There Has to Be a Better Way to Free Methadone

    I had a gut feeling there would be gaslighting, but I didn’t think it would start the minute Dr. Alan Leshner opened his mouth to kick off “Methadone Treatment for Opioid Use Disorder: Examining Federal Regulations and Laws,” hosted by the National Academies of Science, Engineering and Law on March 4 and 5. Leshner, the director of the National Institute on Drug Abuse (NIDA) back in the 1990s, stressed that the workshop he helped organize was not about “lamenting the past as much as how to solve these terrible problems for the country.”

    But how could we not lament it and learn from it? Methadone policys past and present is one of systemic, shocking human and civil rights abuses. The Drug Enforcement Administration (DEA), and the Substance Abuse and Mental Health Services Administration (SAMHSA) are the two main architects. These federal agencies have designed nonsensical, demeaning and deadly barriers to access.

    Two days of presentations largely avoided asking the DEA and SAMHSA to answer for a racist, stigmatizing and cruel system that has contributed to unprecedented overdose deaths—over 100,000 last year—by pushing people back to the adulterated street supply of opioids.

    OTPs are just another front in the War on Drugs, which is why the DEA, a police agency, is centrally involved in the operation of clinics.

    Methadone clinics, also called opioid treatment programs (OTPs), also escaped real scrutiny. They not only enforce federal regulations but add on a host of their own, often even more restrictive. A culture of cruelty forces patients to line up outside like cattle in the cold early morning, six days a week; to urinate while someone watches; to lift their tongue up for the nurse to check if they swallowed the dose; to “earn” the “privilege” of take-home bottles. The humiliation, degradation, powerlessness, punishment, suspicion, pain and trauma that people who take methadone endure at the hands of clinic nurses, doctors and counselors were mostly erased at this event.

    OTPs are just another front in the War on Drugs, which is why the DEA, a police agency, is centrally involved in the operation of clinics. It views methadone patients as criminals who cannot be trusted with their lifesaving medication, and acts accordingly.

    There was another elephant in the Zoom room. Leshner had convened a meeting to discuss reforming federal regs only because of COVID-19. The DEA and SAMHSA temporarily relaxed restrictions on take-home doses in March 2020, because it was just too obvious that not doing so would cost lives (even though this has always been true). It took a pandemic to get more take-home medication. Several studies presented during the workshop showed unequivocally that giving more take-home bottles to patients didn’t result in “diversion” to the street or an increase in overdoses. Is anyone really surprised? And who will answer for the decades-long failure to act?

    It’s infuriating that pleas from patients and research showing the need to ease regulations have been so long ignored. The Institute of Medicine reported, “Current policy, in the committee’s view, puts too much emphasis on protecting society from methadone, and not enough on protecting society from the epidemics of addiction, violence, and infectious diseases that methadone can help reduce.” That was in 1995!

    Day one of the event began, promisingly, with 10-minute presentations by three people with lived experience: Abby Coulter, from the Urban Survivors Union and an author of The Methadone Manifesto; Brenda Davis, a patient advocate and member of the National Alliance for Medication Assisted Recovery; and Walter Ginter, the project director of NAMA Recovery’s Medication Assisted Recovery Support (MARS) project, who has taken methadone for 44 years.

    Each touched on the problems of methadone policy—like the devastation of losing take-homes for positive drug screens—but also explained how the medication had transformed their lives for the better. Coulter called methadone a “miracle molecule.”

    Yet in subsequent sessions, the vast majority of presenters were medical doctors, PhDs, researchers, federal bureaucrats or lawyers, so that the opening session felt tokenizing. The “professionals” were promoted as the real experts. Leshner allowed them to shift the narrative away from a serious examination of the harms of the clinic system into dry discussions about “regulatory innovation” and “bundled payments.”

    The speakers from the DEA and SAMHSA escaped any direct criticism. Instead, they were lauded for extending take-home flexibilities for another year, never mind that large numbers of clinics are not giving patients the 14- or 28-day take-homes they should be getting (as several other speakers did mention).

    “We are committed to expanding access to medication assisted treatment and to help break down barriers to those suffering from substance use disorder,” Kristi O’Malley, a senior advisor for the DEA’s Diversion Control Division, read from her slides. “We are working hand in hand with SAMHSA to improve access to treatment options and for ways to expand access to methadone and buprenorphine.”

    No panelist or moderator challenged her. Really? The DEA are the good guys? More gaslighting.

    As in many Zoom webinars, the real debate took place in the chat. One participant wrote, “With all due respect, the DEA should not have a role in methadone treatment. What other areas of medicine are patients mistrusted and treated as criminals upon entering care?”

