A State-by-State Guide to the Cruelty of the Methadone Clinic System

    A chart book of blue national maps newly compiled by Pew Charitable Trusts is a powerful visual distillation of information about opioid treatment programs (OTPs). Seventeen maps illustrate how hobbled methadone clinics are by a web of federal and state regulations that are not based in evidence, reinforce stigma and significantly limit access.

    Pew examines regulations from 49 states and the District of Columbia. The state of Wyoming, whose motto is “Equal Rights,” has zero methadone clinics. The chart book focuses on regulation that “worsens patient experiences” and “limits access to care.” In the midst of an opioid-involved overdose crisis, it’s vital to understand why OTPs, the only setting where methadone is available to treat addiction, are failing so spectacularly.

    Nineteen states and the District of Columbia require a “certificate of need” for a clinic to open.

    The problem begins with the lack of OTPs in many communities. As of 2018, 80 percent of US counties, representing nearly a quarter of the population, had none. The reasons behind this number are state restrictions on the opening of new clinics, moratoriums, capping of their numbers, and requirements for a “certificate of need.”

    Nineteen states and the District of Columbia require this certificate before a new clinic can open. It’s a legal document that demonstrates the need for a new facility—as if that weren’t self-evident when methadone reduces mortality for people with opioid use disorder by half or more, during a fentanyl-related crisis that killed over 100,000 people in 2021. The process of obtaining one is time-consuming and expensive, can provoke community resistance and may result in denial.

    Incredibly, West Virginia, at one point the epicenter of the overdose crisis, is the most restrictive state, with a legal moratorium forbidding the opening of new clinics. “Amidst the greatest loss of life from drug overdoses in the recorded history of the USA, the death rate of the state of West Virginia stands above all others,” researchers wrote in 2020. “West Virginia has experienced statistically significant increases in drug overdose deaths every year since 2013 with an age-adjusted death rate of 57.8 per 100,000 in 2017…”

    Another set of regulatory barriers is pharmacy-based. Sixteen states require that OTPs be licensed or registered as pharmacies; five require clinics to follow general pharmacy regulations which apply to neighborhood drugstores; and 15 states require OTPs to hire a pharmacist or a consultant pharmacist. Methadone clinics are clearly not pharmacies—in no way do they resemble a CVS or Walgreens—and according to Pew, these requirements limit access to care.

    The chart book features a map of the 10 states that require “observed urine specimen collection.”

    A constant complaint from people on methadone is clinic hours. Week day times are typically 6:30 am to 2:30 pm and weekends from 6 am to 9 am. These narrow windows interfere with family and work responsibilities and contribute to missed or skipped doses. Clinics are notorious for not allowing patients who are late, even by one minute, to get dosed. Limited dose times force people to organize their lives around the clinic. Pew’s chart book asserts that being open for more hours per day helps patients access and stay in care. But only nine states require OTPs to be open outside of typical business hours of 8 am to 5 pm.

    In OTPs, the results of positive urine drug screenings profoundly affect the course of patients’ treatment and their ability to get take-home bottles. Federal rules require eight screenings a year, but 26 states mandate more. Urine screenings are a central feature of the system’s culture of cruelty. The chart book features a map of the 10 states that require “observed urine specimen collection”: Colorado, Florida, Idaho, Indiana, Kentucky, North Carolina, Ohio, Oregon Pennsylvania and, once again, West Virginia. This is humiliating and can cause trauma, especially for survivors of sexual abuse. One patient told Pew, “I don’t like someone looking at me, or behind me … It’s not a pleasant experience for anybody. Actually, I think it’s undignified, and I feel it’s wrong.”

    Forcing people out of OTPs for rule violations, called “administrative discharge,” is widespread. A major reason, “It’s common for people who use opioids to also use multiple substances as well as return to opioid use, even among people on medications for opioid use disorder (MOUD),” Pew notes. “Although federal guidelines and recommendations list neither as a reason to end medication treatment and research supports that continuing MOUD is safer than suddenly stopping, some programs terminate clients because of continued drug use.”

    Given these facts, opening more OTPs is not the answer.

    In the era of fentanyl, kicking patients out of treatment is not only cruel, it’s potentially deadly. The ability to terminate a patient’s treatment for continued drug use doesn’t apply to any other health condition. It’s pure discrimination. Only Massachusetts and South Dakota prohibit administrative discharge for not being abstinent. And all states allow administrative discharge for non-participation in counseling or other ancillary services, and for missed methadone doses.

    Other clinic-generated barriers the maps illustrate include: Discouraging long-term treatment, capping medication dosages, inflexible counseling requirements, and difficulty guest dosing.

    The chart book documents yet more evidence that clinics are deeply dysfunctional and punitive, and that regulations are not evidence-based. Given these facts, opening more OTPs is not the answer.

    That many states want OTPs to be regulated like a pharmacy, replete with a pharmacist on staff, is curious. Instead, close clinics and let patients pick up methadone at a real pharmacy.   



    Photograph by Helen Redmond

    • Helen is Filter‘s senior editor and a multimedia journalist. She is on the methadone, vaping and nicotine train. Helen is also a filmmaker. Her two documentaries about methadone are Liquid Handcuffs and Swallow THIS. As an LCSW, she has worked with people who use drugs for over two decades. Helen is an adjunct assistant professor and teaches a course about the War on Drugs at NYU. She lives in Harlem.

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