Opioid 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and most effective medications to treat this disorder — methadone — is out of reach for many people, largely due to outdated federal laws.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.

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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  • Bottom line is the government will never treat addicts with respect , they are uneducated on methadone treatment and think people will sell it on streets , not knowing that the only time someone wants methadone is to get clean , it’s not a drug that is used to get high only to stop withdrawals. Fact is if they allowed methadone to be prescribed like other drugs more people would seek out help in a private setting , having to stand in line for the rest of your life is cruel and unusual punishment, even if your clean and have a job and pay your taxes for 30 years you are still made to go to clinic forever, it should be a minimum amount of time then you can switch to your own doctor, I know people who have been on 25 mg for 20 years , work , own a home , raised a family and still have to stand in line a couple times a month to get take homes that you can lose at any moment if they make a mistake on a drug test or paperwork. If you have shown you can function for years then you should be free to go to a dr . No forced to stand in lines with people right off the street in active addiction, it’s a temptation that you shouldn’t be forced to deal with but they do not care , it’s wrong .

    • I do certainly agree with you Fred. im a 62 yr old disabled towboat captain who went through a botched cervical neck surgery that was immediately prescribed opiate meds for pain, which for 10 yrs. was hell. then 20 yrs ago i started driving to Morehead ky. about 1 hr away from home to the nearest methadone clinic and in a few months when my system was purged from all the opiates for the past 20 yrs i never had one drug screen come back dirty and have always been in compliance with councilors, callbacks, ect. then may 31 i fell pretty ill to a issue with my stomach that ive had monthly battles with from diabetes so i was desperate and tired of gagging and vomiting and took a couple hits from a little weed my sis had i went to the clinic later that day to pick up my 2 weeks of takehomes and was given drug screen which came back showing 26 nanograms of thc. for which they promptly took back to step 0 and told me in 30 days i would get them back if i have no more dirty screens well that has been almost 4 months. i pay the whole month on the 1st from my disability funds which is my only income the drive is over 40 miles and your right the standing in line is aggravating and degrading like herding cattle and they obviously don’t give a crap or even see us as human in the one place they claim that really cares, please all it is is like legalized govt. sanctioned dope dealers oh by the way if i could find a primary dr. that would there’d be no problem for him to prescribe this for pain management which is the only reason i still go the clinic of which i take 60 milligrams having not changed this dose for 12 yrs. Ps prescription will cost 75 cents for a month needless to say im not sure how much more i can endure thanks for your take and God bless

  • I have been in treatment 12 plus years and the clinic I go to is in California VISALIA went to one in Pennsylvania for 9 years the one in Cali I have stood in line past the time I have to be at work 5 times I have got points at work I will be fired if I get 2 more point I will be fired from a 70000 a year job that took me 7 years to get
    They treat all patients as if they are home less and don’t work I waited 9 hrs for dr to show up and he never did show but if you want s cup a coffee they will stop all proceed to get you some not to mention the ease one could go outside and buy anything from a gun to black tar could not get first shift job for 2 years

  • I just want to point out an inaccuracy in this article: while primary care doctors in the US are allowed to prescribe buprenorphine, they are only allowed to prescribe it for PAIN MANAGEMENT purposes, NOT for substance abuse disorders. So yes, that act in 2000 did open up bupe to many new people, but those people were pain management people, not substance abuse disorder patients.

    • That’s incorrect. The are allowed to prescribe bupe for substance abuse issues in a primary care setting as long as they have completed the 8 hour ONLINE course and are certified with SAMHSA.
      https://pcssnow.org/medication-assisted-treatment/buprenorphine/

      It’s methadone that can only be prescribed by a primary care for pain mgt. otherwise you have to go to an approved methadone clinic. Now some of those methadone clinics also do bupe so maybe that’s what you we’re thinking about?

  • To “lilgirllost”
    I have a lot of the same experiences as you. I too have been on MMT for 25 years. It has allowed me live productively after a couple of stints in Dept Of Corrections and almost losing my great kids at the time. I have to go once a week here in Indiana and have not had a dirty Urinalysis since I have been on MMT. I live 60 mile round trip and am 65 years old. I too had to wake up from surgery with no pain medication because of methadone. It has been a tough road but I have held my head up and never used again after beginning the maintenance on methadone. I agree It is real tough to get off of, but there is a good chance of relapsing and I never want to go through that hell again. All I can do is hope that some day the research on opioid recovery will be better understood and a doctor can prescribe it just like insulin or antibiotics. We do not need to be punished. Most of us found a way out of using and that is a plus for the communities and our families!

