A major restriction imposed on mobile methadone vans may soon be lifted by the Drug Enforcement Administration. Filed in late February and open to the general public for comment until April 27, the agency’s proposed rule-making would eliminate certain registration requirements for opioid use disorder (OUD) treatment programs that aim to truly meet patients where they’re at.
Currently, the more-than 1,700 DEA-registered service providers dispensing methadone or buprenorphine, termed narcotic treatment programs (NTP), must separately register their mobile services with the federal agency—a bureaucratic hoop that has limited socioeconomically and geographically marginalized patients from accessing standard-of-care OUD treatment.
Under the new proposal, that requirement would be waived. Mobile delivery would instead be allowed to proceed as “coincident activity” to normal operations, contingent only on regulatory compliance and local DEA supervision.
“These revisions to the regulations are intended to make maintenance or detoxification treatments more widely available, while ensuring that safeguards are in place to reduce the likelihood of diversion,” states the February 26 DEA notice.
For many advocates, the revisions’ adoption would be a big win in the fight to increase access to a medication that has been out of reach for 80 percent of people in need of OUD treatment, according to 2017 national data.
“This is a positive step towards increasing access to methadone and buprenorphine to underserved communities,” writes Kellen Russoniello, senior drug policy manager for the Drug Policy Alliance* (DPA). “NTPs will be able to utilize mobile components to reach people in rural areas and also provide services to incarcerated people and those reentering the community through partnerships with law enforcement.”
The American Society of Addiction Medicine (ASAM) agrees. “By allowing mobile components of registered NTPs to be considered a coincident activity, this proposed rule would reduce the costs of expanding an NTP’s geographic reach and increase access to treatment,” writes Dr. Paul Earley, ASAM’s president. “It is a common-sense and cost-saving way to improve public health amid our country’s ongoing opioid-related addiction and overdose crisis.” The National Council for Behavioral Health and the College of Psychiatric and Neurologic Pharmacists express similar reasons for supporting the proposal.
But the potential positive impact of the rule-change may still be hindered by continuing or newly added restrictions, DPA cautions. For one, rural communities may still not be reached because providers would continue to be restricted by the DEA from delivering medication to patients’ own states. Some patients, particularly in the Southeast and Midwest, have to cross state-lines just to access care, as one 2011 study illlustrated.
Russoniello of DPA suggests restrictions based on distance rather than political geography: “One way to do this would be to authorize an NTP’s mobile component to operate across state lines so long as it remains within a 200-mile radius of the DEA-registered site. This will increase access to remote areas that will otherwise remain underserved.”
The cost-savings of mobile delivery may also be limited by a requirement for vans to return daily to the site where they’re registered. Russoniello warns that it would increase “staff time, travel costs, and wear and tear on vehicles. These expenses could easily rival the cost of opening a new brick-and-mortar NTP.” As an alternative, the DEA could require vans to return to the registered site on a weekly basis, in order to “ensure increased access while safeguarding against potential diversion,” writes Russoniello.
Maintaining the contested policy of programs dispensing methadone doses to new patients only on a daily basis would further undercut the efficacy of mobile programs, Russoniello adds. This policy “essentially dictates that a mobile component will need to go to the same location every day to serve new NTP patients, which many if not most of these patrons will be given their location in underserved areas.”
The urgency behind the proposed rule-change is further elevated by the complications posed by the coronavirus pandemic. New York City has rolled out a courier system to deliver methadone to isolated patients, but only on a temporary basis. A vast coalition of harm reductionists and allied organizations has called on the federal government to overhaul the long-term regulation of OUD medication delivery.
*The Drug Policy Alliance has provided a restricted grant to The Influence Foundation, which operates Filter, to support a Drug War Journalism Diversity Fellowship.
Photograph of a van from which buprenorphine is prescribed outside a jail in Baltimore, courtesy of the Behavioral Health Leadership Institute.