per week, per patient, for bundled methadone, counseling, and drug testing but only $40.71 for a week’s worth of take-homes. The report says these reimbursements are “incentivizing daily doses and maximally invasive care.”
What’s it like to have those 27 days of take-home doses now?
It is somewhat liberating, but I know that I could lose my take-homes at any time. For example, I sometimes get a random “bottle recall” notification. The OTP calls to say I have to bring in all 27 bottles of my take-homes, empty or full, the next day so they can confirm that I haven’t been selling my medicine. If I don’t show up—even if I have work—they can take away the take-homes that I spent eight years “earning” and put me back on a daily commute to the clinic.
I will also lose some of my take-homes if I continue to taper my methadone. I’ve been slowly tapering my dose since 2019, with the goal of eventually getting to zero. My next step is to go down to seven milligrams a day. My OTP told me that if I do that, I have to give up my month’s worth of take-homes and go back to twice a month. They didn’t explain why, but they don’t really have to, because I have no other choices. Going back to twice a month will be disruptive to my work and life, so I’ve held off on this next step-down. Sometimes I think, “What’s the point of decreasing my dose if it’s going to be so disruptive?” I’m trying to do the thing so many people say I should do—stay in recovery, get off methadone altogether—and the OTP is making that harder for me.
OTPs can play an important role in access to methadone for OUD. A bill currently in Congress, the Modernizing Opioid Treatment Access Act, would expand methadone provision beyond OTPs, allowing board-certified addiction specialists registered with the Drug Enforcement Administration to prescribe methadone for OUD and allowing pharmacies to dispense the medication. Expanding methadone access beyond OTPs would bring it more in line with every other prescribed medication in the country and would open up some access for the many Americans who live out of geographic reach of any OTP. It would also create options for patients and potential patients, which in turn could improve how all market actors provide methadone to people seeking recovery from OUD.