In 2016, dispatchers in my hometown of Mansfield — a Rust Belt city in rural North Central Ohio — fielded over 363 overdose-related police calls. The community organized an opiate response team, created to help individuals following an overdose, which could only respond to those experiencing their second overdose. Around the country, small towns and rural communities are making heroic efforts to prevent opioid-related overdose deaths. But matching action by the federal government has been lacking, leaving many rural communities without basic resources for effective treatment. Mansfield, like many rural communities, is over a one-hour drive from the nearest methadone clinic — the only place in the United States where this life-saving medication can be prescribed and dispensed.
A decade into the opioid epidemic, there remains a well-documented shortage of access to methadone and the other medications for opioid addiction. This problem is most acute in small towns and rural communities like Mansfield. Methadone prescribing facilities tend to be concentrated in urban areas, and the availability of the drug steadily diminishes in the transition into suburban and rural areas, where health care funding and resources are spread over a greater geographic area.
Congress is currently considering a package of legislation to address the opioid epidemic. Any steps to expand access to treatment will be welcomed, but most indications suggest our legislators are still not broaching bold solutions on the scale with this national tragedy. They could start by following their own recommendations. The president’s commission on combating drug addiction and the opioid crisis earlier this year recommended all medications for opioid addiction be made available in every community.
In order to meet this mandate, the president and Congress should act to authorize approved providers at outpatient clinics to prescribe methadone. Granting this power to outpatient clinics such as federally qualified health centers and rural health clinics would vastly expand access to care. Reforming prescription rules at outpatient centers would bring the U.S. into line with existing systems in Australia and Canada. In both countries, this change expanded rural access to methadone by allowing approved primary care providers and pharmacies to prescribe and dispense methadone for opioid addiction.
Access to methadone is crucial because the three medications for opioid addiction — naltrexone, buprenorphine, and methadone — are not equivalent or interchangeable. Randomized controlled trials and other studies set in the community demonstrate methadone prevents overdose deaths when compared to those who receive no medication treatment. Buprenorphine and naltrexone are alternative medications, but as with any chronic disease, each medication has advantages and disadvantages, and methadone may be the best hope to reduce overdose risk for many individuals.
Many of the disadvantages of methadone result not from the drug itself but from how we as a nation control its distribution. Current regulations stipulate medication can only be prescribed by facilities approved by the Substance Abuse and Mental Health Services Administration. These facilities, or opioid treatment programs, must adhere to stringent standards. New program participants must present in person five to six days a week to receive their methadone dose. Barriers of mobility and cost make this process too burdensome for many clinics and individuals who would otherwise seek treatment.
The current rules governing methadone prescription also separate the medical management of opioid addiction from the rest of medical care, exacerbating the stigma around addiction and contributing to the counterproductive stereotype of methadone clinics as magnets for bad actors. This, in turn, fosters misconceptions in the broader community that feed resistance to effective treatment. Authorizing outpatient prescribing would reduce stigma by integrating the treatment of opioid addiction into the rest of our health care system — a long overdue reform within the United States.
Given that lax prescription procedures played a role in aggravating our current opioid epidemic, resistance to easing methadone regulation is understandable. But innovations such as state prescription monitoring programs and successful outpatient distribution of buprenorphine within the United States demonstrate the risk can be mitigated. The success in Australia and Canada and similar programs in the United States provide models to expand access safely to rural areas. Fear of criminality, meanwhile, would dissipate as opioid treatment is integrated into our larger health care system.
Congress may be at perpetual loggerheads, but addressing the opioid epidemic is one issue that still generates bipartisan interest. Over 10 years ago, a center-right government in Portugal decriminalized most drug use and expanded access to treatment in the name of public order and safety while facing their own opioid epidemic. These reforms are now widely considered a success. As we continue to face our own opioid epidemic, it’s time for the president and Congress to take bolder action to ensure access to treatment. Reforming the regulation of methadone in order to expand access in rural communities like Mansfield, Ohio is a clear and achievable goal.
Paul Joudrey is an internal medicine physician.
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