Applications are due July 27. Some grants have pre-application webinars scheduled in the coming days.

The largest investment, $68.25 million, will support the “Medication-Assisted Treatment – Prescription Drug and Opioid Addiction” grant. SAMHSA anticipates up to 91 recipients, awarded around $750,000 each.

Among other requirements, recipients would need to “ensure access” to methadone, either by providing it directly or by coordinating with other programs, as well as ensure that “all applicable practitioners” complete the training necessary to prescribe buprenorphine. Recipients are required to offer at least one MOUD, but thankfully no particular mention is made of naltrexone (Vivitrol). They would also be required to create “tobacco cessation programs” for people receiving MOUD, noting that integrating the two treatments “improves overall health outcomes without compromising OUD recovery.”

In addition to harm reduction, the funding notices similarly warn against applications that are supportive of Housing First, or that “promote denial … of the sex binary in humans, or the belief that sex is a chosen or mutable characteristic.”

In September 2025 SAMHSA unveiled new strategic priorities that aligned with President Donald Trump’s executive order targeting street-homeless communities and people who use drugs in public. The agency has redefined harm reduction as a model that promotes or enables drug use, while simultaneously redefining MOUD and naloxone access as issues that are unrelated to harm reduction.

In April, the agency removed fentanyl test strips from funding eligibility, along with overdose hotlines that support people using drugs alone.

Other funding allocations include $34.7 million for First Responders-Comprehensive Addiction and Recovery Act grants. These support naloxone (and nalmefene) trainings for first responders as well as local businesses and organizations that are viewed as “community anchors.” The best examples of these seem to be faith-based organizations, now that syringe service programs can’t apply for these grants or be mentioned in them.

If HHS was putting all this money toward what it viewed as a purely medical problem, you’d think the solution would be viewed the same way.

The funding opportunities are part of the Trump administration’s Great American Recovery Initiative, which since its launch in January has been credited in several similar funding announcements from SAMHSA, though none previously so weighted toward MOUD. The initiative is based in the brain disease model of addiction, a favorite among anyone who wants to say they’re compassionate toward people who use drugs while advancing policies that don’t quite reflect that.

“Addiction is not a moral failure. It is not a character flaw. And it’s not simply a behavioral issue,” Great American Recovery Initiative Co-Chair Kathryn Burgum stated at the Oval Office launch in January. “Addiction is a lifelong, chronic, relapsing medical disease—as real as diabetes, cancer and heart disease.”

If the Department of Health and Human Services was putting all this money toward what it viewed as a purely medical problem, you’d think the solution would be viewed the same way. But as with SAMHSA’s other recent funding opportunities—and funding restrictions—the grant notices specify that MOUD must be provided with other psychosocial services. Methadone and buprenorphine are often enormously effective with or without psychosocial services, ironically for the same reason that “the disease of addiction” is not just a medical issue—it’s a socioeconomic one. To a certain extent this is also true of diabetes and cancer and heart disease, but we don’t usually make the medical treatment of those conditions contingent on counseling and behavioral therapy.

Photograph by Helen Redmond and Marilena Marchetti

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The Advisory covers all three Food and Drug Administration-approved MOUD, but the crux of it is about buprenorphine (commonly known by brand name Suboxone). Unlike methadone, which is confined to its own clinic system, and naltrexone, which is unhelpful, bupe is an evidence-based medication that can be picked up from a pharmacy once a month like most other prescriptions. It’s the most widely prescribed of the three MOUD, but access is still limited in many regions and for many demographics, and patients and prescribers alike still face inordinate surveillance from the Drug Enforcement Administration. In recent years, there’s been a growing push for pharmacists to be able to prescribe bupe to patients directly.

Some pharmacists have been able to prescribe bupe through collaborative practice agreements with licensed physicians—but only in the minority of states that authorize them. In 2022, the Mainstreaming Addiction Treatment Act eliminated the X-waiver and allowed bupe to be prescribed to more patients by more types of providers, including pharmacists, with fewer bureaucratic hurdles. But pharmacists’ ability to prescribe bupe was still restricted at the state level.

In late 2025, the SUPPORT Act authorized DEA-licensed pharmacists to prescribe bupe independently after completing an eight-hour training that’s specific to buprenorphine (rather than one more broadly focused on substance use disorder). But to date, only California and Idaho have approved pathways for pharmacists to prescribe bupe independently.

“A pharmacist’s ability to prescribe and dispense MOUD is especially important for communities that have limited access to or awareness of OUD treatment,” the Advisory states. “[P]harmacists are often the first point of contact on the continuum of care for people with OUD, and most pharmacies have longer hours of operation than other medical providers. These considerations mean that, where state laws allow, DEA-registered pharmacists are well-positioned to provide patients with streamlined, low-barrier access to MOUD.”

“Medication diversion is a complex topic and is often misunderstood,” the Advisory states.

SAMHSA has recently been shifting its rhetoric around long-term MOUD maintenance toward tapering, validating the very dangerous idea that bupe and methadone are only step-downs on the road to “full” abstinence—which encourages scrutiny of the many people who have been stable on those MOUD for years or even decades. But rather than push the concept, the Advisory frames tapering only as a possibility that some patients might decide to pursue, while “clinical experience shows that [others] may require long-term treatment with medications.”

It also addresses pharmacists who might be wary of prescribing bupe to patients who also use other substances besides opioids, stating that in the context of the overdose crisis “it is safer to initiate MOUD without requiring abstinence from multiple substances.”

Urine drug-testing is discussed only briefly, to note that the practice “may be useful for assisting with treatment adherence,” but in isolation “has limited utility and effect on patient outcomes,” and “may be viewed as punitive by patients.”

For pharmacists concerned about “diversion,” meaning the bupe getting used in some way it wasn’t meant to, or by someone it wasn’t prescribed to, SAMHSA states that they shouldn’t decline to fill a prescription without first talking to both the patient and provider.

“Medication diversion is a complex topic and is often misunderstood,” the Advisory states. “Pharmacists who have concerns about the prescribed buprenorphine treatment regimen should not automatically decline to dispense it … buprenorphine is rarely associated with fatal overdose, and, when it is, other substances are almost always present.”

