Peter Vanderkloot’s groundbreaking article—Methadone: Medicine, Harm Reduction or Social Control—hit me hard. As a social worker, I helped people who used heroin get into methadone programs. His insightful analysis and refreshingly angry takedown of the United States methadone clinic system explained both negative interactions I’d had with clinic staff and traumatic incidents that clients shared with me. I go back and review the article often.
Vanderkloot describes in precise detail how clinic regulations disrupt and damage patients’ lives. He shows how a medication that embodies harm reduction is held hostage by a system of harm production. He knows what he’s talking about. For years, he’s stood in line waiting to be called to the plexiglass window by a nurse who pushes a plastic cup filled with red liquid through a chuckhole.
Then he drops this time bomb: “The methadone clinic system is a weapon of the drug warriors, and as long as it exists it will be used to control, degrade and injure.” Vanderkloot argues for the destruction of the clinic system and for methadone prescription parity.
His article was published back in 2001.
But a current federal bill fails to recognize and seize this chance.
Twenty-one years and a pandemic later, abolishing the clinic system and establishing the right of patients to do something as ordinary as pick up a methadone prescription at CVS or Walgreens is a real possibility.
But a current federal bill fails to recognize and seize this chance. On May 18, it was announced that methadone provisions of the Opioid Treatment Access Act of 2022 (HR6279), proposed by Rep. Donald Norcross (D-NJ), were being folded into another bill—the Restoring Hope for Mental Health and Well-Being Act (HR7666), sponsored by Rep. Frank Pallone Jr. (D-NJ). The provisions are woefully inadequate in eliminating methadone restrictions to address the overdose crisis.
Growing Momentum for Change
“It shouldn’t have taken a global pandemic to get more take-homes,” Louise Vincent, the executive director of the Urban Survivors Union and a methadone user, told me in an interview for a documentary I’m co-directing about methadone and COVID-19.
But it did. It took COVID for the Substance Abuse and Mental Health Administration (SAMHSA) and the Drug Enforcement Administration (DEA) to finally change take-home regulations that were anchored in place for over 40 years. It can take months and even years to “earn” take-home doses (THDs) and they can be revoked at any time. But in March 2020, the unthinkable happened. SAMHSA issued temporary guidance to clinics, or opioid treatment programs (OTPs), that allowed every patient to immediately be screened for 14 or 28 THDs.
Patients who got them felt a powerful sense of freedom that they didn’t know was possible. Suddenly they didn’t have to stand outside in the rain in a line at 5 am until the clinic opened. They could sleep in, spend more time with family, not be late for work because the clinic computers crashed, and save money because the six-day-a-week commute was gone. One woman told me, “I was able to feel like a normal person.”
As a result of COVID, clinic regulations are being critically examined.
In November of last year, SAMHSA extended the “methadone take-home flexibility for one year while working toward a permanent solution.”
As a result of COVID, clinic regulations are being critically examined. In 2020, the Urban Survivors Union published The Methadone Manifesto—a scathing attack on the deadly culture of cruelty, with the ultimate goal of eliminating the clinic system. The media is publishing more sympathetic stories about people who take methadone, and seriously questioning barriers to care. The racism of the clinic system is being exposed. Black people disproportionately attend methadone clinics, while more whites are offered buprenorphine, which can be picked up at a pharmacy. In some cities, clinics are disproportionately clustered in low-income communities of color, which can trigger not-in-my-back-yard (NIMBY) resistance.
There are more calls to consider regulatory reform in OTPs. The New York Society of Addiction Medicine is advocating for “updating methadone regulations.” In March, the National Academies of Science, Engineering and Medicine (NASEM) organized a two-day virtual workshop packed with experts who “explored potential options for modifying federal regulations.” Three people who take methadone were featured speakers and there was a session on Australia’s pharmacy-based dispensing system. OTPs are discussing changes to federal regulations too, at an upcoming symposium sponsored by the Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA). Dr. Chinazo Cummingham, the commissioner of the New York state Office of Addiction Services and Supports (OASAS) is a featured speaker.
