Policymakers Move to Expand Addiction Treatment with the Modernizing Opioid Treatment Access Act

In 2021, opioid overdoses killed over 200 people a day in the United States, with the synthetic opioid fentanyl responsible for most of these deaths. The good news is that policymakers are making progress toward effective, harm reduction-centered solutions. Last week, Sens. Edward J. Markey (D-Mass.) and Rand Paul (R-Ky.) and Reps. Donald Norcross (D-N.J.) and Don Bacon (R-Neb.) introduced their bipartisan and bicameral Modernizing Opioid Treatment Access Act. The bill aims to improve patients’ access to methadone treatment for opioid use disorder (OUD) by modernizing outdated rules, allowing board-certified physicians to prescribe methadone to patients and letting pharmacies dispense methadone to individuals in need.

Expanding access to medications for opioid use disorder (MOUDs) is key in reducing fatal overdoses in the country. Unfortunately, the stigma associated with people who use drugs continues to drive unnecessary regulatory hurdles. There are three Food and Drug Administration (FDA)-approved MOUDs in the United States, two of which have lengthy, proven histories of reducing overdose risk and opioid-related morbidity compared to abstinence-based treatment options: buprenorphine and methadone.

Physicians have reported that fentanyl is more likely to cause withdrawal symptoms for patients on buprenorphine, compared to other MOUDs such as methadone. This makes induction of new patients who are accustomed to using fentanyl extremely difficult. Methadone, a gold standard MOUD, remains effective even with the rise of novel synthetic opioids but is far more difficult to access than buprenorphine. If policymakers care about the overdose crisis, increasing access to heavily regulated methadone should be a top priority. The Mainstreaming Addiction Treatment Act, passed in late 2022, expanded access to buprenorphine, but did not address access to methadone.

The Substance Abuse and Mental Health Services Administration (SAMHSA) allows physicians to prescribe take-home doses of buprenorphine for medication-assisted treatment, but regulates methadone by requiring the majority of patients to travel daily or almost daily to methadone clinics to take the MOUD (take-home methadone prescriptions are authorized for chronic pain only). The current system harms patients seeking treatment, particularly those in rural or remote areas with few or no clinics and those lacking access to transportation. A few of the states with the worst access include Wyoming (zero methadone clinics), Nebraska (3) and Mississippi (4).

Due to the COVID-19 pandemic, SAMHSA lifted some of their methadone restrictions to allow clinics to dispense small quantities of take-home methadone. Overall, take-home methadone was well-received by patients and was associated with similar (and sometimes improved) treatment outcomes compared to methadone accessed in a clinic. Furthermore, the real world experiment demonstrated that safety concerns related to overdose and diversion were overwrought. Consequently, many providers are calling for an extension of the COVID-19-era relaxations.

But simply extending these temporary changes does not go far enough.

There is no reason for the Drug Enforcement Administration to restrict access to take-home methadone because it is proven to be safe. The United States is an outlier among developed countries regarding restrictions on harm reduction strategies such as methadone. Canada, the United Kingdom and Australia all allow pharmacy dispensing and have lower rates of opioid overdoses than the United States. And studies have demonstrated that pharmacy programs and innovative technological interventions can support patient safety, autonomy and recovery. By altering methadone regulations to permit physician prescribing and pharmacy-based programs, the Modernizing Opioid Treatment Access Act will allow physicians to have more flexibility to treat their patients according to individual needs and preferences.

The overdose crisis affects victims, loved ones and entire communities. This legislation is an opportunity for both Democrats and Republicans to pass meaningful change in a time of crisis. In addition to the bipartisan appeal, the bill is met with support by a wide range of organizations, including the Massachusetts Health & Hospital Association, the Overdose Prevention Initiative and the American Society of Addiction Medicine. As R Street’s Integrated Harm Reduction Policy Director Mazen Saleh explained in a statement for the record for a House Judiciary Subcommittee hearing on the fentanyl crisis earlier this month, permanently reducing the barriers to methadone is necessary to “maximize the potential recovery-oriented benefits of a harm reduction ethos.” We fully support the Modernizing Opioid Treatment Access Act as a measure to reduce the stigma around addiction and save lives.