Overdoses in the United States caused by opioids have reached alarming levels, driven by the rise of high-potency synthetic opioids like fentanyl and metonitazene. Medication-assisted treatment (MAT) has proven to be a life-saving intervention, with unparalleled success in patient outcomes for individuals with opioid use disorder (OUD). This comprehensive approach combines FDA-approved medications, such as methadone or buprenorphine, with counseling and behavioral health support. However, the proposed Modernizing Opioid Treatment Access Act (MOTAA) raises concerns that it may exacerbate the crisis rather than provide a solution, as it dismisses decades of data supporting MAT programs as the gold standard for OUD treatment.
MOTAA aims to eliminate the safety guardrails of MAT by allowing doctors to prescribe methadone outside of highly structured opioid treatment program (OTP) clinics. As an addiction specialist working with patients in an office-based opioid treatment center, I witness the devastating impact of addiction to high-potency synthetic opioids like fentanyl every day. While there is an urgent need to increase treatment accessibility as the epidemic evolves, the approach proposed by MOTAA is unlikely to achieve this goal and risks compromising patient and public safety.
The alarming misuse of high-potency synthetic opioids necessitates the OTP approach to methadone treatment. Patients addicted to these dangerous substances often require more time and higher dosing levels than those historically used for heroin treatment. This poses a challenge in reaching a therapeutic dose quickly and safely. The induction period for methadone typically ranges from 2 to 8 weeks, with high-potency synthetic opioids often requiring even longer. During this time, individuals may resort to using other substances, contributing to grave risks such as overdose and death. Methadone, being a long-acting opioid with a half-life of 24 to 36 hours, accumulates in the body and can cause delayed toxicity. This underscores the importance of accurately assessing patient tolerance, increasing doses appropriately, closely monitoring patients, and addressing underlying components of addiction throughout the induction and stabilization periods.
In effective MAT, close oversight and wraparound services are essential. Daily interactions with patients, as the optimal dose of medication is titrated, play a crucial role in ensuring safe recovery and long-term retention in treatment. This involves providing wraparound services such as counseling, case management, peer support, and referrals to housing or job assistance. MAT, when conducted under the guidance of a multidisciplinary team, facilitates the development of personalized treatment plans tailored to individual needs. Supporters of MOTAA argue for the benefits of broad deregulation of methadone, suggesting that private practice physicians should be able to prescribe it. However, it is important to recognize that methadone misuse, without proper supervision and wraparound services, can lead to overdose and death. Various independent reports, including those from the Substance Abuse and Mental Health Services Administration (SAMHSA) and other federal agencies, have consistently highlighted the dangers associated with prescribing methadone outside of OTPs. Daily interactions during methadone induction are vital in preventing relapse and ensuring patient safety.
Expanding access to treatment is imperative, but MOTAA’s approach may not be the solution. Many physicians remain hesitant to prescribe buprenorphine, even after the elimination of X-waiver requirements that were previously seen as a barrier to treatment. Patients also often encounter difficulties in accessing buprenorphine prescriptions at local pharmacies. Considering that methadone is a significantly more potent opioid agonist than buprenorphine, it raises concerns whether doctors practicing outside of regulated OTPs would readily prescribe it. Additionally, pharmacies may face administrative burdens and liabilities, alongside concerns regarding scope of practice. To address these challenges, innovative partnerships between OTPs and federally qualified health centers can be promoted. Furthermore, increased federal investment in OTP mobile clinics to serve rural and underserved communities, coupled with reduced regulatory barriers, can improve access to methadone treatment.
It is crucial for policymakers to carefully assess the potential pitfalls of MOTAA and encourage research initiatives by organizations such as SAMHSA and the National Institute on Drug Abuse. Implementing large-scale legislative changes without a strong evidence base may have unintended and dire consequences. Together, we must work towards expanding access to evidence-based MAT in ways that prioritize patient and community safety. By considering innovative delivery models in pilot programs and building upon existing successful initiatives, we can collectively navigate the complex landscape of opioid addiction treatment and save lives.
Philip D. Isherwood, MD, is a nationally recognized addiction specialist and the medical director of Office-Based Opioid Treatment Services for BayMark Health Services. Additionally, he serves as the medical director for an OTP in Breaux Bridge, Louisiana, and is a member of the American Society of Addiction Medicine and the American Academy of Family Physicians.