It was the weirdest thing. Representative Donald Norcross (D, NJ) agreed with me that his Modernizing Opioid Treatment Access Act (MOTAA), “doesn’t go far enough,” that more clinicians should be allowed to prescribe methadone, and that the clinic system should be abolished.
But then he said none of that was possible at the moment, because: “That’s our political system.”
Norcross made these remarks at a panel he and I were speaking on, “Expanding Access to Methadone Treatment,” held by the Cato Institute in Washington, DC, in September.
A central flaw with MOTAA, as Norcross acknowledged, is that it would allow methadone prescribing outside of opioid treatment programs (OTP, or methadone clinics)—but only by board-certified addiction medicine physicians.
A recent Cato report found that there are only 5,517 such doctors in the United States. Just 15 are practicing in Delaware. South Dakota has nine, and Wyoming five. In Arkansas and Alambama, the report found that there are well over 3,000 people with opioid use disorder (OUD) per qualifying prescriber.
“Even if all these physicians were accepting new patients, it would not be enough,” authors Dr. Jeffrey Singer and Sofia Hamilton concluded. “There must be more of them to serve the millions of Americans with OUD who are not currently getting treated.” They recommend allowing primary care doctors, nurse practitioners and physician assistants to prescribe methadone in office-based settings.
Norcross said he agreed that the clinic system should be eliminated, but that things could only change incrementally.
Norcross and his small entourage arrived about 15 minutes late for the panel, and five minutes into my presentation. I was showing photos I’d taken of signs at OTPs, and one on the large screen illustrated the narrow windows of time when patients can get dosed. If you are late, you are locked out with no medication. Everyone is late getting places sometimes, I pointed out. Norcross, sitting in the first row, laughed audibly.
I concluded by calling for the elimination of methadone clinics and for prescription parity with other medications.
Norcross took the stage and talked about why methadone reform was important. He told a somber story about a snowstorm that shut down the entire city of Camden, New Jersey, where he lives.
From the windows of his apartment, he could see footprints in the snow, leading from the subway to the methadone clinic. “Those needing methadone had to go,” he said. “There was no ‘I’ll skip a day, I got medication at home.’”
He lashed out at the OTPs bent on protecting their lucrative turf, and called them “cartels.” He said, “The system is broken … and it has to change. That’s why I introduced MOTAA.”
Glancing at me, Norcross said he agreed that the clinic system should be eliminated, but that things could only change incrementally.
During a brief Q&A, I confronted Norcross about the problem of limiting prescribing to addiction specialists. In many rural communities, I explained, there are none—but there are nurse practitioners. I told him legislation had to make methadone easier to get than fentanyl.
Norcross replied that MOTAA was compromised because, “It was about negotiating and trying to get something through Congress.…” He then asserted that if MOTAA passes, it will show that it works, and he then can go back and make “the fix more widespread.”
There is no guarantee that he will ever be able to come back to amend the bill. Decades could pass; take the Drug Addiction Treatment Act of 2000.
Norcross is wrong. If MOTAA passes, it will reveal that it doesn’t work. Because of its tight restrictions and the inaccessibility of addiction doctors for most people, only a tiny group of wealthier, mostly white patients in urban areas will benefit. The overdose crisis will grind on as if MOTAA never existed, and that will allow the likes of AATOD (American Association for the Treatment of Opioid Dependence, the principle industry group representing OTPs) to fuel a backlash.
And there is no guarantee that Norcross will ever be able to come back to amend the bill. Decades could pass before more regulatory changes are made.
Take the Drug Addiction Treatment Act of 2000. In 2002, it made buprenorphine, another effective OUD medication, available by prescription, but with tight restrictions. It then took Congress 14 years to amend the legislation to allow certain nurse practitioners and physician assistants to prescribe buprenorphine and 21 years to eliminate the X-waiver—the bureaucratic obstacle that contributed to an ongoing shortage of doctors willing to prescribe the medication in many parts of the US.
Changing legislation before it passes is far easier than doing so retroactively. And amid more than 80,000 opioid-involved deaths per year, we cannot afford to wait on Congress to fix a bill that should have been fixed in the first place.
The next time I heard Rep. Norcross speak was a week later, at the conference Liberating Methadone: Building a Roadmap and Community for Change—held at New York University and organized by the National Coalition to Liberate Methadone.
In a surreal moment, Norcross agreed that incremental reform of methadone access means more people will die.
During the panel “A Chance For Change: Where Could We Go From Here,” the moderator raised the issue of limiting prescribing to addiction doctors but didn’t press Norcross hard. In a room full of doctors, nurses, researchers, and people with lived experience, no one robustly challenged Norcross to amend the bill that everyone agrees “doesn’t go far enough.”
In a surreal moment, Norcross agreed that incremental reform of methadone access means more people will die of overdose.
How can we possibly accept, during this catastrophic overdose crisis, that “our political system,” as Norcross put it, should lower our expectations to the point of accepting deaths that are totally preventable? A long list of prominent harm reduction and drug policy reform organizations have endorsed MOTAA; they should think again, and threaten to withdraw their support for the bill if he doesn’t make meaningful changes. We cannot waste the opportunities we have to confront Norcross and his colleagues, to urge them to fight harder to save lives.
Fighting hard is exactly what the groups that want to “responsibly” expand access to methadone are doing. They include the American Society of Addiction Medicine (ASAM), which is believed to have negotiated with Norcross to limit methadone prescribing to the professionals it represents. And before AATOD decided to go to war against MOTAA, it held meetings with Norcross for two years, arguing about provisions in the bill.
This month, Norcross told the publication Roll Call that negotiations got so heated, he cut off communication with AATOD:
“They have become very aggressive in trying to defeat this,” Norcross said in an interview, adding that he had changed the legislation to try to get their support.
What? He changed the legislation to get the support of AATOD?
If Norcross can change the MOTAA for the methadone clinic “cartel” he rightly denounces, why can’t he change it for those of us who want to make this life-saving medication available by prescription from any health care provider, for everyone who wants and needs it?
Photograph of Rep. Norcross in 2019 via Picryl/Public Domain