The government is always lamenting how there are too many barriers to accessing bupe even though its risks are negligible, how the overdose crisis makes this a matter of utmost urgency, how only a fraction of the people eligible for a prescription are able to get one. Then when the people take matters into their own hands it’s called “diversion,” and we have to stop them before too much life-saving medication gets into the community, where just anyone could take it. This is why these resource guides always overlook the fact that the more appropriate way to dispense bupe, compared to the current restrictive setup, would be to just launch it into the streets with a T-shirt cannon.

Image (cropped) via California State Board of Pharmacy

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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

The post “Consider Tapering”—SAMHSA Turns Against Long-Term Methadone Use appeared first on Filter.

So far in April, HB4708 has passed the Restorative Justice & Public Safety Committee, received a second reading and changed chief sponsor to Assistant Majority Leader Rep. Will Guzzardi (D). It’s calendered for another committee hearing April 16. The pilot would begin January 1, 2027, in at least one IDOC facility.

As introduced, HB4708 would have required the pilot to provide a minimum of 4,000 doses and bridge participants to community treatment upon release, “including, but not limited to, a referral to a harm reduction provider.” It has since been amended to require that the pilot provide a full course of treatment to at least 3,000 people. It also stipulates that this would be covered by opioid settlement funds, and that the pilot should not commence until full funding has been secured so that every participant “may receive the full course of treatment clinically indicated.” There’s no longer any reference to harm reduction providers, but prior to a participant’s release IDOC would be required to make an appointment with an “appropriate provider or treatment site” and share the relevant medical information.

The bill would also now require an independent third-party evaluation, which would determine the pilot’s success by tracking a handful of metrics for each participant. These are primarily concerned with whether participants continue treatment in the community, but the evaluator would also record any post-release fatal or non-fatal overdose, any rearrest or other further interactions with the criminal-legal system, “institutional safety indicators” and of course cost-effectiveness. The latest amendment would require IDOC to publicize the pilot eligibility criteria and selection process, and a report would be submitted to lawmakers by January 1, 2029.

While it’s obviously important that participants don’t have their treatment cut off because funds ran out, or because IDOC failed to ensure continuity of care upon release, the effect of these provisions will be to deprioritize everyone who has more than a year or two left on their sentence. Not that they wouldn’t have been deprioritized already—MOUD is widely considered inappropriate for anyone whose release date is not imminent.

This is due to the misinformation about the harms of MOUD “diversion”; the lack of staffing resources and political will to contemplate treating the much larger share of the prison population; and the fact that while corrections departments across the country justify any and all policy changes by saying they’re necessary to combat the tidal wave of incoming contraband, they also cling to the narrative that there are simply no drugs in prison and so there’s no need to treat anyone unless they’re about to get out. Notably, the bill does not instruct the third-party evaluator to look into overdose rates among participants while they are still incarcerated.

Another Illinois bill introduced in 2025, SB2185, would require IDOC to screen everyone in custody for OUD and provide medication to anyone eligible, with funding from the Illinois Opioid Settlements Initiative. It’s currently in the Senate Appropriations-Public Safety and Infrastructure Committee, which is required to report on it by April 24. But this bill heavily emphasizes providing MOUD to people who were already enrolled in a treatment program at the time of their arrest, and makes clear that IDOC can defer or discontinue their MOUD if medical staff determine it’s no longer necessary. IDOC considers MOUD for prisoners who weren’t already taking it when they began their sentence, but only at its two women’s facilities.

The bill states that even if they weren’t already enrolled in treatment, an eligible “committed person shall be authorized to receive [MOUD] immediately and for as long as clinically indicated.” But again, IDOC gets to decide that. Even if all the other criteria are met, people with decades left on their sentence aren’t usually found clinically indicated in these situations.

The best-known long-acting buprenorphine product is Sublocade, a monthly injection manufactured by Indivior Pharmaceuticals.

HB4708 does not distinguish between long-acting injectable versions of naltrexone and buprenorphine. But the former, better known by brand name Vivitrol, is already widely used in reentry settings despite the fact that naltrexone is the only MOUD not shown to decrease overdose risk, and has been repeatedly associated with increasing overdose risk. 

The best-known long-acting buprenorphine product is Sublocade, a monthly injection manufactured by Indivior Pharmaceuticals. In 2025 Indivior expressed plans to focus its energies on Sublocade, which is exponentially more profitable than the company’s other ventures.

In late March, an Indivior-funded study published in the Journal of Current Medical Research and Opinion suggested that based on treating 100 patients per month, Sublocade would save over $22,000 and 747 staffing hours per month compared to oral buprenorphine, which in prisons must be dispensed every day. (Sublocade also managed to perform better than all other MOUD in the study, including beating a competitor brand’s other long-acting injectable buprenorphine product by $23 and one staffing hour per month.)

In an April 3 paper published in the Journal of Correctional Health Care, 87 percent of prison staff surveyed responded that long-acting injectable buprenorphine could help reduce “diversion” of prescribed Suboxone. Two of the seven authors are employed by Indivior.

Notwithstanding Indivior’s obvious incentive to produce science that shows its product to be just what corrections departments need, making Sublocade widely available in prisons would have substantial benefits. But a central problem plaguing this type of legislation is that it relies on the idea that MOUD provision requires steady, uninterrupted care—which it does—while only making it available to people at the last possible minute before release.

There is, however, at least one Illinois bill under consideration that acknowledges this. HB4583, introduced by Guzzardi in January and currently in the House Rules Committee, would require that everyone in IDOC be assessed for OUD and that medication be provided to anyone at risk, regardless of whether they’re nearing release.

“The Department of Corrections does not currently have extensive medication-assisted treatment programs readily available to meet the needs of all committed persons with opioid use disorder, despite estimates that more than half of the committed population meets the criteria for having a substance use disorder,” the bill states. “Individuals with opioid use disorder living in correctional settings are entitled to the same level of care as those in community-based settings.”

Image via Weber County, Utah

The post Illinois Bill Would Put Long-Acting OUD Meds in Prisons, Sort Of appeared first on Filter.

In 2018, the SUPPORT Act established Medicaid coverage for all three medications for opioid use disorder (MOUD)—methadone, buprenorphine and naltrexone. But the 251-page document doesn’t acknowledge harm reduction outside of a single paragraph covering syringe service programs, and the 2025 reauthorization doesn’t add anything on the subject.

The original Act commissioned a study focused on access barriers to buprenorphine, naltrexone and “buprenorphine-naloxone combinations” AKA Suboxone. It left out methadone, the MOUD with the most obvious access barriers, but seven years later one of the more notable additions in the new version is a section that advances the potential rescheduling of Suboxone, or any buprenorphine/naloxone combination product. 

