With drug overdose deaths estimated to topple 100,000 this year, government officials, organizations, and researchers are seeking ways to reduce the stigma of drug addiction and better treat patients with substance use disorders (SUD). Two government programs, one introduced during the pandemic to allow for take-home methadone doses and the other part of the Biden Administrations Build Back Better Act (BBBA), could help improve access to medication-assisted treatment for SUD.
“Methadone is totally unrestricted in its use for pain, which is completely backward as most of the morbidity and mortality from methadone comes from very uninformed prescribing for pain,” commented Jim Anderson, MPAS, PA-C, DFAAPA, an addiction medicine expert who works at Evergreen Treatment Services Opioid Treatment Program in Seattle. The stigma drives the restrictiveness of methadone prescription for the treatment of opioid use disorder (OUD) “is indeed a reflection of the discriminatory and prejudicial beliefs about both OUD patients and OUD clinics,” he said.
SAMHSA Extends Methadone Take-Home Flexibility
Substance Abuse and Mental Health Services Administration (SAMHSA) is extending their successful methadone take-home flexibility program for 1 year and is considering making this flexibility permanent.1
“I can only hope that the increased flexibility of the take-home methadone program will help start to move the needle on the hyper-restrictive climate,” said Anderson, who is also the current president of the AAPA Society of PAs in Addiction Medicine. “It is a big topic where I work, and most providers I know in the field hope that some of the changes will be made permanent since the data shows that there was not a big uptick in morbidity and mortality related to the exemption.”
This is a continuation of the take-home medication flexibility exemption initiated in March 2020 to reduce potential exposure to the COVID-19 among health care providers and patients with OUD who were required to visit clinics on a daily basis for their medication. The exemption allowed opioid treatment programs (OTPs) to dispense 28 days of take-home methadone doses to stable patients and up to 14 doses of take-home methadone for less stable patients who are determined to be able to safely manage this level of take-home medication.
Almost 2 years after the exemption was first granted, increased engagement with treatment, improved patient satisfaction, and relatively few incidents of misuse or diversion of medication have been found, according to preliminary research. Fewer office visits for patients with OUD have allowed greater access to long-term treatment for people who live far away from an OTP location or have transportation barriers, SAMHSA noted.
“This may also reduce stigma for those seeking treatment while providing more equitable access to care [through] telehealth in OTPs is expanded,” said Health and Human Services (HHS) Assistant Secretary for Mental Health and Substance Use Miriam Delphin-Rittmon, PhD.
“There is much stigma about methadone, and the ultra-restrictiveness is itself a reflection of that,” Anderson said. “There appears to be little appetite toward loosening what I consider to be the bizarre level of restrictions for the use of methadone for treating OUD.”
The extension is also in line with the HHS Overdose Prevention Strategy, which emphasizes equitable access to essential health care and support services without stigma. Preventing SUD is the first step towards addressing overdoses, according to HHS.
Build Back Better Act
The US House of Representatives passed key provisions in the Build Back Better Act (BBBA), which will help teach, standardize, and cover evidence-based addiction prevention and care nationwide. The bill has yet to be passed by the Senate and signed into law.2 These provisions would increase equitable access to comprehensive, high-quality addiction care.
For example, the act would help enforce insurance coverage parity for mental health and addiction treatment by authorizing civil monetary penalties for group health plan sponsors, plan administrators, and issuers that violate the Mental Health Parity and Addiction Equity Act. The BBBA also would provide Medicaid/Children’s Health Insurance Program (CHIP) coverage for individuals involved with the criminal legal system 30 days before their release to ensure continuity of care for addiction upon return to the community; overdose deaths often occur upon prison release.
“Now is the time for bold action that will save lives and address long-standing disparities in access to addiction care,” said William F. Haning, III, MD, DLFAPA, DFASAM, president of the American Society of Addiction Medicine (ASAM). “We commend House lawmakers for passing key provisions in the BBBA and urge the Senate to pass them.”
Target Institutions With Highest OUD ED Visit Rates
More than half of the 1.5 million OUD-related emergency department visits nationwide occur in 25% of hospitals, new research suggests.3 These institutions are predominantly in metropolitan areas (86%) and are teaching hospitals (52%). The findings are based on data from the 2017 Nationwide Emergency Department Sample (NEDS), in which the weighted national estimate for OUD visits was 1,507,550 and opioid-related overdoses accounted for 295,954 of these visits.
“Emergency departments are critical touchpoints for encounters among patients with [OUD], but implementation of ED-initiated treatment and harm reduction programs are lagging,” the study authors wrote. They suggested that targeting OUD care programs to hospitals with high OUD visit rates may have the greatest effect on population health.
1. SAMHSA Extends the Methadone Take-Home Flexibility for One Year While Working Toward a Permanent Solution. November 18, 2021. Accessed November 23, 2021. https://www.samhsa.gov/newsroom/press-announcements/202111181000
2. ASAM praises inclusion of key provisions in the House-passed Build Back Better Act; urges Senate to pass them to expand access to addiction treatment. November 19, 2021. Accessed November 23, 2021. https://www.asam.org/docs/default-source/advocacy/asam-bbba-press-release—final.pdf?sfvrsn=83d05fc2_2
3. Khatri UG, Samuels EA, Xiong R, Marshall BDL, Perrone J, Delgado MK. Variation in emergency department visit rates for opioid use disorder: Implications for quality improvement initiatives. Am J Emerg Med. 2021;51:331-337. doi:10.1016/j.ajem.2021.10.047