Editor’s note: This brief was updated on March 24, 2022, to reflect the percentage of patients with opioid use disorder who had received medication for the condition in 2020.
Drug overdose deaths have skyrocketed during the COVID-19 pandemic. According to provisional data, there were more than 100,000 fatalities in the 12-month period ending June 2021—a 20.6% increase over the previous 12 months.1
To address this crisis, states should expand their treatment offerings and remove unnecessary regulations so that more people can access lifesaving treatment for opioid use disorder (OUD). Although medication is the most effective treatment for OUD, only a fraction of the people who need medication receive it: In 2020, just 11% of the 2.7 million people with OUD in the U.S. received medication for opioid use disorder (MOUD).2
Much attention has been given to expanding treatment using buprenorphine, one of the three FDA-approved medications for OUD, in primary care and other settings.3 But less has been paid to opioid treatment programs (OTPs)—the only facilities where all forms of MOUD can be offered, and the only care setting where methadone is available.
Methadone was first approved for the treatment of OUD in the 1970s and for decades was the only FDA-approved medication to treat OUD.4 Research conducted in the years since its approval has reinforced methadone’s safety and effectiveness in reducing overdose deaths, illicit opioid use, and the transmission of infectious diseases such as hepatitis C and HIV—while improving retention in care compared with treatment without medication.5
Opioid treatment programs have been historically stigmatized and siloed from the rest of the health care system, despite providing effective treatment.6 They were originally authorized by federal regulations in the 1970s during the Nixon administration’s “war on drugs,” with the primary goal of reducing crime in Black communities, including the use of illegal drugs and behaviors thought to be caused by drug use.7 Unfortunately, these regulations, based on treatment programs serving predominantly Black clients, still include punitive rules that reflect a distrust of patients—such as observed daily dosing, regular urine drug screens, and limits on access to take- home medication—rather than encouraging a collaborative setting in which the provider and patient work in partnership.8
Further, OTPs are not evenly distributed across the country.9 Counties with highly segregated Black and Hispanic/ Latino communities have more OTPs per capita than other counties, while predominantly White communities have more buprenorphine providers than communities that are predominantly Black or Hispanic/Latino.10 The result is that communities of color are disproportionately subjected to stringent treatment requirements, such as having to come in person to receive methadone doses—rules that can negatively affect the lives of OTP patients by requiring daily travel over long distances or trips to a clinic during times that may conflict with work schedules and child care responsibilities.11 Because methadone is usually administered as a liquid, these rules are often referred to as “liquid handcuffs.”12
Although the federal government sets minimum basic standards for regulating OTPs, states have the discretion to establish additional policies. According to the American Society of Addiction Medicine, these additional state rules often are not evidence-based13—meaning that even when people with OUD can access an OTP, they may have markedly different experiences in getting the medication they need or the related services they require, depending on where they access care. These differences across states can exacerbate racial disparities in treatment access and retention.
In order to promote high-quality, effective, and equitable addiction care, state officials should implement policies that ensure that OTPs are accessible, patient-centered, and integrated with medical and mental health care, and that they offer services tailored to their patient populations.
