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Susan Calcaterra is an associate professor of medicine at the University of Colorado. She focuses on the treatment of addiction in the hospital setting.
We long ago lost the war on drugs. It’s time to make a tried-and-true change to methadone access for people who use opioids.
I met a man I’ll call Mr. R on my hospital rounds. He had been hospitalized after being found unconscious at home. Decades of cigarette use meant he was on oxygen to prevent suffocation. Mr. R also had pain, emotional and physical, as a result of time he spent in the Army. Every day, Mr. R injected heroin to manage his pain.
He told me, “I have PTSD (post-traumatic stress disorder). My drug abuse covers that pain so I can function normally.” Mr. R preferred heroin, but lately it was scarce. Fentanyl, however, was ubiquitous. The fentanyl high was intense but short-lived, and the withdrawals wreaked havoc on his body.
It was clear Mr. R was experiencing opioid withdrawal — he was anxious and jittery and had goose bumps, and his breathing was ragged and weak. We started methadone to treat his opioid withdrawal. He felt better immediately. His symptoms lessened, his breathing became steady and he remained in the hospital to receive medical treatment for his lung disease.
COVID-19 has magnified the drivers of drug use — isolation, job loss, worsening mental health and lack of social support. This, in combination with illicit fentanyl contamination of our drug supply, has contributed to a tsunami of overdose deaths in the U.S. More than 100,000 people died from a drug overdose in the 12-month period ending in April 2021, a 28 percent increase from the prior year. Not surprisingly, hospitalizations related to the complications of drug use have soared during the pandemic, further straining our health care workforce.
Despite the death and despair, there is a silver lining. In the U.S., there are no legal restrictions on the use of methadone to treat opioid withdrawal in the hospital setting. If a hospitalized patient develops opioid withdrawal, their doctor has legal authority to use methadone to keep them out of withdrawal. This is a win-win because patients are more likely to complete their medical care, and their medical team gains a sense of satisfaction and meaningfulness by providing high-quality health care.
Hospitalization is a critical time to identify patients with addiction and offer lifesaving treatment. When taken regularly, methadone is associated with an almost 50 percent reduction in death. People feel better and live longer when they are prescribed methadone to treat opioid use disorder, or OUD.
Mr. R wanted to remain on methadone after hospital discharge. In the U.S., methadone for OUD can be accessed only through federally licensed opioid treatment programs, or OTPs, which are commonly known as methadone clinics. There are fewer than 1,700 OTP locations in the U.S., and many rural areas lack OTPs. People have to complete a four- to six-hour intake at the OTP, followed by a daily visit (except Sundays) to receive their methadone dose.
Patients living in rural areas can spend an average of 12 hours each week on travel just to receive their methadone dose, which doesn’t include traffic, construction or delays with public transportation. This lack of treatment access to a lifesaving medication is unnecessary and punitive. With more than 100,000 drug overdose deaths last year, we’ve lost the war on drugs. It’s time to rethink our antiquated federal regulations and oversight of methadone for OUD.
Let’s consider an alternative approach. Imagine if primary care providers were given legal authority to prescribe methadone for OUD in their clinics. Patients could pick up their daily methadone at a local pharmacy. The pharmacy would ensure safe distribution of methadone with oversight from the community doctor. In this scenario, drive times would drop dramatically. This change could greatly increase access to treatment — a key aspect to stem overdose deaths in the U.S.
Methadone prescribing in primary care with pharmacy dispensing of methadone is not a radical idea. This has been standard practice in Australia, Great Britain and Canada for 50 years. Providing easy access to lifesaving treatment is essential to saving lives.
Scientists have warned, under our current practices and policies, more than 1.2 million Americans will die of an opioid overdose by 2029. We urgently need to change the status quo. Doctors prescribing methadone in their clinics and pharmacies dispensing methadone will increase access to treatment for our loved ones struggling with OUD and reduce death.
Sadly, Mr. R did not make it to the methadone clinic. The daily visits with his oxygen tank and lack of transportation were too onerous. Three months after hospital discharge, Mr. R’s daughter found him in his apartment. He died alone from an overdose.