The American Society for Addiction Medicine (ASAM) successfully fought to prevent expansion of methadone prescribing to a wide range of medical practitioners in a current federal reform bill, alleges a source familiar with the negotiations.
Limiting prescribing to the much smaller group of specialists represented by ASAM weakens the bill’s ability to promote widespread, equitable access to the life-saving medication and prevent overdose deaths.
The United States’ policy of restricting methadone access to clinics, also known as opioid treatment programs (OTPs), is a death sentence. It is a major reason so many are dying from overdose.
In 2019, for example, in the midst of the ongoing opioid-involved overdose crisis, only somewhere over 400,000 people in the US received the medication which can cut their mortality risk by half or more—out of an estimated 1.6 million people with opioid use disorder (OUD).
There simply aren’t enough clinics to meet the needs of everyone with OUD. And the clinics themselves present high barriers to treatment with cruel and punitive rules, requiring many people to dose seven days a week. This leads to low treatment retention rates and dissuades people from seeking treatment in the first place. The OTPs’ culture of cruelty drives some people back to using the adulterated illicit fentanyl supply. If those people die, the clinic is responsible.
Created during the corrupt presidency of racist Richard Nixon, who launched the “War on Drugs,” the clinic system has seen no substantive regulatory changes in over 50 years, as if it existed in a time capsule.
But no more: Amid the unprecedented overdose crisis, and the lessons of the COVID loosening of take-home guidelines, OTP practices are being scrutinized and criticized like never before. And politicians finally took action.
MOTAA is fundamentally flawed. In no way does it end the clinics’ stranglehold.
The Modernizing Opioid Treatment Access Act (MOTAA, HR 1359) was introduced into the US House by Reps. Donald Norcross (D-NJ) and Don Bacon (R-NE) in March. The bill has 24 cosponsors. A similar bill (S 644) has been introduced in the Senate by Senator Edward Markey (D-MA).
As the latest iteration of the Opioid Treatment Access Act (OTAA) of 2022, MOTAA in its current form makes two major changes: It allows board-certified addiction doctors and psychiatrists outside of OTPs to prescribe methadone for OUD; and it permits pharmacy dispensing.
“We must end the monopoly on this life-saving medicine that only serves to enrich a cartel of for-profit clinics and stigmatize patients,” Rep. Norcross said in a March press release.
He’s right. But MOTAA is fundamentally flawed. In no way does it end the clinics’ stranglehold.
By not allowing all health care providers to prescribe the medication, MOTAA will help only a small number of people escape the carceral clinic system, and will leave many with no access at all. It keeps the Drug Enforcement Administration (DEA), the drug-war agency that oversees the clinic system, in control of registering new methadone prescribers. And by preserving the status quo to a large degree and limiting non-clinic prescribing to specialists, it reinforces the structural racism of access to OUD medications.
ASAM estimates that there are 7,000 physicians specializing in addiction who would be eligible to prescribe methadone under the current version of the bill. Another estimate puts it lower, at under 4,000. Neither number is anywhere near enough.
Yes, that’s more than the 1,900 methadone clinics in the US. But consider that medical specialists of any kind are only accessible to mostly privileged, mostly white patients.
As ASAM noted in a May statement to a US Senate committee, “Shortfalls exist at all levels of the addiction care workforce … the most grievous is among addiction specialist physicians.”
Yes, 7,000 or 4,000 is more than the 1,900 methadone clinics in the US. But compare totals of over 1 million active physicians and roughly 60,000 pharmacies. And consider that medical specialists of any kind are only accessible to mostly privileged, mostly white patients.
In the state of Wyoming, there are no OTPs and only two addiction physicians.
When methadone saves lives, and methadone “diversion” is a DEA talking-point refuted by the pandemic experience, why can’t physician assistants or nurse practitioners, for example, prescribe methadone like any other medication?
A former staffer for Norcross, speaking on condition of anonymity, told Filter that when the terms of MOTAA were being negotiated, they believe ASAM fought to prevent such a game-changing expansion.
That isn’t proof. Another former Norcross staffer who would have been familiar with events at the time did not respond to Filter’s request for comment. But when Filter put this allegation to an ASAM representative, she neither confirmed nor denied it, focusing instead on ASAM’s advocacy to include addiction physicians.
“Last Congress, a draft methadone bill was sent to ASAM requesting ASAM’s endorsement,” Kelly M. Corredor, ASAM’s chief advocacy officer, told Filter. “That draft bill would have allowed only OTP clinicians to prescribe methadone for OUD to be dispensed from retail pharmacies.”
“It was my understanding at the time that even that draft bill was not being supported by some within the OTP industry, hence the reason behind the outreach to ASAM for possible endorsement,” she continued. “ASAM requested expansion of the bill to include addiction specialist physicians as eligible prescribers.”
“MOTAA is not methadone for everyone, prescribed by anyone. It represents a responsible expansion in methadone access for OUD…”
ASAM, according to its website, “believes in a future in which addiction prevention, treatment, remission, and recovery are accessible to all, and where they profoundly improve the health of all people.”