Bolstering the call for change, a number of studies conducted during the pandemic found that giving more take-home bottles didn’t result in an increase in overdoses and that “diversion” was rare. For decades, the DEA and SAMHSA have cited these supposed reasons to block reform.
Like the agencies that regulate them, clinics themselves have erected barriers that increase deaths.
Hanging like a shroud over all these discussions is the overdose crisis. The Centers for Disease Control (CDC) just released new provisional data showing there were almost 108,000 overdose deaths last year alone, a 15 percent increase from 2020. Since 2001, more than a million people have perished.
Throughout, individual OTPs refused to eliminate burdensome requirements like daily dosing, forced patients out of treatment for taking Adderall or benzodiazepines, and drove them back to the poisoned, illicit market while knowing that methadone reduces the death rate among people with opioid use disorder by over 50 percent. Like the agencies that regulate them, clinics themselves have erected barriers that increase deaths. This deadly negligence should call into question the very existence of the clinic system.
Inadequate Federal Bills
The catalyst for Rep. Norcross to introduce his original bill—HR6279—was a conversation with an addiction medicine doctor who described her frustration with methadone restrictions, and how eliminating them could prevent overdose deaths.
HR6279, introduced in December and referred to the House Committee on Energy and Commerce, contained several reforms. It stipulated that positive drug tests should no longer be used as the sole reason to rescind THDs; reduced the eligibility requirement for THDs from 90 to 45 days; permitted office-based prescribing of methadone and pharmacy pick-up outside of OTPs, subject to “time in treatment” regulations; and expanded methadone prescribing—but only to physicians board-certified in addiction psychiatry or addiction medicine.
Restricting methadone prescribing to addiction specialists would appear to be a sop to ASAM, blocking primary care doctors from becoming competition.
Britton T. Burdick, Rep. Norcross’s communications director, told Filter that the Opioid Treatment Access Act of 2022 was informed by feedback from six advocacy groups. These included the American Society of Addiction Medicine (ASAM), a politically moderate organization of the very physicians who were to be granted exclusive methadone prescribing privileges; and the National Alliance for Medication Assisted Recovery (NAMA Recovery), a patient advocacy organization whose president is an OTP owner.
Restricting methadone prescribing to addiction specialists would appear to be a sop to ASAM, blocking primary care doctors from becoming competition. According to the American Board of Medical Specialties, there are only 1,883 addiction medicine and 1,288 addiction psychiatry physicians nationwide. Over 400,000 people take methadone in the US. The math doesn’t add up. The shortfall would be felt in rural areas especially, where there are far fewer addiction specialists and OTPs than in metropolitan areas. In communities with no office-based addiction specialists, patients would still be required to attend an OTP to start the medication.
Neither is reducing the time to “earn” THDs from 90 to 45 days a true reform, when the status quo allows immediate, blanket exemptions for OTPs to dispense up to 14 THDs for “unstable” patients and up to 28 THDs for “stable” patients.
This provision, in any case, appears not to have made it into the Pallone bill, HR7666. Elsewhere, a confusing section in HR7666 states that “a medical practitioner appropriately licensed by the State to prescribe or dispense controlled medications” outside of an OTP can determine if a methadone patient is eligible for THDs. It’s unclear whether this, like the Norcross bill, would restrict prescribing to addiction medicine and addiction psychiatry physicians only. And where the medication could be obtained is also unclear, when the Norcross bill’s provision for pharmacy pick-up doesn’t seem to survive in the Pallone bill. Burdick did not respond to Filter’s requests for clarification on these points by publication time.
If the goal is to make it far easier to get methadone to save lives, these tepid reforms won’t cut it.