Patients with OUD should have access to the medication that works best for them as soon as they are ready to engage in treatment. For some, this means having a nearby OTP so that they can receive methadone. Yet, in many states, particularly in their rural areas, these services are out of reach.14 For example, Wyoming has no OTPs, so people must go to another state to receive methadone.15
In other cases, access is hindered by state regulations that prevent or discourage new OTPs, such as prohibiting OTPs near schools, requiring new OTPs to obtain a certificate of need (a legal document demonstrating public need for new facility services), or requiring licensure by the state board of pharmacy, a level of oversight not required by the federal government.16 West Virginia law even prohibits new clinics from opening at all.17
The flip side is represented by Indiana, which has set an example that states with restrictions that discourage new OTPs should follow: After lifting its moratorium on new OTPs in 2015, the Hoosier state is now actively working to open new sites so that no one is more than an hour’s drive from a facility.18
In addition to opening new sites, OTPs can extend their reach by establishing medication units that can offer dosing and urine screens, but not drug counseling.19 These sites can make treatment more convenient for patients who receive dosing daily or multiple times a week by providing medication in additional locations. States can help OTPs open these sites by creating a regulatory pathway to do so. For example, Ohio regulations allow medication units in homeless shelters, jails, prisons, local boards of public health, community health centers, residential treatment providers, small counties, and counties in Appalachia.20
Mobile methadone is another way to provide dosing close to where people live or in sites where they otherwise could not access it. For example, in Atlantic City, New Jersey, a mobile methadone treatment unit provides care to people in the Atlantic County jail.21
Until recently, federal rules did not permit the establishment of any new mobile methadone units. However, the Drug Enforcement Administration in 2021 established new rules that will allow OTPs to add mobile services for the first time since 2007.22 To help providers deliver this care where needed, states should revise any regulations that may serve as barriers to the establishment and use of mobile units, ensure that Medicaid will reimburse for mobile treatment, and provide financial resources to cover startup costs of mobile units.23
Some people also face financial barriers to accessing OTP services. Medicaid is the largest insurer for people with substance use disorders, with federal law requiring states to cover methadone and other medications for OUD through September 2025, unless the state certifies to the U.S. secretary of Health and Human Services that doing so is not feasible because of provider or facility shortages. Nonetheless, two states—Mississippi and South Dakota—have no OTPs that accept Medicaid.24 States should cover methadone in their Medicaid programs without exception, and OTPs should accept this payment so that people with OUD do not have to choose between paying for necessary care and paying for other needs such as housing and transportation.
Once methadone is covered, policymakers can act to increase OTP participation in Medicaid by ensuring that reimbursement rates are adequate—or even requiring facilities to accept Medicaid as a condition of licensure, as Massachusetts has done.25
People with OUD vary in their goals, how their body responds to medication, and what they need from treatment providers. But too often, OTP care takes a one-size-fits-all approach that offers a single medication at a dose too low to reduce opioid cravings, an assumed goal of abstinence from all illicit substances, and strict treatment rules that create high barriers to care by punishing noncompliance with discharge from care or requiring additional visits to the clinic to receive medication.26
Instead, OTPs should provide care that is guided by a patient’s needs and preferences—and based on shared decision-making with the provider.27 This patient-centered care should prioritize:
Given that patients have varying treatment needs and may respond to each medication differently, it is important that patients and providers have a choice of medications available at OTPs. But although nearly all OTPs provide methadone, the two other FDA-approved medications for OUD—buprenorphine and injectable extended-release naltrexone—are less readily available. Nearly a fifth of OTPs nationally did not offer buprenorphine in 2020, while just six states offer buprenorphine at all of their facilities.28 In addition, only 39.5% of OTPs provide naltrexone.29
It is especially important to offer buprenorphine since research shows that, like methadone, it is effective at reducing fatal overdoses. Some patients with OUD prefer it to methadone because they feel it is less stigmatizing or has fewer side effects.30
As with other medications, MOUD dosage matters. If the dose is too low, the patient will not experience reduced drug cravings and reduced drug use and may drop out of treatment.31 One study found that more than 40% of methadone patients receive a dose that is, on average, too low to be effective—a problem found to be more common at programs that primarily serve Black patients.32
To address this issue, Pennsylvania requires OTP physicians to review dose levels at least twice a year33— providing clinicians and patients an opportunity to check in and adjust the dose if necessary.
Many states create additional restrictions on treatment beyond federal regulations, resulting in practices that are not evidence-based and make it harder for patients to remain in treatment. To address this problem, states should examine their OTP rules and ensure that they:
and transgender people whose ID may not match their gender.38 OTPs can verify their patients’ identities in other ways: For example, OTPs in California can provide patient identification cards that include the individual’s photo, a unique identifier, and a physical description.39
Federal take-home rules include limits on the number of take-home doses a patient may receive based on their time in treatment, with just a single take-home dose per week permitted during a patient’s first 90 days of treatment if they meet specific “stability” criteria such as not using other substances or missing OTP appointments.43 Some states prohibit clinics from providing even this limited autonomy in the first months of treatment.44
But the federal government eased these requirements during the COVID-19 pandemic to allow people to continue treatment at a time of social distancing, and early research shows that methadone diversion during this period has been minimal.45 However, not all OTPs took advantage of these relaxed rules.46 To the extent permissible under federal law, states should enact these flexibilities, encourage their providers to offer them to patients, and remove all state-level regulatory barriers to receiving take-home doses, including those requiring patients to meet a definition of “stability” beyond what is in federal rules and those triggering automatic loss of take-home privileges because of a positive drug screen.
