“Overdose deaths could have been prevented if more people had access to methadone”: An Interview with Dr. Jeff Singer
Methadone is a medication for opioid use disorder (MOUD) that is considered a “gold standard” for treating opioid use disorder (OUD). But access to methadone is extremely limited, as it’s the most highly regulated prescription medication in the United States. Methadone for OUD treatment is available almost exclusively through specialized clinics called opioid treatment programs (OTPs), which are inaccessible to many Americans.
Recent policy and regulatory proposals to expand methadone access beyond OTPs have been met with opposition from the OTP industry. They claim that if doctors can prescribe methadone as they do other medications, it will create too much risk for abuse and overdose via drug diversion, such as illegal buying, selling, or sharing of prescribed medications. We talked with Dr. Jeff Singer, a surgeon and a senior fellow at the Cato Institute, who says that claim doesn’t add up and makes the case that methadone diversion is largely a symptom of poor access to this lifesaving medication.
Jessica Shortall: Medically, methadone is used in two different ways: for pain relief and for OUD. What’s the difference?
Dr. Jeff Singer: Methadone was developed in the 1930s to treat pain. For pain, we usually prescribe it for people whose pain is difficult to control, such as terminal cancer patients. However, clinicians discovered as far back as the 1960s that methadone can help people who have OUD. If you administer oral methadone in a lower dose than OUD patients require to achieve euphoria, it can prevent withdrawal from and craving for heroin or other opioids (Editor’s note: such as synthetic fentanyl or prescription opioids) on which they have grown dependent, while avoiding euphoria and drowsiness.
Shortall: What practical impacts do you see in the lives of patients with OUD who start taking methadone?
Singer: Methadone can enable people with OUD to resume normal lives and to overcome their disorder. People on methadone for OUD no longer have to spend their hours trying to buy illicit opioids on the underground market. They can return to a more stable life, re-establish relationships (crucial to overcoming OUD), and work on overcoming the issues that may underlie their substance use.
Shortall: Many in the OTP space reject the idea that doctors should be able to prescribe methadone for OUD, saying that this access needs to remain with OTPs. Their arguments tend to point to research on diversion and misuse of methadone prescribed for pain. How much diversion is there of methadone prescribed for pain?
Singer: Methadone for pain is not the most commonly diverted prescription pain reliever. In 2023, 18.3 percent and 17.5 percent of people who used prescription fentanyl and oxymorphone respectively reported that they misused these drugs. For methadone, reported misuse drops to 14.3 percent. Overall, only 2.4 percent of people who misused any prescription pain reliever in 2023 reported misuse of methadone.
Shortall: What do we know about why people use this diverted methadone?
Singer: The evidence suggests that most people who obtain diverted methadone are doing so to self-treat their OUD (i.e., to prevent withdrawal from or craving for the heroin or fentanyl on which they are dependent). This is in large part because it’s so difficult—and for some people impossible—to regularly access methadone for OUD at an OTP. These people are trying to get help but face some kind of barrier to getting to the OTP every day. If their motivation was to get high rather than to try to self-treat their OUD, they would be seeking fentanyl or heroin—both readily abundant and easier to obtain—not methadone. This context is left out from the OTP lobby’s claims about diversion.
In one survey, giving methadone away was the most common form of diversion, and missing a medication pickup at the OTP was the most common reason for using diverted methadone. This aligns with other findings that 80 percent of people who reported diverting methadone did so to help others who misused substances. Another report found that methadone diversion is linked to limited access to treatment, naming missed medication pickups at OTPs, long waits for treatment, and self-management of withdrawal symptoms as key drivers of diversion. Yet another study found that people using diverted methadone primarily did so to manage withdrawal symptoms or for detoxification and highlighted access challenges, such as long waiting lists and daily OTP visit requirements, as leading contributors to this behavior.
I have seen this dynamic in my surgical practice. People with OUD often present to the emergency room with infected limbs (Editor’s note: often from injecting illicit opioids). Many volunteer to me that they have taken methadone or buprenorphine (Editor’s note: buprenorphine is another medication for OUD) from a friend to try to stay sober—and to keep them from painful withdrawals—while waiting endlessly to get into a drug treatment program.
Shortall: To summarize, it sounds like people with OUD use diverted methadone largely because they want help but can’t access the medication through formal channels. It would follow that expanding methadone access for the treatment of OUD might actually reduce the market for diverted methadone. Do we have any other data to contextualize how better access to methadone for OUD would impact diversion?
Singer: The National Institutes of Health reported that “[t]he percentage of overdose deaths involving methadone declined between January 2019 to August 2021.” This was during the time when OTP rules were relaxed to accommodate pandemic lockdowns, allowing some patients to take home several days or weeks of doses of methadone. Americans had more access to methadone for OUD than they had ever had before, but overdose deaths involving methadone went down, not up.
Shortall: Advocates for the OTP industry might say that this pandemic-era data is an outlier because of the unique circumstances around COVID-19. Do you agree?
Singer: After the pandemic lockdowns, federal take-home regulations were made permanent, and overdose deaths involving methadone have stayed flat. These deaths remain much lower than overdose deaths related to other opioids, such as fentanyl. For example, Centers for Disease Control and Prevention data shows us that in the 12 months through March 2021—a year after methadone take-homes were introduced—there were 3,900 overdose deaths involving methadone. After lockdowns, in the 12 months through December 2023, there were 3,500 overdose deaths involving methadone. This is in comparison to the more than 90,000 overdose deaths in 2023 involving opioids like fentanyl, morphine, codeine, and heroin—some of which could have been prevented if more people had access to methadone.
Shortall: Much of medical care involves weighing risks and benefits. How would you describe the public health and individual benefits of expanded methadone access for OUD compared to any risks this expansion might pose?
Singer: Increased access to methadone can save countless lives, while the minimal risk of diversion does not outweigh the benefits.
Shortall: In your view, what would help prevent or reduce diversion of methadone?
Singer: If people with OUD had greater access to methadone treatment, they would not have to buy methadone from pain patients.
Additional resources on methadone for OUD:
● Dr. Singer’s argument that “the evidence doesn’t back up” claims that physician prescribing of methadone will lead to diversion and methadone overdose deaths
● Dr. Singer and Sofia Hamilton’s policy paper, “Expand Access to Methadone Treatment”
● Dr. Singer describing his ability to prescribe methadone for pain, but not for OUD
● R Street’s virtual panel, “Methadone Diversion: Separating Fact from Fiction”
● R Street’s Stacey McKenna’s explainer, “Unshackled from OTPs, Methadone Can Still Be Safe and Effective”