The Pallone bill still prohibits using positive drug tests as the sole reason for rescinding THDs. That’s good, on the face of it. But how it would be enforced is not specified—a critical omission. And HR7666 goes on to codify the rest of the absurd SAMHSA criteria for “earning” THDs.
“The provisions of my Opioid Treatment Access Act that were included at today’s markup [HR7666] will help ensure those suffering from opioid misuse disorder will get the treatment they need,” Rep. Norcross said in a press release. “I am proud that this bill will help modernize our nation’s approach to the opioid epidemic and help save lives in the process.”
What planet is he on? If the goal is to make it far easier to get methadone to save lives, these tepid reforms won’t cut it. Neither will further tweaks through congressional horse-trading years into the future. The bill fundamentally doesn’t recognize the urgency to go big and break down all the barriers, making methadone widely available during an unprecedented overdose crisis and a lingering pandemic. Its narrow provisions would help relatively few patients, depend largely on staff discretion, and keep the power of the clinic system firmly entrenched. It’s still “liquid handcuffs.”
We Need a Pharmacy-Based System
OTPs have a long history of ignoring or misinterpreting federal guidelines. Each clinic is its own fiefdom. They operate within a contradictory maze of federal, state and local regulations along with their own “in-house” policies which shield them from oversight and accountability.
Recent history has shown that clinics can’t even be trusted to protect patients’ lives during a pandemic. NAMA Recovery received dozens of complaints from patients around the country, supported by video and photo evidence, during the early months of the pandemic. With COVID-19 raging patients reported that there “were no social distancing protocols whatsoever,” that they were forced to line up for medication in close proximity inside and outside, and that they were mandated to attend the clinic for in-person bottle counts and group counseling—putting their health at great risk.
In April 2020, Nama Recovery stated, “The regularity of these reports across multiple states suggests that many of these concerns are systemic and widespread within the OTP system across the United States.”
No number of reforms can curtail the perverse culture of cruelty.
Patients with chronic health conditions reported being denied 14-or 28-day take-homes. In New York, OASAS officials endorsed federal rules, but according to activists at VOCAL-NY, didn’t enforce the new take-home guidelines, saying “it’s up to the clinics.” One study found that fewer than half of clinics permitted new patients a 14-day supply. To be sure, thousands of patients did get increased THDs, but it was time-limited. OTPs started scaling them back well before COVID infection and death rates declined, and for some patients completely rescinded them, forcing them back to daily or weekly dosing.
The existence of the methadone clinic system is the problem. Clinics are the physical embodiment of stigma against people who use opioids. It’s not possible to fundamentally transform a system controlled by the DEA, a police agency waging the racist War on Drugs. No number of reforms can alter the massive power imbalance between patients and staff or curtail the perverse culture of cruelty—from humiliating observed methadone ingestion by nurses to counselors “supervising urines” to being denied medication for being a minute late, to missing your father’s funeral in another state because guest dosing couldn’t be arranged in time. The cruelty is the point.
The permanent solution that SAMHSA should propose is as obvious as it is overdue; a pharmacy-based pick-up system that allows any health care provider to write a prescription for methadone. Prescription parity, as Vanderkloot advocated for 21 years ago. Methadone has been available by prescription in Canada since 1963, in Britain since 1968, and in Australia since 1970.
In addition, there must be a moral and ethical reckoning with 40 years of a clinic system based on racism, punishment and control, which has perpetrated civil and human rights violations against patients. People who take methadone have endured a profound loss of freedom and suffered outrageous indignities at the hands of clinic staff. Their oppression has rarely been acknowledged. For that reason, any bill must include a Truth and Reconciliation Commission to investigate these systematic clinic abuses and to give a voice to traumatized patients.
At the end of Peter Vanderkloot’s seminal article, he says that patients and harm reduction allies must work together for the normalization of methadone, and for the destruction of the system which produces harm.
He’s right. It’s past time. Let’s get to work.
Photograph by Helen Redmond and Marilena Marchetti