Kayla’s Story: A Call for Change
Kayla came to our addiction clinic after a visit to the emergency department for a skin infection, common among those who inject drugs. Acknowledging her escalating fentanyl use, she sought help to start buprenorphine, a primary treatment for opioid use disorder (OUD). While her initial consultation was hopeful, follow-up visits showed persistent withdrawal symptoms and strong cravings. Despite our best efforts, Kayla became frustrated with the treatment and eventually lost faith in it. We knew we needed another approach. Expanding Methadone Access
The Methadone Dilemma
Methadone, a potential alternative treatment, is severely restricted due to federal and state regulations. The Modernizing Opioid Treatment Access Act (MOTAA) proposes a solution: allowing addiction specialists to prescribe methadone directly to pharmacies, making this life-saving medication more accessible.
Life-Saving Potential of Medications for Opioid Use Disorder (MOUD)
Treating patients with medications like buprenorphine or methadone can reduce the risk of death by half. These medications interact with opioid receptors in the brain, disrupting addiction’s hold on the reward pathways. MOUDs not only reduce mortality but also free patients from the vicious cycle of withdrawal and cravings, helping them regain control over their lives. Expanding Methadone Access
Buprenorphine vs. Methadone: A Comparative Challenge
Although buprenorphine is effective, it can only be prescribed through community pharmacies, which presents challenges for patients like Kayla, whose opioid tolerance is high due to fentanyl use. In some cases, buprenorphine can worsen withdrawal symptoms, deterring patients from starting treatment. Methadone, however, is often preferred but is restricted to specialized opioid treatment programs (OTPs), creating a significant barrier.
Regulatory Changes and Persisting Barriers
Kayla had some familiarity with methadone, as her relatives used it. They described the daily visits to OTPs, which would conflict with her overnight job. When Kayla asked about receiving methadone from our clinic, we had to decline and refer her to an OTP. Unfortunately, she never returned.
During the COVID-19 pandemic, methadone access was expanded due to social distancing. In February 2024, the Department of Health and Human Services formalized this expansion, allowing some patients to take home 14 or 28 doses. This move is a step forward but still keeps methadone separate from other medications for OUD.
The Promise of MOTAA
The MOTAA aims to eliminate these barriers by allowing addiction specialists to prescribe methadone directly from community pharmacies. This would eliminate the need for daily clinic visits and offer continuous care without the need for OTP referrals, improving patient access and convenience.
Addressing Concerns and Moving Forward
Opponents of MOTAA, particularly OTPs, worry about losing revenue and argue that structured environments are essential for patient success. They also fear methadone diversion and increased overdose risk. However, data from the pandemic challenge these concerns, showing that the expanded access did not result in significant negative outcomes.
Conclusion: A New Era for OUD Treatment
Patients like Kayla, facing a deadly drug supply, need access to all available treatments. Physicians working to combat the overdose epidemic require every tool at their disposal. The stigma around methadone must end, as it is proven to be effective. While the Final Rule is a step forward, the passage of MOTAA is essential to fully integrate methadone into routine medical practice and treat it like any other medication for a life-threatening disease.
For more insights, visit Stanford Physician Advocate.