What the…? Safer From Harm on Methadone

Methadone is a “gold standard,” Food and Drug Administration-approved treatment for opioid use disorder (OUD). It substantially reduces a person’s risk of using illicit drugs and improves a range of outcomes, including their ability to pursue work and family obligations. But methadone is over-regulated, stigmatized, and out of reach for many Americans. Here, we talk to Stacey McKenna, R Street’s Resident Senior Fellow in Integrated Harm Reduction, to understand how methadone works, identify existing barriers, and learn what is being done to expand access to this lifesaving medication.

Q: What is methadone?

Methadone is a type of opioid. A slow-acting “full agonist,” it binds to the same opioid receptors in the brain as drugs like fentanyl and heroin. It reduces opioid cravings and withdrawal symptoms and blocks the euphoric effects of faster-acting opioids. Because methadone is regulated, it is also far safer than illicit drugs, which have unknown potencies and may be contaminated with unknown substances.

Q: Why do people take methadone?

Methadone has short- and long-term benefits for people with OUD because, as explained by the director of the National Institute on Drug Abuse, it is “very effective in decreasing the need, the desire, the motivation to take drugs.” Despite a persistent culture of abstinence-based treatment, methadone is more effective for long-term recovery than non-medication options. People taking methadone use fewer illicit opioids and are more than four times more likely to stay in treatment compared to people in non-medication treatment. They are also 59 to 80 percent less likely to die of an overdose compared to those not taking methadone or similar medications.

Q: What are methadone’s short-term benefits?

When a person who is opioid dependent suddenly reduces or stops taking opioids, they can go into withdrawal, experiencing nausea, vomiting, diarrhea, sweating, increased heart rate and blood pressure, and more. These symptoms can be life-threatening, and they may drive people to seek illicit drugs in order to feel well again. In fact, people dependent on opioids often seek out drugs to stave off painful withdrawals and feel “normal” rather than for a rush. One dose of methadone can alleviate withdrawal symptoms for two days or more—much longer than fentanyl or heroin—and block the euphoric effects of heroin, fentanyl, and other fast-acting opioids.

Q: What are methadone’s long-term benefits?

Chronic opioid use can change brain chemistry for months, years, or a lifetime. These changes can cause lack of motivation, inconsistent sleep, and mood swings from deep depression to high anxiety. These symptoms can make it difficult for people to take part in the activities that make life stable and meaningful and can trigger a return to illicit opioid use. Methadone helps people whose brains have been changed by OUD feel well, stable, and able to focus on their responsibilities and goals.

Q: Can people get “high” on methadone?

Most people are familiar with media portrayals of opioid use, which emphasize a euphoric rush. Fast-acting opioids can produce this type of high, especially in people who have not developed dependence.  However, because methadone is relatively slow acting, euphoria-driven highs do not occur when it is used as prescribed, and highs are extremely difficult to achieve with methadone. Experts liken methadone to “driving down a highway”—steady and stable—versus the “roller coaster” of highs and withdrawals from fast-acting opioids.

Q: Why is methadone so hard to access for people who need it?

Methadone is uniquely regulated among prescription drugs in the United States. When used to treat OUD, methadone is only available through opioid treatment programs (OTPs)—also known as “methadone clinics”—where patients take the medication under staff supervision. Most patients, especially in the first months or years of recovery, must visit the OTP almost daily. A quarter of Americans live in a county with no OTP, and patients might travel an hour or more each way before waiting in line to take their medication. Study after study shows that these barriers make it hard for patients to keep a job and care for their families. This system prevents many people from seeking treatment altogether. And because any given OTP may be the only methadone resource available to a patient, there are few incentives for OTPs to improve access or provide more patient-centered care.

What’s more, financial and logistical barriers prevent many jails and prisons from providing methadone, even though more than half of incarcerated people meet the criteria for OUD. When they do provide it, the OTP-only system means that many lose access to their medication upon release, putting them at greater risk of return to use and overdose as well as criminal recidivism. 

Q: What’s happening in methadone access now?

Recent changes to regulatory guidelines have enabled some patients to receive several days’ or a few weeks’ worth of “take-home” doses much earlier in their recovery than under older guidelines. However, state laws are typically more restrictive than federal recommendations, and OTPs are not required to offer take-home doses. Those that do can revoke access at any time, forcing patients to resume their daily commute to the clinic—which can disrupt work, family, and adherence to the medication.  

A bipartisan bill in Congress, the Modernizing Opioid Treatment Access Act (MOTAA), would be the first step toward expanding methadone access beyond the OTP monopoly. MOTAA would allow addiction medicine doctors outside of OTPs to prescribe methadone for OUD and permit regular pharmacies to dispense it

Q: Why do some policymakers worry about expanding access to methadone?

Some worry about diversion, roughly defined as distributing or accessing medication outside of formal health care channels. But diversion of methadone prescribed for OUD is rare, and it often happens in response to the access barriers described here. People who access diverted methadone may be trying to alleviate withdrawals or even initiate self-treatment outside of the restrictive OTP system.

Another concern we hear from policymakers is that freeing methadone from the OTP-only system will decouple the medication from mandatory counseling. Many OTPs require counseling as part of methadone treatment. However, the quality of that counseling is inconsistent across OTPs, and research suggests that methadone alone is sufficient to drastically improve many patients’ lives. Under MOTAA, addiction medicine doctors could still encourage their patients to access counseling outside of the OTP system, as they do with buprenorphine (another medicine for opioid use disorder that is not subject to the same regulations as methadone). Because the existing body of research suggests that compulsory counseling does not enhance OUD treatment, offering counseling rather than requiring it makes sense.

We know that methadone can save lives and meaningfully reduce the harms of opioid use disorder to patients and communities. Keeping the OTP-only system means retaining massive access barriers—and those barriers are costing lives. 

What the…? is Safer From Harm’s series that breaks down harm reduction concepts and busts myths for people who don’t spend all day thinking about harm reduction.