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pioid use disorder, which claims 115 lives a day by overdose in the United States, is a complex, chronic medical condition, but one that can be successfully treated with proven medications. And yet, one of the oldest and most effective medications to treat this disorder — methadone — is out of reach for many people, largely due to outdated federal laws.

Of the three medications approved by the Food and Drug Administration to treat opioid use disorder, federal law relegates only methadone to be dispensed in separate clinics apart from the general health care system. It’s not unusual for methadone clinics to be in out-of-the-way locations and often inaccessible by public transportation, especially in rural and suburban communities. When individuals trying to break an addiction to opioids can’t get to a methadone clinic on a daily basis, they can’t get treatment.

The other two federally approved medications, buprenorphine and naltrexone, can be prescribed and administered in primary care settings, where treatment can take place as part of an overall clinical care plan.

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Methadone is typically taken daily in a highly structured setting, an approach that benefits many patients. But methadone should be treated no differently than other FDA-approved medications for opioid use disorder. As we write in the New England Journal of Medicine, it’s time for Congress to remove this barrier to treatment and allow methadone to be prescribed in primary care settings, as well as in existing standalone clinics.

Only about 20 percent of Americans who have an opioid use disorder are being treated with buprenorphine, naltrexone, or methadone, a woefully small percentage that shows the extent of the barriers to treatment that we need to remove to stop this public health crisis. Restricting the availability of methadone to designated clinics has contributed to this treatment gap.

Methadone has been available by prescription in primary care clinics in Canada since 1963, in Great Britain since 1968, and in Australia since 1970. In these places, methadone is the most commonly prescribed treatment for opioid use disorder, and it isn’t controversial because it has been shown to benefit the patient, the care team, and the community.

Methadone works. In a 2017 review of all causes of death among people with opioid use disorder, those receiving this medication were one-third less likely to have died during the study period than those not treated with methadone.

Methadone is a synthetic opioid that reduces cravings and withdrawal symptoms for heroin and other opioids. Developed in 1937 as a pain medication, it was first studied as a treatment for heroin addiction in New York City in the 1960s.

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By the 1970s, the system for delivering methadone that we know today had been fully developed. Patients visit a designated clinic, typically every day, take methadone under observation, and get specialized, highly structured care, including counseling and periodic drug tests.

The methadone clinic model was carved into law in the United States in 1974, when Congress passed the Narcotic Addiction Treatment Act. The regulations around methadone, driven by fears of accidental overdose and diversion, evolved in such a way that primary care physicians almost never delivered methadone treatment. Stigma and a not-in-my-backyard mentality resulted in the placement of a sizable number of methadone clinics in locations that were hard for many to reach.

The last time Congress expanded access to medication for opioid use disorder in primary care was when it passed the Drug Addiction Treatment Act of 2000. It allowed physicians to prescribe and administer buprenorphine in their offices, making this medication more available to thousands of patients. But the barriers to the delivery of methadone remain intact.

Methadone has saved many lives and could save many more. Several studies have shown that methadone treatment in a primary care setting is both feasible and successful. In rare cases, it has been allowed in primary care offices. Our experience in Boston over a 10-year period with a limited number of patients who received methadone treatment in a primary care setting after being stable in a methadone clinic was excellent, with no adverse incidents.

We call on Congress to allow methadone treatment to be delivered in primary care settings, as well as through special methadone clinics. That would be just the beginning. We also need to enhance physician training about opioid use disorder, create incentives for prescribing medications to treat it, and integrate treatment into existing models of care.

From the federal government down to community partners, we are all desperately searching for solutions to stem the opioid epidemic. Increasing the availability of medications that can effectively treat opioid use disorder — including methadone — will be essential if we are to succeed in saving lives.

Jeffrey Samet, M.D., is the chief of general internal medicine at Boston Medical Center and a professor of medicine at Boston University School of Medicine. Michael Botticelli is the executive director of the Grayken Center for Addiction at Boston Medical Center. Monica Bharel, M.D., is the commissioner of the Massachusetts Department of Public Health.

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  • @Dr Greeley, sorry, let me clarify a statement in my previous reply. I went back on the methadone after I weaned myself off because I thought it wasn’t working as it should. I went back on it. Taking the methadone along with the physical dependence it entails is a SMALL price to pay to have a measure of pain relief with a semblance of quality of life.

  • @Dr Greeley – I personally did develop physical dependence (as opposed to addiction) – this I found out when I weaned myself off because I felt I was not getting enough pain relief. Small price to pay to have a some quality of life.
    Everything else in your post – I totally agree. It is shameful how the bureaucracy ties physicians’ hands, with chronic pain patients ultimately paying the price.
    Somehow we must divide the 1) patients needing methadone to get clean, 2)the drug seekers, from the 3)legitimate patients needing long term chronic pain relief.
    The bureaucrats and do-gooders are lumping all 3 groups together (or totally disregarding the pain patients) as they attempt to block access to all opioids.

