Biden Drug Czar: All options are on the table to expand access to methadone

wASHINGTON The federal government is aggressively exploring ways to increase access to methadone, a key Biden administration official told STAT.

Methadone, a common addiction drug, is the most effective drug currently used to treat opioid use disorder. But it is only available in the context of specialist methadone clinics, making it nearly impossible for many patients to obtain.

As opioid overdose deaths have skyrocketed in recent years, a growing number of physicians, patient advocates and public health experts have pushed to allow patients to receive methadone the same way they receive any other drug: in a doctor’s office or pharmacy.

The Biden administration appears to be moving in a similar direction. When it comes to expanding access to methadone, all options are on the table right now, Rahul Gupta, director of the White House’s Office of National Drug Control Policy, told STAT.

Gupta said the federal government has convened conversations between two key agencies with jurisdiction over methadone: the Department of Health and Human Services and the Drug Enforcement Administration.

Gupta touted existing administration policies that favor expanded access to methadone, such as allowing longer supplies of take-home doses and legalizing methadone vans or mobile centers where patients can receive the drug.

It also floated an option the federal government hasn’t formally proposed: allowing patients to pick up methadone at a retail pharmacy even when it’s prescribed at a specialty clinic known as an opioid treatment program, or OTP.

We are looking into whether people can be prescribed at an OTP but dispensed at a pharmacy, he said. Methadone vans [are] another piece, methadone to take home is another piece. We’re working within the interagency process right now, we’re bringing together HHS and DEA to figure out what we can do to expand access.

Gupta’s comments came during an extensive interview with STAT last week at the ONDCP headquarters in Washington.

His position represents the latest sign of a major shift in national attitudes towards methadone. The drug remains controversial in some circles, because methadone is itself an opioid used to treat pain and, if prescribed improperly, can contribute to sedation or even overdose.

As recently as the 1990s, national political figures such as Sen. John McCain (R-Ariz.) and Rudy Giuliani, then mayor of New York City, were forcefully advocating adding severe restrictions to methadone treatment or eliminating it altogether.

Recently, however, the prevailing opinion has changed. Senators Ed Markey (D-Mass.) and Rand Paul (R-Ky.) introduced legislation that would allow board-certified physicians to prescribe methadone directly to patients, who could then pick up the drug at a pharmacy. Several advocacy groups, including the American Society of Addiction Medicine, have announced their support.

The methadone access debate is one of several political controversies in Washington surrounding access to addiction drugs. In addition to voicing his support for increased access to methadone, Gupta applauded a separate decision by the DEA to delay a proposal that would have added new restrictions on buprenorphine, another drug often used to treat opioid use disorder.

The proposal would have required all patients receiving buprenorphine via telehealth to receive an in-person exam within 30 days to receive a refill.

After widespread protests, however, the DEA announced it was delaying its decision by six months, leaving in place Covid-era emergency rules that allowed providers to fill buprenorphine prescriptions via telehealth.

There should be no extraordinary burden on people suffering from the disease of addiction to be quickly forced into treatment or introduced [in person]he said. The six-month extension and 38,000 comments is proof that we were in no rush to force things on people, especially when life and death is the issue.

However, Gupta argued that people with addiction often have other untreated health conditions, both physical and mental. Requesting an in-person visit at some point, she said, gives health care providers a chance to assess patients’ needs beyond just addiction medications, such as routine vaccinations, cancer screenings or diabetes care.

I’ve been on the other side of that, where I’ve had patients die of heart attacks and cancer because we were all treating their HIV and ignored everything else, she said. And then we recognized that as people are surviving longer, they also have other conditions and their other health is being ignored. So I think that’s a good level of care, but we need to be aware that when people are going through an addiction, they need the help of addiction treatment first.

Gupta also expressed optimism regarding harm reduction, the public health philosophy that aims to help people avoid the worst consequences of drug use, such as disease transmission and death, while acknowledging that requiring abstinence snapshot is often impractical.

Several state governments recently blocked proposals to expand supervised drug use services, the controversial practice of providing medical supervision to people who use drugs.

Despite harm reduction losses in states like California, Pennsylvania and Colorado, Gupta said he believes support for the philosophy, in general, is still growing.

I remember very clearly the time naloxone was controversial, about 10 years ago, he said. People really thought this would allow people to experiment with drugs. This didn’t work out. The evidence didn’t suggest that. And Republicans and Democrats have understood the evidence, and we’ve seen more and more schools putting naloxone in schools.

He also cited the growing popularity of test strips used to detect the presence of fentanyl in illicit drugs, which until recently were illegal in most states thanks to decades-old drug paraphernalia laws.

However, most states have now passed legislation to legalize test strips, including many that are traditionally conservative, such as Texas, Tennessee and Kansas.

I am pleased that more and more states are now accepting drug supply trials, Gupta said. Because they recognize that it’s about saving lives, not making judgements.

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