addiction, methadoneAs I’ve mentioned, I receive several e-mails each day asking questions about opioid dependence.  There are a number of confusing opinions, attitudes, and regulations that ultimately get in the way access to treatment.  And with opioid dependence, access to treatment can mean the difference between life and death.

One area of confusion relates to the use of methadone to treat opioid dependence.  Methadone is a potent, low-cost pain medication.  While a month’s prescription for Oxycontin may retail for $400, $500, or much more, a prescription for a similar amount and potency of methadone costs less than twenty dollars.

Besides treating pain, methadone is used to treat addiction to opioids through highly-regulated programs.  Laws allowing for these ‘methadone maintenance clinics’ were enacted in the early 1970’s, to counter the surge in heroin use that began in the late 1960’s .  The clinics were located mainly in inner cities, where most of the intravenous heroin addicts were located at that time.

Over the past ten years several corporations have purchased, consolidated, and refurbished methadone clinics, moving them to suburbs and rural areas to match the dramatic increase in addiction to heroin and other opioids in those areas.

The locations have changed, but the clinic programs have remained largely the same; addicts on methadone begin treatment by presenting for a dose of the medication each morning, and they must remain free from other substances in order to remain in the program.  Use of other substances, missed counseling appointments, or inability to pay the daily $10-$20 cost of treatment results in discharge from the program—which in turn means either buying drugs on the street, or going through months of painful withdrawal.

Over a period of months, clinic patients who do well are entrusted to take some doses at home, allowing them to skip the morning visit to the clinic.  But many methadone patients grow to resent the need to appear at the clinic each morning, cash in hand.  A question from one such person, and my answer, continues below:

I a woman in my late thirties, and I have been on methadone maintenance for the past twenty years. Are there any doctors who can prescribe my daily dose as opposed to me going to the clinic every day?

My answer:

The Harrison Act was enacted over 80 years ago, making it unlawful to prescribe or administer opioids to treat addiction or to prevent withdrawal.  Before that time, opium was a component of many tonics and elixirs sold in pharmacies or by traveling vendors, and in the 1920’s many doctors provided opium or morphine to ease withdrawal. There are only two exceptions to the Harrison Act:  the methadone programs described above, and DATA 2000, a law enacted ten years ago that allows schedule III, IV, or V medications to treat opioid dependence, provided that the medications are FDA-indicated for that purpose.

Doctors CAN prescribe methadone for indications other than addiction—for example for pain treatment.  For those patients doctors can provide prescriptions to cover 30 days, and two additional prescriptions for 30 days each—up to 90 days total– providing all three scripts are for the same dose and directions for use.  But for addiction, it is illegal to prescribe methadone– or any potent opioid– except for the two closely-regulated exceptions described above.

Methadone clinics were facing dire business conditions about five years ago, when buprenorphine and Suboxone were becoming more popular, pulling patients from methadone treatment to Suboxone.  But the limited number of buprenorphine-certified physicians, the 100-patient cap, and the continued escalation of heroin use across the country have secured the need for methadone programs going forward– for as far as the eye can see.

Photo by Eric Huntsaker, available under a Creative Commons attribution license.