Naloxone is not a controlled substance. But buprenorphine is, under Schedule III alongside drugs like ketamine and testosterone. The Act directs the Department of Health and Human Services (HHS) to “review the relevant data pertaining to the scheduling of products containing a combination of buprenorphine and naloxone that have been approved under section 505 of the Federal Food, Drug, and Cosmetic Act [and] if appropriate, request that the Attorney General initiate rulemaking proceedings to revise the schedules accordingly with respect to such products.”

This requirement appeared in the reauthorization bill approved by the House Committee on Energy and Commerce in 2023, but neither that bill nor the Senate version was advanced in time to replace the original Act before it expired that September.

The reauthorization quietly advances the campaign to install nalmefene as a viable alternative to naloxone.

Among the other additions that weren’t in the 2018 version is an amendment approved by legislators in June—proposed by Rep. Robert P. Bresnahan (R-PA), whose cousin died of overdose. It prohibits HHS grant guidance from singling out naloxone as the default opioid-overdose reversal medication:

“The Secretary of Health and Human Services shall ensure that, as appropriate, whenever the Department of Health and Human Services issues a regulation or guidance for any grant program addressing opioid misuse and use disorders, any reference to an opioid overdose reversal drug (such as a reference to naloxone) is inclusive of any opioid overdose reversal drug that has been approved … for emergency treatment of a known or suspected opioid overdose.”

Bresnahan, who since taking public office for the first time in January has become best known for ethically dubious stock trades, described this slightly differently in his testimony to colleagues. He stated that current “HHS regulations refer to certain name-brand drugs, such as Narcan, which can limit usage of other versions that may be more readily available.”

This is a really good point, though completely different from the one Bresnahan is intending to make. Using the brand name “Narcan” rather than the generic “naloxone” does contribute to generic injectable naloxone being overlooked by public officials, even though it’s more affordable and in many cases more humane. This is not the problem Bresnahan is looking to solve.

Many overdose-response regulations refer to naloxone as the default opioid-overdose antidote because up until 2023 there weren’t any others. But since Food and Drug Administration approved the first such antidote formulated with nalmefene, a different chemical compound, pharmaceutical companies and other stakeholders have been pushing legislators to cut references to naloxone in favor of “any opioid overdose reversal drug” approved by the FDA. The campaign to install nalmefene as a viable alternative to naloxone has continue despite emphatic warnings from public health experts about nalmefene’s higher risk of overdose and unnecessary suffering for people who regularly use opioids.

Image (cropped) via Drug Enforcement Administration

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Researchers analyzed data from seven county jails in Massachusetts, which under a state-mandated pilot program began providing all three Food and Drug Administration-approved MOUD—methadone, buprenorphine and naltrexone—in 2019. Outcomes for 2,711 people who received MOUD in jails in late 2019 were compared to 3,689 people who did not receive MOUD. The study was published September 10 in the New England Journal of Medicine and funded through the Justice Community Opioid Innovation Network, a National Institute on Drug Abuse initiative launched in 2019.

In the six-month period following release, receiving MOUD in jail was associated with a 52-percent reduction in fatal opioid overdose risk; a 24-percent reduction in nonfatal opioid overdose risk; a 56-percent reduction in risk of death from any cause; and a 12-percent reduction in risk of reincarceration.

Of the MOUD group, 82.7 percent accessed treatment upon release, compared to 52.1 percent of the non-MOUD group. And after six months, 57.5 of the MOUD group remained in treatment, compared to 22.8 of the non-MOUD group.

Notably, 67.9 percent of the MOUD group received buprenorphine while 25.7 percent received methadone. Only 6.5 percent received naltrexone, which of the three is has by far the most uptake among corrections departments. 

Most of the jails had already been offering naltrexone. 

Methadone and buprenorphine, which are full and partial opioid agonists, respectively, are both strongly associated with reductions in overdose risk. Naltrexone is an opioid antagonist—like naloxone, or the lesser-known nalmefene—and carries a warning about raising “risk of opioid overdose” as a side effect.

Better known by the brand name Vivitrol, naltrexone is formulated as a once-a-month injection. It blocks the effects of opioids like fentanyl or heroin, but it doesn’t ease cravings or treat withdrawal, and over the course of the month it wears off. As as a result, people end up using greater quantities of opioids than they would have otherwise.

The authors noted that while all seven jails offered all three MOUD as of the study start date, most of them had already been offering naltrexone. 

“[I]nstitutional and other barriers slowed the uptake of the agonist medications, buprenorphine and methadone, which have stronger evidence for reducing mortality,” the authors wrote. “These findings provide the impetus for the majority of jails in the United States and internationally that do not provide agonist [MOUD] to implement these effective medications.”

County jails are uniquely positioned to exacerbate the racial inequities of MOUD access, but also to improve them.

Jails and prisons have made some limited concessions in providing buprenorphine, and to a lesser degree methadone, to people who were receiving them prior to arrest; mostly because they’re compelled to do so by law. This is why nearly three out of four people in the MOUD group had been receiving methadone or buprenorphine in the community prior to their incarceration—which, in turn, likely contributed to the high rate of continuity of care after release. 

There’s significantly more resistance when it comes to initiating treatment for people who would be first-time patients, especially with methadone. This would be why the buprenorphine-heavy MOUD group was 75-percent white. But the data are also a stark illustration of how county jails are uniquely positioned not just to exacerbate the racial inequities of MOUD access, but also to improve them.

“Some jails did go beyond the [pilot program] mandate to offer MOUD induction to all persons with OUD soon after intake,” the authors wrote, “including those who were using street opioids and had short stays (e.g., nonsentenced, pretrial detention); jails with a greater Black non-Hispanic and Hispanic population might have been less proactive in offering early induction to persons who were not receiving MOUD at jail entry.”

Jails and prisons are the most obvious settings to effectively offer MOUD; previous research has suggested that almost half the community overdose deaths in the US represent people who were formerly incarcerated. But as the authors note, access to MOUD in correctional settings, “especially the agonist medications,” has progressed very slowly.

Corrections departments love naltrexone because it is a punitive, abstinence-rooted MOUD. They also love it because they’re understaffed.

As of 2023, less than half US county jails were estimated to offer some form of MOUD to some small subset of detainees, and less than 13 percent of jails were estimated to offer MOUD to anyone who requested it.