But it didn’t seem concerned about equal access when Dr. Stephen M. Taylor, its president-elect, testified to a US Senate committee in May. He stated, “MOTAA is not methadone for everyone, prescribed by anyone. It represents a responsible expansion in methadone access for OUD…”
This statement is a disgrace. We need rapid expansion of methadone access, not “responsible expansion,” whatever that even means, to prevent more deaths. The goal of any legislation must be to make methadone faster and easier to get than illicit fentanyl.
Whatever the factors that produced it, MOTAA’s prescription-exclusivity dooms the effectiveness of the bill to drive down overdose deaths.
“The limitations in the Norcross bill of only allowing board-certified addiction specialists virtually guarantees that there will be ongoing barriers to access to methadone in poor and rural communities, and especially in communities of color,” Dr. Bruce Trigg, a former medical director of OTPs in Albuquerque, New Mexico, told Filter. “Like buprenorphine, those with financial resources will have better access to these specialists who can prescribe office-based methadone and those at greatest risk will be left out in the cold.”
If MOTAA is “not methadone for everyone,” as Taylor said, who is it for?
“If you’re a hyperspecialist, you know who your clientele is going to be, rich and largely white … it’s the same exclusive group that currently gets buprenorphine.”
“The way that it works in this country is, the better insured and the more money you have, the more access you have to hyperspecialists like board-certified addiction psychiatrists,” Dr. Helena Hansen, one of the authors of Whiteout: How Racial Capitalism Changed the Color of Opioids in America, told Filter.
“So if you’re a hyperspecialist, you know who your clientele is going to be, rich and largely white,” she continued. “If we rely on this same small group that does buprenorphine prescribing to do methadone prescribing, if you look at who gets served by them, it’s the same exclusive group that currently gets buprenorphine.”
“The last national study showed that white Americans were three to four times as likely to get buprenorphine as Black Americans,” Hansen added, “and the most common form of payment was out-of-pocket, followed by commercial insurance.”
ASAM did not provide comment on the legislation’s impact on racial disparities when asked to do so.
Separately adding to racial disparities are the Substance Abuse and Mental Health Services Administration’s original and revised criteria to assess patients for unsupervised, take-home methadone doses—which ASAM endorses.
These continue to focus on a person’s ability to comply with nonsensical DEA rules and norms—not whether take-home doses would improve their health, quality of life and freedom. Moreover, they ignore OTP bias and the structural drivers of inequality, racism and poverty that set up Black and Brown patients to be denied take-home doses.
There are more poison pills in MOTAA. A major barrier to access is constant DEA policing and surveillance—a role the drug warriors have played in buprenorphine prescribing. The bill ”directs the DEA to register certain practitioners to prescribe methadone that is dispensed through a pharmacy for an individual’s unsupervised use.”
Doctors who prescribe buprenorphine have been targeted by the DEA and other law enforcement agencies for raids, arrest and license revocation. In 2018, the Federal Bureau of Investigation had the audacity to search the patient office and home of Stuart Gitlow, a prominent addiction physician and a past president of ASAM. DEA harassment of buprenorphine providers will undoubtedly extend to methadone providers.
To avoid DEA scrutiny, many will refuse to prescribe the medication, further winnowing down the numbers of people able to escape the clinic system and pick up methadone at a pharmacy.
Another provision in MOTAA will further restrict access to office-based methadone: “A state may request that the DEA stop registering such practitioners in its jurisdiction.” State Opioid Treatment Authorities (SOTA) exist to reinforce clinic control of methadone, so expect them to request this opt-out, and the DEA to grant it. States are already opting out of SAMHSA’s updated methadone take-home extension guidelines.
Nonetheless, politicians and ASAM are touting the bill as a true transformation of the system.
“It is vital that they get it right from the start. It will not be easy to fix once the problems are widely recognized. The bill must be amended to allow any licensed medical provider to prescribe methadone.”
“MOTAA ends the monopoly that puts profits over patients,” Jayce Genco, communications director for Rep. Norcross, told Filter. “Its current form gives us the best chance of passing in this divided Congress and helping the millions of Americans that suffer from opioid use disorder.”
“ASAM and other MOTAA supporters are doing our best to get it passed in the face of some strong OTP industry opposition,” ASAM’s Corredor said. “Nearly 100 groups, including the Drug Policy Alliance, are on record in support, knowing this is a solid step in the right direction.”
It is not a solid step in the right direction. When the US is suffering the greatest loss of life from overdose in recorded history, and as this unprecedented moment shines a political spotlight on methadone, reforms need to be epic and scaled up in size so that they help the vast majority of people. It is a grave mistake to support a bill that takes baby steps while reinforcing structural racism.
Ominously, the inevitable failure of MOTAA to move the dial could also result in a right-wing backlash where opponents of clinic reform, like the American Association for the Treatment of Opioid Dependence, argue that dispensing methadone outside of OTPs did not work.
“It is vital that they get the legislation right from the start,” Trigg warned. “It will not be easy to fix once all the problems are widely recognized. We have seen from the buprenorphine regulatory experience that it will take many years and even decades to modify the federal regulations. The Norcross bill must be amended to allow any licensed medical provider to prescribe methadone.”
Photograph by Helen Redmond