Ease access to opioid addiction medication, new research suggests

With overdose deaths surging during the COVID-19 pandemic, new findings from researchers at Oregon Health & Science University suggest easing access to a key medication to treat addiction.

An evidence review published today in the American Journal of Psychiatry recommends making methadone more widely available through office-based visits with primary care physicians. The current federal standard largely requires it to be administered only through specialized clinics.

The study is one of five evidence reviews led by Dennis McCarty, Ph.D., professor emeritus of public health and preventive medicine in the OHSU School of Medicine and the OHSU-Portland State University School of Public Health, and Roger Chou, M.D., director of the OHSU Pacific Northwest Evidence-Based Practice Center.

“Methadone is the most highly regulated medical treatment in the U.S.,” McCarty said.

It is one of three medicines approved by the Food and Drug Administration to treat opioid dependence, along with buprenorphine and naltrexone. Methadone is a full agonist, meaning it fully acts on the same targets in the brain as prescription opioids or heroin. Buprenorphine is a partial agonist, and naltrexone is an opioid antagonist. Methadone and buprenorphine inhibit opioid withdrawal symptoms, while naltrexone blocks the euphoric effect of opioids.

Federal regulations originally established in 1971 require methadone to be administered through federally certified opioid treatment programs, to reduce the risk of overdose among people who are less tolerant as well as the risk of patients “diverting” it to sell to people without a prescription.

The study published today suggests the need to revisit regulations requiring methadone to be administered only in specialized clinics. McCarty noted that allowing methadone to be administered and dispensed in primary care clinics will reduce hefty transportation costs currently paid by Medicaid while also greatly improving access and convenience for patients with addiction.

“If you’re on the coast and you have to drive to a methadone clinic in Roseburg, that’s a two-hour drive,” McCarty said.

McCarty and Chou found 18 studies of methadone completed in office-based settings such as primary care, and that patients in those settings had better treatment retention rates and greater satisfaction compared to patients who received care in opioid treatment programs. However, their study was limited by the fact that only highly stable patients were recruited to participate in these studies.

It remains to be seen whether it would work for all patients.

“We don’t know, because nobody’s tried it,” McCarty said. “Some patients stabilize very quickly. They have a job, they have a family and their life is in pretty good order.”

The nation’s opioid epidemic has worsened during the pandemic.

Provisional data from the U.S. Centers of Disease Control and Prevention found the number of drug overdose deaths in the United States exceeded 90,000 for the calendar year that ended in December, up 29% from the previous year.

The OHSU research was supported by Arnold Ventures, which contracted with McCarty and Chou to conduct a broad review of methadone policy research with recommendations for changes in federal regulations.

The work culminated in five publications, including the one published today in the American Journey of Psychiatry.

Each study generally suggested easing access to methadone:

• Interim methadone: Federal regulations require patients to be assigned to a counselor at the initiation of methadone treatment, with an exception granted for clinics with a full caseload. They found six studies that consistently found that patients treated through this exception found quicker access to medication, decreased drug use, enhanced retention and better outcomes than those forced to wait. Published online in the journal Drug and Alcohol Dependence.
• Mobile methadone medication units: In a study published online in the Journal of Substance Abuse Treatment, researchers found only four poorly controlled studies regarding the effectiveness of mobile medication units allowed by the U.S. Drug Enforcement Administration to administer and dispense methadone in rural communities and other underserved locations. They conclude that new regulations should create opportunities for more research and economic analysis of mobile services, which do appear to improve access to people living in rural areas, living with housing instability and having more severe cases of opioid use disorder.
• Adolescents and young adults: An OHSU review in the Journal of Addiction Medicine found that access to mediations for opioid use disorder increased with age, and that federal regulations should be reviewed to encourage development of age-appropriate services for younger people with opioid use disorder.
• Telemedicine: With the onset of the COVID-19 pandemic, federal authorities loosened regulations to allow treatment programs to use telehealth services. OHSU’s review of studies conducted to date suggest that telemedicine outcomes were comparable to in-person care, and that access to telemedicine care should become routine in opioid treatment programs and in primary care settings.

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