“[A]fter extended-release naltrexone (XR-NTX) received FDA approval for OUD, criminal justice officials have been more receptive to it than agonist treatments, in part, because XR-NTX has no abuse potential,” the authors wrote in the study supplementary materials. “Reluctance to deliver the agonist treatments in jails is understandable given concerns about misuse and diversion, the need for secure storage and dispensing, and the burden of daily dosing on clinical and correctional staff time.”

This accounts for a lot of what the authors describe as “continued skepticism in some quarters about the benefits of … the agonist MOUDS in particular” that prompted their research.

Corrections departments love naltrexone because it is a punitive, abstinence-rooted medication that essentially presents recovery as a matter of willpower. They also love it because they’re understaffed. A medication that only has to be dispensed once a month, and is of no interest in the contraband drug market, is a lot more appealing than ones that have to be dispensed every morning amid a ton of additional surveillance and security protocols. They offer it because it’s the easiest to offer. Not because it’s effective.

Photograph (cropped) via Stanislaus County Community Corrections Partnership

The post County Jail Data Show Importance of All Three OUD Meds, Besides Vivitrol appeared first on Filter.

In 2005, Mischley became one of the first people in his Michigan county to be prescribed buprenorphine for OUD. Buprenorphine has been a Food and Drug Administration-approved pain medication since the 1980s, but was only approved as a medication for opioid use disorder (MOUD) in 2002. Tighter regulations wouldn’t arrive until later, and Mischley’s initial prescription was for 64 mg—a dose that would be unheard of today. 

Mischley was on his mom’s health insurance plan, which was a good one because she had a government job with the United States Postal Service. Even that didn’t cover the entire prescription, leaving him with $200 or $300 in out-of-pocket costs each month.

“I told them that was too much, the cost was too much,” he said. “Everything was too much.”

But within a year his prescription was dropped to 32 mg, and things got easier for a little while.

Buprenorphine is a partial opioid agonist. It doesn’t affect people as strongly as full agonists such as methadone, which has been an FDA-approved MOUD for over 50 years, or unregulated opioids like heroin and fentanyl. Buprenorphine dulls the effects of full agonists, but on its own it can be enough to keep withdrawal at bay, which is all many OUD patients are looking for. And unlike methadone, which can only be dispensed at a clinic, buprenorphine can be picked up at a pharmacy like any other prescription. 

Mischley still had access to street-supply opioids that more readily produced a high, and found this challenging since he wanted to avoid them. But with a 32-mg buprenorphine prescription he managed to make things work by waking at the crack of dawn, taking two of his four daily pills and then falling back asleep. By the time he woke up again to actually start his day, the medication would have kicked in and would make other opioids feel like nothing if he took them. Which he found helpful.

“If I went and shot heroin after using Suboxone, it wouldn’t do anything,” he said. “It would just be like injecting water.”

The two MOUD tablets that the FDA approved in 2002 were Subutex, the brand name for buprenorphine, and Suboxone, which contains both buprenorphine and a smaller amount of naloxone. The Substance Abuse and Mental Health Services Administration (SAMHSA) endorsed the new MOUD up to 32 mg per day, which clinical evidence strongly supported as the maximum dose. The FDA, however, sent them onto the market with the following labeling:

The recommended target dose of SUBOXONE is 16 mg/day. Clinical studies have shown that 16mg of SUBUTEX or SUBOXONE is a clinically effective dose compared with placebo and indicate that doses as low as 12 mg may be effective in some patients. The dosage of SUBOXONE should be progressively adjusted in increments / decrements of 2 mg or 4 mg to а level that holds the patient in treatment and suppresses opioid withdrawal effects. This is likely to be in the range of 4 mg to 24 mg per day depending on the individual.

Over the next two decades, the impact of this would be that insurers generally won’t cover anything higher than 24 mg, and most prescribers won’t push them because they won’t consider higher doses in the first place.

But for many OUD patients, higher doses are what make buprenorphine effective.

Buprenorphine prescriptions above 24 mg have been linked to higher treatment retention, including in the period immediately after initiation. They’ve also been linked to a 50-percent reduction in emergency department visits and inpatient care. And over the past decade as fentanyl has taken the place of heroin in the unregulated drug supply, opioid tolerances are increasing and more people are finding that a maximum dose of 16 mg or 24 mg isn’t enough to keep them well. 

Centers for Disease Control and Prevention data for 2023

For those patients, the options for avoiding withdrawal are generally street-supply opioids, or methadone.

Health care providers who prescribe opioids for pain management use a framework called morphine milligram equivalents, or MME, to calculate what a patient’s dose for one opioid would correspond to for a different opioid. This doesn’t apply to MOUD, for a laundry list of pharmacological reasons starting with the fact that buprenorphine is a partial agonist and methadone is a full agonist; it’s a little like comparing apples to oranges. There is no universal equation that can say exactly what 24 mg or 32 mg of buprenorphine translates to in methadone. But for anyone taking more than 8 mg buprenorphine, standard practice would be to make the switch by abstaining for 24 hours, then starting with 30 mg methadone and going up from there.

Both methadone and buprenorphine are invaluable MOUD, but they are very different. Not everyone wants to go from a partial agonist to a full agonist, and vice versa. But the biggest reason someone struggling on a high dose of buprenorphine wouldn’t want to switch to methadone isn’t because of the medication itself, but because of the clinic system. Getting methadone for OUD usually means reporting to an opioid treatment program at dawn daily. Everything else in life—work, travel, illness—has to fit around that. Add to that the heavy surveillance, lack of privacy, long commutes for people in rural areas and notoriously punitive clinic culture, and it’s clear why for many people the biggest advantage of buprenorphine is that it can be discreetly picked up once a month at a pharmacy. 

Capping medication at a dose that doesn’t provide adequate relief is what pushes many patients to street supply, which is more dangerous than pharmaceuticals but easier and often more dignified to access. Research on extended-release injectable buprenorphine suggests that for people who inject opioids, doses higher than 32 mg could result in less use of street supply—if insurance weren’t a barrier.

In 2010 the FDA doubled down following its approval of Suboxone film (which has become the more recognizable formulation, compared to the tablets) stating that doses higher than 24 mg “have not been demonstrated to provide any clinical advantage.”

As part of the approval process, manufacturer Reckitt Benckiser Pharmaceuticals Inc stated that anything above 16 mg should be considered an exception.