    • Yes! Brendaelk! The fear of relapse is why I’m still on it 20 years later. I’ve tried several times to get off and failed. I know this will keep me clean and I never want to go back to what it was like before. I’m 47 and I think “ Geesh I don’t want to be on this for the rest of my life” but I know if I wasn’t on methadone (which keeps me from getting high when I take anything) I would go right back to it. Good luck to you!

  • I’ve been on ORT via MMT for almost 20 years. I’ve tried several times to taper off and have been unsuccessful. The clinic I go to is over 1 1/2 hours away (one way) but I’ve been on so long and am eligible for once a month clinic visits now. It would be so helpful (and probably do much cheaper) if a regular GP could prescribe methadone. I know the actual medicine itself is cheap at the pharmacy (if you can find a pharmacy who actually carries it and/or will order it). At the clinic I go to, it cost $380 a month. About every 2-3 months They “randomly” call me to come in for a medication check (where they count my take homes) but again, it’s a 1 1/2 hour one way drive. I have to come in the very next day after they call so trying to do that interferes with my job. On those days I have to get up at 2am, go to clinic & back which is 3 hour round trip and still come home and go to work for 8 hours. If they allowed regular doctors offices to do it, I would only have a 15-20 minute drive.
    Of course this is also a double edged sword because in MY personal opinion, I don’t think the docs who can prescribe suboxone went through adequate training and a lot of them only so it for the money. I’ve had so much stigma from doctors about being on methadone because they don’t really understand addiction and/or how ORT really works. I’ve been denied pain medication after surgery because they think the methadone should be more then enough to treat my pain and I’ve had doctors refuse to treat me at all (a dentist wouldn’t see me and an obgyn refuses to treat me all because I was on methadone at the time). I say all that to say this, taking an ONLINE class that can be completed in a weekend DOES NOT adequately train someone in addiction treatment and ORT. I think a lot of them see it as an easy way to make money and don’t really care about the addict and treating them. That’s not to say ALL of the physicians are that way, but in my experience, the majority of them have no clue.
    20 years is a long time to still be on methadone for ORT. I get it and I’m sure plenty of you reading this are probably shocked that I am still on it. All I can say is that this is what works for me. Yes, I’ve tried many times to taper off and would relapse again. Yes I would love to get off methadone. Some see it as the weak way out, ok. Good. You are entitled to your opinion. I just know that this is what keeps me clean and sober. If this is what it takes, this is what I will do. I do think they should make it easier for those of us on MMT or those needing MMT to be able to access it here in the US.

