Leaders call restricting methadone treatment to clinic settings outdated

Leading voices in the addiction research and policy communities believe current limits on the delivery of methadone treatment are antiquated, and are suggesting that some clinicians be allowed to prescribe methadone in primary care office settings.

A trio of authors that includes former Office of National Drug Control Policy (ONDCP) director Michael Botticelli (who now directs the Grayken Center for Addiction at Boston Medical Center) published a commentary today in the New England Journal of Medicine stating that the federal Controlled Substances Act could be amended to allow clinicians who are trained in prescribing buprenorphine to engage patients in methadone treatment as well. The authors wrote that improving access to opioid use disorder treatments is essential to curbing the epidemic of opioid overdose.

In making this argument, the authors point to the examples of practices in Australia, Canada and Great Britain, all of which have allowed methadone prescribing in primary care since at least 1970. “Methadone prescribing in primary care is standard practice and not controversial in these places because it benefits the patient, the care team, and the community and is viewed as a way of expanding the delivery of an effective medication to an at-risk population,” they wrote.

Article co-author Jeffrey H. Samet, MD, MPH, tells Addiction Professional that current U.S. rules that restrict methadone treatment to highly regulated clinic settings are “an anachronism, built out of a time of fear” over diversion and accidental overdose.

Samet, a professor at Boston University's schools of medicine and public health, says he and his co-authors, who also include Monica Bharel, MD, MPH, of the Massachusetts Department of Public Health, don't claim to have all the answers on how best to administer a system of expanded access to methadone. But they consider the lack of a move in this direction to this point a “missed opportunity,” he says.

Not replacing clinics

These authors' perspective, Samet says, is not one of calling for a replacement of methadone clinics. “The highly structured setting is very helpful to certain patients,” he says. However, the opioid treatment program (OTP) poses a barrier for others, the authors say.

“The ability to obtain a prescription for methadone in the course of routine primary care is especially valuable for people living in nonurban areas, in which the infrastructure required for a methadone clinic may be too expensive and disproportionate to the level of need,” they wrote. “Regardless of cost, establishing a new methadone clinic can be challenging in any setting, given the common 'not in my backyard' sentiment, which pits perceived local concerns against public health benefits.”

The authors also acknowledge that Congress acting to change the law would not alone transform practice. More physician training on treating opioid use disorders would be needed, and incentives for prescribing might need to be implemented, they believe.

Getting Congress to act at all could be a tall order, given that this issue has not been aired in the recent past in Washington—and given the potential opposition to office-based practice from the present methadone treatment community. Samet says he remains optimistic that the issue could be heard, however.

The authors believe that overseas evidence backs their point of view. The journal article states that three primary care practitioner-based studies that were included in a larger 2017 meta-analysis found overall benefits from methadone treatment in reducing all-cause mortality.

The authors added, “In the United States, methadone has been prescribed in primary care settings under rare circumstances in which extensive efforts were made to meet all pertinent regulations. Our experience in Boston over a 10-year period with a very limited number of patients who were transitioned into a primary care-based methadone program after being stable on treatment at a methadone clinic was excellent.”

Samet suggests that pharmacies also could play a role in an expanded treatment system. As he has observed in Australia, pharmacies could deliver methadone on a daily basis for individuals who need a higher level of support early on in treatment, with the prescribing physician remaining available when needed.