“[T]here should be little difference in clinical effectiveness at doses between 16 mg and 24 mg in most patients,” Reckitt Benckiser advised. “When a patient expresses a need for a higher dose, consider the possible causes [and first] explore other alternatives. Also consider the possibility that the patient may be exaggerating symptoms to obtain additional medication for diversion.”

There has been no watershed moment for access to doses above 24 mg or even 16 mg—but there has been some progress.

Pre-pandemic data show that only around 3 percent of buprenorphine prescriptions were for doses above 24 mg, and only around 4 percent of prescribers were writing them.

“A lot of physicians and nurse practitioners have been afraid to write [prescriptions] for higher doses,” Dr. Edwin Chapman, an internal and addiction medicine specialist who has been treating OUD patients for 25 years, told Filter. “In their training, they were told for years that 16 mg was the target dose, 24 mg in special cases.” 

Patients and providers have been advocating for years to remove the additional layers of bureaucracy and surveillance that come with prescribing buprenorphine for OUD, like urine drug screens and extra steps required for insurance approval. In 2023, the Drug Enforcement Administration eliminated the X-waiver, a federal requirement that had been created specifically for buprenorphine and had severely restricted access to prescriptions. Telehealth prescribing has also now been expanded, building on momentum that began during the COVID-19 pandemic. There has been no watershed moment for access to doses above 24 mg or even 16 mg—but there has been some progress.

In 2023, Chapman and dozens of other stakeholders presented the FDA with their case for doses over 24 mg having benefits for many patients, at no added risk. The concept gained traction with federal agencies, and in December 2024 the FDA made a public recommendation that manufacturers of buprenorphine products that dissolve under the tongue (meaning tablets or film, but not the longer-acting injectable formulations) update their labeling.

“[N]either 16 mg/day nor 24 mg/day should be interpreted as maximum dosages,” the FDA stated.

The agency advised removing references to a “target dose,” and noting that doses above 24 mg “have not been investigated in randomized clinical trials but may be appropriate for some patients.”

In a letter explaining the decision to prescribers, Dr. Marta Sokolowska of the FDA’s Center for Drug Evaluation and Research noted that the agency was aware that insurers had been restricting access to higher doses as a consequence of the language previously used on the labeling.

In 2023, one of Chapman’s patients overdosed after United Healthcare capped his buprenorphine coverage at 24 mg. The patient survived—and the story made the front page of the Washington Post. Since then, United has covered Chapman’s patients up to 32 mg without issue. But he still has to go through the process of obtaining prior authorizations. And months after the FDA formally clarified that buprenorphine has no maximum dosage restrictions, this hasn’t changed. 

“8-2MG” refers to a standard Suboxone strip containing 8 mg buprenorphine combined with 2 mg naloxone. Insurers will often cover prescriptions up to three strips (24 mg buprenorphine) per day, but not four.  

“I don’t know if it’s just because of me or whether other doctors have difficulty getting above 24 mg with United Healthcare,” Chapman said. “But the point is they’re still saying 24 mg [is the limit].”

Like every other extra bureaucratic hurdle attached to buprenorphine, prior authorizations are associated with decreases in treatment retention.

The American Medical Association, one of the organizations that pushed the FDA to revise its labeling recommendation, has urged insurers to update their policies accordingly. The FDA is also currently supporting a high-dose buprenorphine study in collaboration with the Department of Veterans Affairs. But experts reached by Filter say it could be a year or more before the FDA recommendations begin to have real-world impact for most patients. Meanwhile, many will lose access amid the arrival of President Donald Trump’s “big, beautiful law” and its $1 trillion in cuts to Medicaid. Of the nearly 2.5 million people in the United States who filled buprenorphine prescriptions between April 2020 and March 2024, approximately 48 percent used Medicaid to do so at least once.

Elimination of the X-waiver has not yet done much to actually increase the number of health care providers prescribing buprenorphine. And, despite the updated labeling recommendations and the removal of the X-waiver, some states also maintain their own restrictions that impede access. 

“I’ve had people tell me not even to send the second prescription because they know they can’t afford it this month.”

Dr. Jared Matthews, an addiction medicine physician in Tennessee, described the state as “a really great example of what not to do.”

Tennessee has taken some recent steps to increase access to 24 mg doses of buprenorphine, but in practice the state effectively caps prescriptions at 16 mg.

“Administrators with the actual Medicaid program, most of their higher-level executives are physicians,” Matthews told Filter. “They are well aware of what the medical evidence tells them they should be doing … yet when they take these proposals to their political leadership, the answer is always No.” 

So for patients who require a higher dose, Matthews writes two separate prescriptions: one for a 16 mg dose covered by Medicaid, and one for whatever remaining number of milligrams the patient needs, which they must pay for out of pocket. Each additional 8 mg can cost upwards of $200 per month.

“I probably have no less than 100 patients where 16 milligrams is not adequate to control the signs and symptoms of their opioid use disorder,” Matthews said. “I’ve had people tell me not even to send the second prescription because they know they can’t afford it this month.”

In Kentucky, prescribing over 16 mg is restricted to advanced practice registered nurses certified in addiction medicine. The state also doesn’t allow buprenorphine to be prescribed for pain management, only OUD.

“Indiana allows it for pain management,” Dr. James Murphy, whose clinic straddles the border between the two states, told Filter. “Federally, it’s allowed. The Veterans’ Affairs nationally actually has Suboxone listed as one of the choices that we can use for chronic pain management. Yet in Kentucky that would be considered illegal.”

Murphy treats some pain patients with buprenorphine, or with methadone; many have complex needs wherein OUD and chronic pain overlap. As a result of the outdated regulations, he fields a lot of calls from pharmacies and insurers alleging that his patients’ doses are too high. But for his patients across the river in Indiana, he’s able to more readily prescribe the doses they need.

“What is it about a river or a line or a border that makes the patient different?” Murphy asked. “The patient with chronic pain and opioid use disorder is the same in Kentucky as [in] Indiana.”

“Red flags” are triggered by activity the DEA considers suspicious.

Buprenorphine is regulated under Schedule III of the Controlled Substances Act. As with other opioid analgesics, and certain other pharmaceuticals like benzodiazepines, buprenorphine prescriptions are tracked by the DEA through a nebulous web of proprietary algorithms known as prescription drug monitoring programs (PDMP). “Red flags” are triggered by activity the DEA considers suspicious.