  • Thank you so much for your enlightening article about potential benefits of MethadonI had a series of car accidents along with a grievous ski accident, and, a hard fall on the back of my head; all of these things occurred in the middle 70’s. From these things, I experienced a broken left arm, ugly, ugly whiplash,= tension, posture issues & seemingly “crystalized-fixated patterns
    of pain, particularly loged in my occipital region. the TMJ, and my lower back. Many days I never got off the floor my back pain was so severe. For 20days I would lie there applying alternatively heat then cold, and eventually, I could crawl to the Chiopractort who would “adjust” me for another rountd.,At that time, I was a proponent (zealot might be more accurate) of “Natural Healing” in those days, and I refused to take any medicine, even, except for rare occasions, Tylenol, or other over-the-counter analgesics. Instead, for the ensuing 25 years, I immersed myself in every available “alternative” modality I could find. These included: Rolfing, est. 100x’s over 25 years, Chiropractic Treatments: Another est,=100 visits.
    I became a massage therapist to learn more about the body, and to associate w/ like-minded folks. Numerous sessions in Rebirthing, dozens of othert types of massage, diet therapy and dozens of other choices, including two-week long Bio-Energetic resident seminars in Canada, 2-3 xs a year,(This was a system of taught by a limited group of psychologists and M&F Counselors. It involved cathartic healing via mostly group therapy & the letting out of “repressed, violent, negative emotions, etc.) EST Training, on & on you name it, I did it. Earlier-on I was called “Mr.New Age”, and/or The man who remakes himself daily.” Along with swimming, tons of bike riding, yoga, Acupuncture, etc. I felt that I was in great physical shape and a healthier person for my habits. But, NIght & Day, the middle of a concert, or a movie, or dinner, or work, or sleep, the pain was always there. There was a relentless throbbing in the jaw and a feeling that a pair of vice-grips had clamped down in several places on my SCM, my scalines, my jaw, my occiput, and so on. I HAD to do something.
    Following advice from the chiopractor, I went to a pain specialist. I started with a series of shots, but after that proved only minimally helpful, the Doctor gave me a RX for Vicodin.
    I had never heard of the drug, and I carried it around with me for a week before I finally,
    with urging & support from my wife, (she said, “Open your mouth), & she placed one tab on my tongue, handed me a glass of water, and within a couple of hours, my life began to change for the good. Eventually I “graduated” to Methadone, and after a week or two on that drug, I began to believe in miracles. I had to make peace w/my own inner-being, which was not that hard, and, (that was in 1998 or so) I have taken Methadone daily ever since. At one point I had worked my way up to 150mg daily (10mg tabs), then I took a “Detox” workshop because I was worried that I had become an addict and that things would get worse. After 3 days, the Doc. in charge gave me a bottle of Buprenorphine–which I had already started on and sent me home 5 days early, saying “Paul, after seeing you for 2 years, and watching you closely the last 3 days, I’m convinced that the only thing you are addicted to is being out of pain. You may be dependent on Methadone, but you are not addicted.” He helped me back-off my daily dose to 9 (90mg) daily, where I stayed until March of this year. Two years ago I moved to Denver—I had recently developed Parkinsonism, which is pretty much under control w/meds—and my daughter recommended her doctor to me, and I made an apt. with him.
    Almost from the first visit, he started hounding me to “cut back on this VERY dangerous drug you are taking,”. H e never failed to bring it up each & every time I saw him. Finally., this past March, through what I felt was a possibly unethical sleight of hand movement, he tapered me off of Methadone, via Suboxone again, with the “understanding” that this was a “trial only,” It took me about a month to give up the Methadone completely. The suboxone, I thought, was not settling well with me, so I did not want to take that, so my doctor tried me on all of the other non-opiate pain killers he had (except for one or two which were not helpful), and it took less than another 30 days before I was convinced, mainly thru having the
    pain come back and beginning to feel that misery that I had not known for 20 plus years.
    When I told my doc. that I wanted the “trial” to be over, and that I wanted to get back on the Methadone, is when he “pulled his fast one on me”, (which I will not belabor you with) and he refused to give me the methadone again. Since that time 6-8 months ago, I have been in constant pain, without relief. For me, it is very simple to see what happens: Constant, untreated pain leads me within a few weeks to constant, miserable depression, and physical
    lethargy. I began to lose interest in everything, and I either could not sleep at all at night or, I wanted to sleep 14 hours a night, then lie on the couch all day.
    I don’t know for sure why I am telling all of this to a website, not knowing if it will even be read, or, if I will get a response, but, I guess it shows the level of my desperation, and it can
    be seen as a call for HELP!!!
    Thanks for all your good Work. Paul

    • Hello and thank you for your work in trying to get congress to approve take home medications through primary care physicians being able to prescribe it.
      I am currently going to a clinic in phoenix and i have been going religiously for 2 months. Methadone gas saved my life because before this my life was just on the edge of death every day. Methadone not only helped me get off heroine and took away all withdrawls from it it has given my brain a break from the channels that were created in it from my yeaars of opiate dependency. I can now wake up every day and go about my life as a normal person as the person i was 8 years ago before i became addictedwithout ebmven knowing i would become addicted and what withdrawls are. Had i known about withdrawls i would have never touched vicodin. From vicodin i was led to ozycodone because there wasnt vicodin so i had to take oxy or become violently ill. From oxy i started snorting it eventually smoking it , i remember my friend saying dont smoke it or you will be addicted for life of course i didnt believe him and he was right.Before that i had no problem quitting opiates and dealing with withdrawl. I think my brain was rewritten at that point. From there i was out of oxy one day and my friend was doing heroin, i asked him if i could smoke some because i was violently ill, he told me he would sell me some but the only way i could do it is if i let him shoot me up. There was no way in hell i would ever shoot up for 30 years prior to this day after begging him to let me smoke it for an hour and him not giving in, i became the guy i never in a million years thought id become. I overdosed that first shot he threw me in the shower with my close on and under cold water i finally came to.
      Anyway the last two months have been so great not waking up everyday with the first thought going through my head being where can i get my next high and how. Thanks to methadone, now i am moving to a place that doesnt have a clinic and i cannot get take homes yet i guess amthough i have been on a stable dose my counselor says it takes a few weeks to get approved or something. I am very scared i cannot find a clinic or dr who prescribes it within 100 miles. I have a feeling i am going to get back on heroin just so i am not sick and who knows if i will live for long after that all because i cannot get a prescription.
      Anyway thanks for all the work you guys are doing. If anyone has any advuce for me please let me know.