People with OUD often have other health problems. One study found that, after “drug overdose and disorder,” the leading causes of death among people with OUD served by a large health system included cardiovascular disease, cancer, and infectious disease.47 Patients need integrated care to address these health problems, yet OTPs are rarely physically integrated with or located near primary care providers. Although almost 2 in 3 community health centers now provide medication for OUD, only 7% of them are certified as OTPs to provide methadone.48
The COVID-19 pandemic has made integrated care more urgent than ever. Patients with OUD and other substance use disorders are more susceptible to COVID-19 than those without, in part because of high rates of other health conditions,49 and they also face a greater risk of hospitalization and death than those without substance use disorder. The risk of hospitalization and death is even higher for Black COVID-19 patients with substance use disorder than for White COVID-19 patients with substance use disorder.50
OTPs should also provide mental health services on-site or work closely with mental health providers. From 2015 to 2017, 1 in 4 adults with OUD had, in the past year, a co-occurring serious mental health disorder—defined as a condition resulting in “serious functional impairment substantially interfering with or limiting one or more major life activities.”51 Yet fewer than half of OTPs (46%) in the U.S. provided mental health services in 2020 for their patients, and 26 states failed to offer mental health services at more than half of their OTPs in 2020.
To provide whole-person care, states and OTPs have a range of options. They can:
Regardless of the pathway they choose, states should design these integrated services carefully to ensure that the services support the goals and desires of OTP patients, rather than create another one-size-fits-all system in which all patients are required to engage in primary care and mental health services to receive medication for OUD. For example, payment models should not incentivize providers to steer patients to services they don’t want. This is especially important because people who use drugs often report having negative experiences with medical providers, such as being shamed for their drug use or receiving inappropriate treatment.56
To avoid these pitfalls, state policymakers should engage patients early in the process of designing integrated services to make sure that OTPs can offer integrated care to those who want it—and continue to focus on providing lifesaving medication to those who don’t..
Beyond medication, OTPs are required by federal rules to offer counseling, vocational, and educational services.57 In planning these programs, OTPs should consider the unique needs of their population: Treatment environments can influence whether individuals remain in treatment, and seeing individuals who share a similar culture or experiences can help build trust and comfort, which is optimal for engagement.58 However, as with integrated medical and mental health services, patients should not be required to participate in these services.
State officials should work with their OTPs to help them offer services that meet the needs of a variety of patients:
And although OTPs should also provide culturally sensitive care that respects patients’ beliefs, languages, and communication needs, many do not provide services in languages other than English. Although fewer people in Montana speak a language other than English compared with Nebraska, North Dakota, and South Dakota, in 2020 all Montana OTPs provided services in multiple languages while in North Dakota only one did, and in Nebraska and South Dakota none did.67
On the other hand, Massachusetts has made culturally and linguistically appropriate services a focus of its substance use treatment system through ongoing provider training, investing in a diverse workforce, and helping providers strategize on how to effectively manage their budgets while engaging the communities they serve.68
OTPs’ treatment and services vary widely across the country, and there are many opportunities to expand their reach and improve the quality of services they provide. State policymakers should work to implement these changes to ensure access to quality, patient-centered care for all of their residents.
Resources for federal, state, and local decision-makers
Data-driven policymaking is not just a tool for finding new solutions for emerging challenges, it makes government more effective and better able to serve the public interest.
Drug overdose deaths skyrocketed during the COVID-19 pandemic: Provisional data covering a 12-month period shows that overdose deaths reached the record-setting number of more than 99,000 fatalities as of March 2021. Opioid treatment programs (OTPs)—the only health care facilities that can offer patients all three forms of medication for opioid use disorder (OUD): methadone, buprenorphine, and injectable extended-release naltrexone—are critical to reducing overdose deaths and providing life-saving addiction treatment. But they do so only if patients are able to access services.
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