Providers, for example, can trigger red flags by writing a lot of prescriptions for higher doses. Pharmacists are required to check for these red flags, and can be held liable for filling prescriptions the DEA determines they shouldn’t have. 

Patients, meanwhile, can get red-flagged by paying for prescriptions in cash—which data suggest is the most common method of payment for buprenorphine prescriptions above 24 mg.

“Sometimes it’s difficult for patients to even fill a buprenorphine script,” said Jonathan Larsen, a public health law expert at Temple University. “If a pharmacist is feeling uncomfortable about [dispensing] buprenorphine because it might raise red flags.”

A secret shopper study conducted in 2022 found that in Tennessee, the majority of pharmacies would likely refuse someone trying to start treatment with buprenorphine. Researchers called 183 pharmacies, across all but one of the state’s 95 counties, asking to fill a prescription for a new patient—and 53 percent of the pharmacies said No. Many had caps on the number of buprenorphine patients they were allowed to serve, as well as waiting lists for when space opened up. Many pharmacies didn’t stock buprenorphine at all, citing pharmacist discretion as one of the main reasons.

Murphy has written prescriptions that patients were unable to pick up because pharmacists refused to fill them. This is a widespread barrier. Fear of being raided and shut down keeps many pharmacists from filling higher-dose buprenorphine prescriptions, even if the insurer has agreed to cover it.

One doctor stopped seeing Mischley after a urine drug screen indicated he’d used marijuana.

These days, Mischley’s prescription is for 24 mg and that’s been working well for him. But over the past two decades, heavy surveillance and aura of illegality around higher-dose buprenorphine has cut off access to his prescription multiple times.

One doctor stopped seeing him after a urine drug screen indicated he’d used marijuana. This was before both medical and adult-use legalization in Michigan, but this didn’t seem to be where the concern was coming from.

“[The doctor] said since his license was federal,” Mischley said, “and [marijuana was] illegal federally, he couldn’t risk that.”

Around 2012, the doctor prescribing Mischley’s buprenorphine by that time was investigated by the DEA, and his practice subsequently shut down. This doctor also issued medical marijuana cards, and apparently the DEA felt he issued too many of them.

Mischley is on his seventh provider. Like paying in cash, frequently changing doctors can be a DEA red flag, too.

Top image (cropped) via Drug Enforcement Administration. First inset graphic via Centers for Disease Control and Prevention. Second and third inset graphics via Dr. Edwin Chapman.

R Street Institute supported the production of this article through a restricted grant to The Influence Foundation, which operates Filter. Filter‘s Editorial Independence Policy applies.

The post The Case for Higher-Dose Buprenorphine appeared first on Filter.

The three Food and Drug Administration-approved MOUD are methadone and buprenorphine, which lower overdose risk, and naltrexone, which raises it. Methadone is the least accessible, and can only be dispensed by licensed methadone clinics, also known as opioid treatment providers (OTP). So corrections departments seeking to provide it either need to become an OTP themselves or partner with one nearby.

The implied focus on methadone is not at all a bad thing. Usually these kinds of documents say they’re about all three MOUD before immediately writing off methadone as a non-starter. But while the guidance is somewhat specific to methadone, it’s not very specific to state prisons. A lot of it reads like generic guidance for adapting methadone dispensing to non-traditional settings—but ones assumed to be less tightly controlled than OTP. So it’s a little awkward.

For example, great care is taken to point out that becoming an OTP will require “consideration of the possibility that controlled medications will be transferred or used by those to whom they were not dispensed.” Corrections departments do consider this. It has occurred to them. Yet SAMHSA continues to reassure them that we can mitigate the risk of diversion by making sure that each dose is counted and stored in a secure area, and by closely observing each patient when they take it. State prisons closely observe people in custody when they take Tylenol. 

There are a number of things the guidance gets right, but they’re all underplayed to the degree that you’d almost miss them. It does state that while MOUD is often more effective when paired with counseling, for many people it’s sufficient in and of itself. It also states that long-term treatment is common and often necessary, and that it’s not advisable to think of MOUD as just a step-down. It explicitly states that MOUD should be accessible to people throughout their incarceration, not just at discharge. This is a slightly bold statement for SAMHSA, but the agency doesn’t really expand on it. 

More than pretty much any other setting, prisons are already set up with all the infrastructure required to dispense methadone.

Becoming authorized as an OTP requires licensing with the state, registration with the Drug Enforcement Administration and accreditation through SAMHSA, which is less work than it sounds like but more than enough to give corrections departments sufficient pretext to not bother. 

But the fact that methadone clinics are already so carceral in nature is why prisons, more than pretty much any other setting, are already set up with all the infrastructure required to dispense methadone. It’s a bit self-defeating of SAMHSA to not even reference this, let alone capitalize on it.

Prisons already have established daily dispensing schedules, wherein everyone who needs a medication dispensed lines up to take it, while staff watches them and checks if they’ve swallowed. Prisons already conduct drug testing. They already have secure vaults for pharmaceutical storage. They have diversion protocols. They have on-site counselors. They have exam rooms. They in theory have at least one licensed medical physician. They don’t exactly have HIPAA-compliant dispensing areas, but this has not stopped them from dispensing other stigmatized medications and it wouldn’t stop them from dispensing methadone.

“Stigma and discrimination are considered primary barriers to MOUD implementation in any setting but may be impediments to improving the correctional treatment system,” the guidance states. “Addressing misperceptions and misinformation regarding MOUD will help dispel stigma. Facilitating a culture change in correctional treatment services may be needed.”

Talking about stigma and discrimination is the kind of thing that sounds right, and might be fine if SAMHSA was in fact writing generic guidance for adapting methadone dispensing to non-traditional environments. But in state prisons, the primary barrier to implementation would be understaffing. 

Unfortunately, the fact that just about all state prisons are in the grip of a severe understaffing crisis is the other big thing that SAMHSA seems to not know about them. One person with decision-making power can override stigma, but not the absence of staff.

For prisons that don’t intend to become an OTP, SAMHSA suggests partnering with a local program and facilitating methadone access under three possible models: transporting people in custody to the OTP to take their methadone there; sending staff to the OTP to pick up the methadone and bring it back; and having the OTP deliver methadone to the prison. To a certain extent SAMHSA does seem aware it’s making some throwaway suggestions here, but it would have been a better use of space to explain why. 

State prisons often do not have the staff to transport one person to a surgery scheduled a year in advance, let alone dozens to an OTP every morning.

