Beware a “Dear Colleague” letter from the Substance Abuse and Mental Health Services Administration (SAMHSA) that offers “updated guidance” on medication for opioid use disorder (MOUD). It could lead to more overdose deaths of people who take methadone or buprenorphine.
The April 24 letter, written by SAMHSA Principal Deputy Assistant Secretary Christopher Carroll, explains the new approach. “SAMHSA remains committed to expanding access to comprehensive, evidence-based treatment,” it states, “including the use of medications … But we are equally committed to ensuring that medications are part of the pathway to long-term recovery and sobriety, self-sufficiency, and thriving, not as a default sentence to life-long medication use.”
So getting people off of life-saving medication is “equally” important as making sure people at risk of overdose have access?
Underneath Carroll’s carefully coded language is an anti-medication bias, and the false notion that to truly be in recovery, medication must be discontinued.
Terms used throughout the letter—“shorter course of treatment,” “consider tapering and medication discontinuation,” “SAMHSA funding can also be used to support individualized tapering and discontinuation of medications when clinically indicated,” “at least annual reviews for continuing treatment,” “consideration of medication treatment duration”—illustrate prejudice against the long-term use of MOUD.
The idea that real recovery requires “living a drug free life,” as the letter puts it, is still pervasive.
Pressuring people to stop methadone isn’t new. Since the creation of the clinic system in the 1970s, there’s been a never-ending battle between viewing it as a maintenance medication, or the opposite—a short-term drug to get off of as rapidly as possible for fear of “enabling addiction.” Some patients report having to taper off in weeks or even in a few days, which is dangerous. It’s known as a “suicide detox.”
There is a long history of clinic counselors, particularly those who formerly worked in therapeutic communities where abstinence is demanded, badgering patients to get off MOUD because it’s “substituting one drug for another.”
That stance has changed in some opioid treatment programs (OTP) amid the life-or-death reality of the opioid-involved overdose crisis.
“My experience is that they are more inclined to push patients up, not to get off or taper down,” Jerry Otero, a person who takes methadone and the manager of the Drug User Health Hub at St Ann’s Corner of Harm Reduction, told Filter. “But it’s kind of arbitrary and it depends on the counselor.”
Yet in the public eye, the idea that real recovery requires “living a drug free life,” as the Dear Colleague letter puts it, is still pervasive.
Many report enormous pressure to stay on methadone. On the other hand, many are forced off it against their will.
The truth is, the clinic system is a Wild Wild West, where the pressure can go both ways and patients have little control over their dosage.
Many report enormous pressure to stay on methadone, even when they want to taper off, which has much to do with maintaining OTP revenues.
Bill Kinkle, a registered nurse who took methadone for many years, faced stiff opposition from clinic staff when he decided to taper off. “There was major pressure to stay on indefinitely,” he told Filter. “In fact, one doctor went behind my back and brought my partner and kids in for an ambush meeting to try and guilt me into remaining on methadone despite me giving concrete, objective evidence of why I desired to be off medication.”
On the other hand, many people who want methadone are forced off it against their will or have their dose decreased as punishment. Staff can lower the amount of methadone for missed doses, or refuse to give a dose if a patient can’t produce a urine specimen. Then there is administrative withdrawal, known as a “feetox,” when patients are forced to taper off due to nonpayment of clinic fees.
People stop taking methadone for a raft of reasons, but often it’s related to the clinics’ culture of cruelty that demands daily dosing and humiliates and punishes them—not to the medication itself.
People deserve to make their own choices armed with evidence-based recommendations. Coercing patients to quit MOUD is not evidence-based.
In the fentanyl era, discontinuing medication that is proven to cut the death rate from overdose by 50 percent is a serious risk. So it makes sense for OTP staff to be concerned if a vulnerable patient wants to stop taking methadone. Ultimately though, it should be the patient’s decision—whatever that is should be supported. And patients who change their minds and return should be welcomed right back into treatment.
People deserve to make their own choices armed with evidence-based recommendations. Coercing patients to quit MOUD is not evidence-based. The American Society of Addiction Medicine concluded two decades ago that methadone should be considered a long-term treatment.
Abysmal rates of retention in opioid treatment programs are evidence that many patients aren’t staying on medication long enough. And according to the Centers for Disease Control and Prevention, 75 percent of people who could benefit from MOUD don’t get prescribed them! So what’s SAMHSA’s hurry to get people off medication, when the real problem is they can’t get on it?
Methadone and buprenorphine have been proven to be safe and effective when used long-term. People take many other prescribed drugs for years; cholesterol- and blood pressure-lowering medications, GLP-1 drugs to maintain weight loss, insulin to manage blood sugar levels, or anticoagulants to decrease the risk of blood clots and strokes. There is no federal guidance to taper off these medications so that treatment doesn’t become “a default sentence to lifelong medication use.”
The ill-advised “Dear Colleague” letter exposes a fundamental problem: SAMHSA’s involvement in the dispensing of medication for opioid use disorder is an unjustified intrusion into the patient-provider relationship. It’s yet one more reason why methadone must be deregulated and integrated into health care and community-based settings. In other words, treated like every other medication in the pharmacopeia.
Photograph by Helen Redmond and Marilena Marchetti