      Thanks, Nathan

    • Paul, I completely understand. I feel exactly as you described. I did well on methadone for many years. I decided to “try” suboxone. I have regretted it ever moment since. I live 100 miles from the nearest clinic. I have felt the desperation you said you feel. I know it’s not much help, but you are not alone. I’m really sorry that you are going through what I know is like torture. I wish I had known about withdrawal and addiction when I filled my 1st rx for hydrocodone so long ago.

    • Paul get down to a methadone clinic they will hook ya up no questions asked and it sounds to me that it its a great pain med for you its drs. Like your daughters dr. Who need to have their licenses revoked who are they to say qhetwr you are in pain or not and just by yor story i can tell you are not an addict. Even if you were who gives a shit you are taking away your physical pain by taking 90mg or however much. Anyway i i know i do not and have not ever gotten high on methadone and i have taken 2000 mg at one time before. That dr. Is a jackass sorry but probably a mormon not that there is anything wrong with that haha.. sorry for my run-on sentences and lack of punctuation cell phones make me ! 😉

  • How would we find a doctor who could prescribe Methadone in Eastern WA?

    Yakima is too far and so is Seattle. So far thats all we can find.

    • Im in eastern washington as well. I wish we had a methadone clinic somewhere close. Spokane is closest to me its 100 miles away. Too far.

  • In UK methadone is routinely prescribed by a GP, {sometimes using drug project staff ”shared care”}
    Methadone is dispensed by a local pharmacy, the nearest one, and trusted people get weekly pickup, which is a great relief, as on isn’t tied to daily visits to the chemist.
    I can’t see WHY it has to be given via methadone clinics, as seeing other addicts would be a massive wind up.
    At my local chemist I hardly ever see another methadone person, and can only tell they are in for a controlled drug as the keys to the cupboard jangle.
    The old style ”DDU”s {Drug dependency units} were hotbeds of gossip, and not nice places to go to for anyone.

  • I’m at a clinic where they won’t let me keep a split dose that’s been working well for me to titrate on. It seems like whatever helps they won’t do. And it’s crazy because the counselor I have to talk to takes her son to work and he’s in the room while discussing my personal information. Isn’t that a HIPAA violation?

    • Well i agree it seems not only in the clinic setting but in the resl world it really doest matter what has proven to work if some companys, clinics, goverment, and any other supposed opioid care advocate if they honestly wanted to help people they would do the research pole people or whstever it takes to actually find out does this help the people who are honestly looking for help . I think with tbe doctors and a trained eye you can easily weed out the people not looking for prolong care .And truly make this so called epidemic less of a talking point and more of a fight to help people . I work everyday for a company that suplies tmmi (toyota Indiana) a very good company . But im looking to go to work for toyota the actual company .Now this is where things get blurred I have taken all test and passed the urinalysis that was given to work for the supplier. I have also passed the assessment given by Tmmi (Toyota Indiana) , but they have flagged my app long and short of this they tell me they are revamping there prescription policy and they will be intouch (I tested positive for methadone) I let them know so no suprise). Im hoping they have done some research and used the big brains at toyota to see thst the people who are serious about life and all thst comes with having one know that this is helping and making a difference if people would pull there heads from there asses maybe this epidemic would be less of a epidemic and more of a American victory

    • Ronald-
      They should have offered job before drug test. That being the law if they now rescind offer because of positive urine for methadone they would be violating the Americans with disabilities act. Reach out to NAMA recovery if that happens and I will try to get you some help. We have several cases that have been litigated and you will have those rulings that even if you operate heavy equipment let me know if I can help
      Paul Bowman Massachusetts chapter director
      National alliance for medication assisted recovery

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