  • I treated hundreds of severe chronic pain patients with methadone, which is an excellent pain drug, an agonist-antagonist like the 100times more expensive Suboxone, and does not develop tolerance (at least not in my patients). 20mgm BID worked for the majority. This removed a large segment of those seeking black market opiates and was a part of the solution to the opiate epidemic. For this, after a 6 year investigation, my MI license was suspended (1 1/2 years after I retired!) for not doing 8 physical exams and inadequate paperwork, according to state bureaucrats. No good deed goes unpunished in medical practice today. Stress R Us

    • No disrespect, but these are the kinds of statements that both astonish and frighten me – when a physician prescribes a potent narcotic and appears to have very little understanding of its effects. Btw, people build tolerance for even Suboxone. Ironic how this drug is to help with addiction and withdrawal yet you can’t stop it abruptly.

  • PLEASE Dr. HELP us in pain..methadone helped me with hydrocodone. Dr Rebecca Holdren put me n living hell..pain unbearable all she said. She don’t like

  • @The posts putting down methadone and pain clinics.
    I have been taking methadone for chronic pain for 5+ years after a horrendous fall that injured my spinal cord. The surgery to relieve pressure on nerves was not done until a year+ after the need for surgery, hence foot drop had taken hold. After surgery, tho the pressure was taken off the nerves, teeth grinding pain remained. A spine and pain clinic associated w/a local major hospital treated me with methadone for the pain and tho it was greatly lessened, because I still hurt I thought the drug was simply no good & why should I continue taking it. With my dr’s permission, knowledge & assistance, he helped me wean off to zero methadone with minimal withdrawal. Let me tell you, I had NO IDEA just HOW much spinal pain that drug DID take away while I was on it, because once it was completely out of my system I was in so much pain I could not function! I had no problem with going back on it, and have no problem taking it AS DIRECTED in order TO LIVE.
    So all you people saying get rid of all these drugs, until you have been in so much pain that you know you cannot live, that you will have ZERO quality of life, be quiet. These drugs are A Godsend to those of who legitimately need them for long term chronic pain relief.

  • Bill. I would love to know what kind of clinic you are talking about. Clinics are very structured. They have Federal and state Regulations they have to adhere to. There must be at least 2 counseling sessions a month each lasting for 50 minutes. There is no such thing as just getting a paper signed. As for seeing the doctor. Do you think that a patient needs to see a doctor each day? The doctor is available each day.. we have yearly exams, if we have any problems we see the doctor who is always of great help. As for not having enough counselors well last month my counselor was sick. They had two other ones available at that time. Where do you idiots get your information? Your post isnt ignorant its just plain stupid

  • Lisa. Where do you get your information? Patients get weekend take homes when they first start. There are a few States that clinics are closed on Sundays so some addicts get one take home bottle. If you know how to read or if you know.anyone in Law enforcement then I suggest you read if you can and if not ask because it has been proven over and over again that 99.9% of diverted methadone comes from people that get it prescribed for pain. You should keep your mouth shut unless you know what your talking about. Something tells me your in a 12 step program or work in treatment because these are the lies that rehab like to pass around. Methadone has been around for over 30 years and is the gold star treatment for opiate addiction. You don’t want to debate me little girl because you will lose. AND FYI people.who get.take homes get them because we are program compliant. They don’t give anyone who wants take home We earn our carries. We sometimes get call backs to show we aren’t diverting our take homes. It’s amazing how stupid people are.

  • Jim. You can’t compare Heroin VS Methadone for differences in strength in the US. Since heroin is illegal here no one know how much heroin they are getting and how much is filler

  • Jim I don’t know how you come to the conclusion you fo about methadone, have you every taken it for pain, because I have and it works better than oxys, Dilaudid and other schedule ll pain killers plus it last longer. As far as being stronger than heroin, that is totally false. The only negative thing is that it gets in your bone marrow and does have the longest horrible withdrawal syptoms that lasted me almost 3 weeks. But with the right dosage for people who will forever need it, it’s is by far the best for pain, because i have first hand experience from it. If anyone hasn’t tried it themselves for pain then they have no business commenting on something they never experienced.

    • Thomas,

      Might be prudent to at least Google pharmacology or pharmacokinetics prior to submitting a rebuttal that I’m false in my comments. In fact, you contradict yourself in your statements when speak of the horrific withdrawal effects of Methadone. It’s roughly 3 – 4 times the potency of Herion. Hence, the horrific withdrawal. Methadone is absolutely far more potent and distractive. The difference is Methadone comes with a legal Rx. Again, do a bit of research before commenting…

    • I have been on Methadone and it is a horrible drug when comes to my pain control. Basically medical care is about individual care so while medication works for some peoples pain for other it may not help at all. However there is something wrong where addicts can get opiate medications because they abuse it while chronic pain patients who take it as prescribed for chronic physical pain cannot get it at all or are getting dropped off the opiates even though they have severe pain.

    • Thomas you made sense until you made the ignorant comment about Methadone getting into your bone marrow. That’s just one of the myths that treatment centers and 12 step programs love to throw out there to scare people. I would love to see where you got this from so I can write a rebuttal its plain and simple BS . The only reason methadone withdrawal last so long is because of the long half life not because of any other reason. As for pain relief, everyone is different. Methadone works for you. Maybe Oxycontin works better for someone else. For me methadone doesn’t work that great for pain because I’ve been on it for Maintenance since 2001.

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