The first two routes are laughable, but only because no one is going to attempt them. If corrections departments did actually promise to start transporting people out to an OTP, for example, we’d have to take the situation more seriously because they’d be starting something they’re not going to sustain, and likely leaving people in worse shape than they were in before.

State prisons often do not have the staff to transport one person to a surgery scheduled a year in advance, let alone dozens to an OTP every morning. Same goes for sending staff to bring methadone back, even if hypothetically it could be done by one staffer once a month. But the guidance seems blithely unaware of this, describing at length how corrections departments will reap the benefits of ongoing meetings and extra trainings and a high level of communication between multidisciplinary teams as they co-create policies.

The third model, partnering with a local OTP and having them bring the methadone into the prison, is much more viable than the other two, if a local OTP has the resources to deliver methadone and a memorandum of understanding can be worked out with the prison. This is absolutely something that would make sense for some corrections departments to pursue, and it’s a little closer to being tailored to them rather than being generic guidance for non-correctional settings. Except that SAMHSA might have mixed up state prisons with county jails.

“Community-based providers are often interested in delivering services in correctional facilities, sometimes for subsidized rates,” the guidance states, “to maintain continuity of care among their patients, thus increasing the likelihood that a resident will return to the OTP post-release.”

Many if not most people incarcerated inside state prisons aren’t going to remain in the community immediately outside that prison after release. Especially in larger states, their home could be hours away. It’s not that relationships with local providers aren’t important—they’re definitely important for connecting people to treatment during their incarceration—it’s just that it somewhat belies the nature of state prisons to refer to “community” as if there’s only one.

Image (cropped) via San Bernardino County Sheriff’s Department

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In 2022, Colorado lawmakers took a step that they claimed would help reduce overdose deaths involving synthetic opioids like fentanyl. The legislature and Governor Jared Polis (D) signed off on a bill to create harsher criminal penalties. Possession of 1-4 grams of any substance containing fentanyl would now be charged as a Level 4 felony, when it was previously a misdemeanor. Anyone convicted would also be mandated to undergo a substance use disorder assessment, and possibly court-ordered treatment.

The bill did also include harm reduction measures, such as $19.7 million in funding for distribution of naloxone and fentanyl test strips, and increased mental health services. Another $3 million in funding went towards expanding opioid treatment in correctional facilities. However, the criminal penalties took effect in July 2022—a year before any money was distributed for these services.

“I was not surprised by the fact that overdose did not decrease, and stayed the same or increased for certain populations.”

The state required a study assessing the efficacy of this new law, and commissioned a team including researchers from the University of Colorado School of Medicine and Kaiser Permanente Colorado Institute for Health Research. Their research, published in January, looked at changes from 2018-2024 and found no correlation between increased felony charges and reduced overdose deaths.

“I was not surprised by the fact that overdose did not decrease, and stayed the same or increased for certain populations,” one it its co-authors, Cole Jurecka, MPH, a senior research services professional at Colorado School of Medicine, told Filter.  

Other benefits the law’s proponents had anticipated did not materialize either. The researchers looked into whether the law made people more likely to seek medications for opioid use disorder like buprenorphine, or more likely to stay on such medications.

“The most surprising finding for me,” Jurecka said, “was that retention on certain medications for opioid use disorder did not increase—in fact, [it] decreased for methadone—given the fact there were some small provisions in the law that would in theory help people access these drugs more easily. That was not the case.”

Beginning in 2018, there was an overall increase in people starting buprenorphine treatment in Colorado, but that trend wasn’t affected by the new law, the researchers found. Regarding methadone treatment, there was no change in initiation—but a decrease in people continuing treatment after the law took effect.  

Felonization’s lack of impact on overdose deaths was in line with Jurecka’s expectations, he said, due to prior scientific literature which “tells me that increasing criminal penalties does not improve health outcomes.”

“There was money spent on expanding services, but it’s hard to disentangle from the criminal penalties. Pairing these together is a catalyst of fear for people who would need access.”

Reflecting on the overall outcomes of the Colorado research, Jurecka noted that the felony penalties and increased treatment funding are policies that are at odds with each other.

“There are two things at play,” he said. “There was money spent on expanding these services, but it’s hard to disentangle from the criminal penalties. Pairing these together is a catalyst of fear for people who would need to access these services. Imagine someone who needs these medications, but is afraid of punishment. That’s why I don’t think there was any real change.”

However, the authors were unable to demonstrate that the decrease in people continuing methadone treatment after the law took effect was caused by the law itself. “Caution is urged in interpreting these results as the methadone data does not include observations of all patients receiving methadone treatment and reporting standards changed for methadone clinics during the study period,” they wrote.

There was no significant change in overdose rates associated with the law over the time period studied, although there was a major spike during the COVID-19 pandemic. The researchers found that non-Hispanic Black residents had higher overdose rates in four of the 16 months following the law’s passage, compared with the equivalent prior period. But again, they stated that they couldn’t conclude this was because of the law.  

Looking at the law’s criminal-legal impact, the researchers found that totals of opioid possession-related convictions actually stayed consistent between 2020-2024, even in the severity of charges increased. The demographics most subjected to these convictions were, in order, Black, Hispanic and white residents. The authors did not find data on how many people were diverted from prison or jail to court-mandated treatment.  

“Community members across the spectrum of experiences, including law enforcement professionals, perceived fentanyl possession criminal penalties to be misguided.”

And in speaking with 31 policymakers, peer support specialists, police and health care providers, the researchers found that these stakeholders were not happy with how the goals of reducing overdose and expanding treatment were being pursued.

“The qualitative analyses suggest that community members across the spectrum of experiences, including law enforcement professionals, perceived fentanyl possession criminal penalties to be misguided,” they wrote, “and that expanding services including medications, other treatment services, and diversion options would be more likely to reduce overdose rates.”

“Participants largely discussed [the bill as having] been driven by emotional responses rather than empirical evidence,” they continued. “While the policy was initially aimed at penalizing those distributing fentanyl, which participants largely agreed this policy should focus on, in practice, the policy continued to target people who use drugs and people engaging in subsistence level drug distribution.” 

Some years prior, Colorado lawmakers had taken a different approach to drug use. In 2019, they approved a measure to reduce penalties for possession of many substances (up to 4 grams) to a misdemeanor. That included fentanyl as well as cocaine, heroin and methamphetamine. Sales and distribution charges remained felonies.