    Another shared, “Re DEA: In Oregon, many rural pharmacies are limiting buprenorphine stock because they report that DEA is cracking down on pharmacies with high dispensing. It is precluding us from offering life-saving treatment in rural counties….”

    “It is more than a little dismaying to see how little progress has been made in methadone treatment in the past 50 years.”

    Yngvild Olsen, acting director of the Center for Substance Abuse Treatment, spoke on behalf of SAMHSA. Despite a token “shout-out” to Coulter, Ginter and Davis, her presentation didn’t address pressing regulatory issues and lacked any urgency to enact changes.

    A chat question asked, “Dr. Olsen: Many of us were disappointed by the SAMHSA interpretation of stable and unstable patients for prolonged take-home bottles that came out in November 2021. It involved a drug-free screen and did not leave it to the treatment team. Can you comment on this?” Olsen did not.

    With 40 presenters, there was no time allotted for discussion or debate, only Q&A. Panelists kept repeating the same points about regulatory roadblocks or referencing the same research about treatment barriers.

    “It is more than a little dismaying to see how little progress has been made in methadone treatment in the past 50 years,” wrote another chat participant. “Many of the problems, criticisms and general observations from participants in this webinar are the same things I heard back in 1972.”

    But there were some stand-out speakers. Dr. Samuel Kelton Roberts Jr. of Columbia University provided a much needed historical, intersectional perspective on racism, stigma and methadone regulation. Kelton said, “Methadone is so tightly regulated it leads people to believe it must be inherently dangerous, something must be wrong!” He explained that the trifecta of stigmatization was being Black, having opioid use disorder and taking methadone.

    Dr. Magdalena Cerdá, director of the Center for Opioid Epidemiology and Policy at NYU, outlined racial disparities. One slide noted, “Methadone is more prevalent than buprenorphine in areas with high concentrations of racially minoritized populations.” It is well-documented that white people have better access to buprenorphine, an opioid use disorder medication that can be picked up in a pharmacy, than people of color. It adds up to a compelling case to abolish OTPs for racial and health justice.

    “We have to reject the white supremacist organizing of methadone to engage Black and Latinx people,” said Dr. Ayana Jordan, an addiction psychiatrist at NYU Langone hospital. Her presentation of the Imani Break Through Program was a breath of fresh air and a potent example of creative thinking. It is a faith-based, culturally informed, harm reduction recovery program that takes place in churches. Jordan also advocated for methadone prescribing in primary care offices and harm reduction settings. The program’s hashtag is #freemethadone.

    What this workshop made absolutely clear is that it will be a struggle to win the reforms to truly free people from the cruelty and indignities of the methadone clinic system.

    Frustration with rigid methadone regulations was palpable in the chat comments. Corey Davis, JD, from the Network for Public Health Law, gave cause for hope that the regs could change quickly. He explained that many of the most onerous hurdles to methadone treatment (daily observed dosing, limited take-homes, OTP exclusivity) can be modified or removed solely by regulatory action from the DEA and SAMHSA. There is no need to change laws or for congressional involvement. “We are optimizing for the wrong things,” Davis asserted. “Diversion control, social control, structural racism and stigmatization over patient needs and desires.”

    What this workshop made absolutely clear is that it will be a struggle to win the reforms to truly free people from the cruelty and indignities of the methadone clinic system.

    At the top, entrenched, ossified and carceral bureaucracies run federal and state oversight. They prefer the status quo and surveillance. Taking off the “liquid handcuffs” isn’t an option. At the bottom, OTP owners are desperate to retain power and profits. They won’t close their doors without a fight, and the idea of losing control of methadone to primary care physicians or to a pharmacy-based pick-up system, like Australia, New Zealand and the UK, frightens and infuriates them. But they know that the pandemic experience means some reforms are inevitable. So they’re attempting to tether reforms to OTPs. They’ll take “liquid handcuffs lite” over abolition.  

     


     

    Image by Helen Redmond and Marilena Marchetti

    Correction, April 19: This article was edited to correct Walter Ginter’s role.

    • Helen is the senior editor of Filter. She has written about nicotine, mental health and drug policy for publications including Al Jazeera, AlterNet, Harper’s and The Influence. As an LCSW, she works with drug users in medical and community mental health settings. An expert on tobacco harm reduction, she provides training and consultation on mental health, nicotine use and THR, and in 2016 organized the first Tobacco Harm Reduction Conference in the US. Helen is also a documentary filmmaker.

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