But politicians soon began to attack this limited reform. Lawmakers initially advanced the current law after a tragedy in which five people died of apparent fentanyl-involved overdose at an apartment complex in Commerce City. Numerous politicians, including Governor Polis, endorsed repealing the 2019 defelonization for fentanyl. The resulting refelonization law was a compromise of sorts—some Republicans wanted to go much further by imposing 250year mandatory minimum sentences and classifying fentanyl as a “weapon of mass destruction.”

Harm reduction advocates blasted the repeal effort. “They keep wanting to incarcerate folks and that has never worked,” Lisa Raville, executive director of the Harm Reduction Action Center in Denver, told Filter at the time. “All that has done is drive use underground. We are in a public health emergency that demands a public health approach.”

Months after the law took effect, Kevin Franciotti reported for Filter on consequences which included police treating drug users more aggressively, community organizations fearful that distributing fentanyl test strips could implicate people, and individuals scared to call 911 in case of an overdose.

Jurecka noted that Colorado saw a small decrease in overdose deaths in 2024, according to CDC data, yet groups including Black and Indigenous residents continue to face increasing overdose rates. He urged lawmakers to embrace a public health approach.

“Expanding access to treatment works,” Jurecka said. “We have so much evidence that confirms the efficacy of medications for opioid use disorder—but it must be disentangled from increasing criminal penalties. Our 50-year history with the War on Drugs [shows] these do not improve health outcomes.”

Image of Colorado State University police by Alex Smith used via Flickr/public domain.

The post Refelonizing Fentanyl Had No Good Outcomes: Colorado Study appeared first on Filter.

Representatives Alice Peisch and Adrian Madaro, and Senator Brendan Crighton—all Democrats in a Democrat-controlled legislature—presented the amended bill, 5143, on December 17. As local NPR affiliate WBUR reported, this was preceded by months of negotiations over whether to include OPC.

The filed bill instead focuses on expanding naloxone access, protections for people on medications for opioid use disorder, reducing legal liability for people receiving and providing harm reduction services, and licensing for recovery coaches, among other measures.

“I think this bill is going to save lives, which we don’t say lightly,” Sen. Crighton said.

Massachusetts has seen a long battle to advance OPC, which have many supporters in the state—including in the legislature.

Lawmakers are due to meet again on December 19, when they could consider passing the bill. December 31 is the final day of the session.

Massachusetts has seen a long battle to advance OPC, which have many supporters in the state—including in the legislature. In the summer, as Filter reported, the Senate unanimously approved an OPC bill, but failure to reach a last-minute deal with the House prevented it from moving forward that session. Similar legislation has been filed for several years now, with lawmakers such as Senator Julian Cyr (D) outspoken in support.

While Massachusetts’ fatal overdose figures have lately fallen overall, they remain at historically high levels and reflect worsening racial disparities. In June, the state health department revealed that opioid-involved overdose deaths declined 10 percent in 2023, the largest drop in over a decade. Yet 2022 had seen a record 2,357 deaths, and 2,125 people still lost their lives in 2023. And while the decline was largest for white residents, deaths held steady among Black women and increased among Black men.

No overdose death has ever been recorded at OPC around the world, and the facilities are also associated with reduced mortality in surrounding neighborhoods.

In December 2023, Massachusetts Public Health Commissioner Robbie Goldstein called OPC “lifelines, serving not only as places of intervention, but as places of empathy, understanding, and healing.” And though Governor Maura Healey (D) has not gone on record explictly supporting OPC, her administration has had Goldstein’s health department study the idea. The department noted that OPC could face federal lawsuits and other challenges, and recommended the state implement legal protections and rules for participants and staff if it approved OPC.

Some Massachusetts cities have considered opening their own facilities without state authorization, as happened in New York City. But those efforts, too, seem blocked. Somerville announced an OPC plan in 2019, but it still hasn’t happened. In July, Cambridge Day reported that the administration became worried about potential legal liability for participants, staff, property owners and the city, and has shifted some of its focus to state-level advocacy. The city of Cambridge has also explored opening an OPC, but so far has only taken steps to study the legal risks involved.

The impasse in Massachusetts stands in stark contrast to history being made in a neighboring New England state. On December 10, the nation’s first state-authorized OPC opened in Providence, Rhode Island.

As for Massachusetts’ remaining bill, it does contain a number of provisions aimed at helping people who use drugs in other ways. It would require health insurance companies to cover the opioid-overdose antidote naloxone with no cost-sharing or prior authorization required. People who request medicines like naloxone would receive protection from discrimination by life insurance providers. And hospitals and substance use treatment centers would be required to give naloxone to patients with substance use disorder histories upon discharge.

The bill would also protect people who use or offer drug-checking services from legal liability. It would add new licensing and oversight requirements for recovery coaches, and require health insurances to pay for recovery services for people who use drugs.

Under the bill, providers would no longer be required to report on parents who take medications for opioid use disorder.

Another important aspect of the bill would apply to parents with substance use disorders. Currently, a parent who takes a prescribed medicine like methadone or buprenorphine to treat opioid use disorder will be reported to the Department of Children and Families. That could lead to an investigation with the potential for the person’s children to be taken away by the state. Under the bill, providers would no longer be required to report on parents who take these medicines as prescribed.

Such investigations still impact many families, as Imprint News reported—even though federal rehabilitation and disability laws protect parents who use medications for opioid disorders (MOUD), and the federal government has sued in several cases where parents were punished. The National Council of Juvenile and Family Court Judges affirmed in 2019 that such parents are protected, yet many states and localities don’t comply. In 2023, the New York Times and Reveal found that no child welfare agency in any US state formally tracks how parents on MOUD are investigated, but that about 4,800 women said they were reported on for taking MOUD during pregnancy and 40 newborn babies were taken into foster care.

The bill would also reduce Massachusetts’ practice of sending men who are civilly committed to receive substance use disorder treatment at a prison—closing the Massachusetts Alcohol and Substance Abuse Center, which is operated by the corrections department, and replacing it with a state public health and mental health facility.

The practice of civil commitment has been pursued aggressively in Massachusetts, as NPR has described. Under the state’s Section 35, a family member, doctor or cop can ask a court to force someone into drug treatment. In one year, over 6,500 people were sentenced in this way to forced treatment, which experts condemn as unethical, ineffective and often harmful.

Photograph by Photo Claude TRUONG-NGOC via Wikimedia Commons/Creative Commons 3.0

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