There are many bills and proposals which would loosen up treatment with methadone or buprenorphine. The better-known proposals to get rid of the X-waiver for buprenorphine are an important part of the story, but this story is specifically about making treatment in opioid treatment programs (OTPs) more convenient for patients. “Methadone reform” is a call to battle to many, meaning on one side to get rid of all OTPs altogether and make methadone almost freely available. This is not going to happen, it’s unrealistic and, considering the past 10 years and more of this country’s history with opioid analgesics such as OxyContin, a political impossibility to make a medication like methadone freely available. However, there is one proposal which is not at all like this. Instead, the BETTER MAT Act would focus on continuing the revisions spurred by the COVID-19 pandemic: notably, more flexible take-homes and, importantly, telehealth.
This bill is still in its early stages. But a draft obtained by AT Forum indicates that the bill would
- allow states and OTPs to keep the COVID-19-era dispensing and telehealth waivers they received from SAMHSA;
- commission a study on such waivers and OTP functioning during COVID-19;
- provide that OTPs may operate a mobile medication unit without needing separate registration;
- clarify that OTP medical directors should not use positive drug tests as the sole cause to end methadone patients’ access to take-home doses;
- at a minimum, cut in half the timeline for take-home methadone medication;
- direct SAMHSA to study and revise the new methadone take-home schedule as needed;
- create guardrails so that the new SAMHSA regulations do not permit more than two consecutive doses of methadone take-homes per week in the first 30 days, or prohibit one month of methadone take-homes to stable patients after two years of continued treatment;
- commission a study on the changes made to patient treatment schedules;
- allow for prescribers affiliated with an OTP to prescribe up to one-month methadone take-home doses to be dispensed to a patient at a pharmacy;
- allow patients receiving methadone take-home medications from a pharmacy to maintain access to other services provided by the OTP;
- inform patients of and give them the right to consent to the differences in privacy protections between OTP and pharmacy dispensing;
- allow states to permit treatment to be conducted via telehealth; and
- require reporting on the number of patients and OTPs operating under this section.
Finally, the bill calls for a Sense of Congress that states should align their regulation of OTPs in a way that breaks down barriers to care.
The bill’s main sponsor is Rep. Donald Norcross (D-N.J.).
“This is a bill that will help patients in our quest for individualized care,” said Zachary Talbott, president of NAMA Recovery. “The current system’s inflexibility for stable patients, especially those who live long distances from OTPs, is costing lives. Current time-in-treatment requirements are arbitrary and not supported by objective evidence, tying the hands of medical providers in the individualization of patient care. NAMA Recovery wholeheartedly endorses the bill, and we applaud Representative Norcross and the other co-sponsors for their vision of increased flexibility while recognizing the critical role OTPs play in the provision of methadone treatment when it comes to safe induction and stabilization and access to comprehensive services.”
“A number of elements of the bill are reasonable,” said Mark W. Parrino, M.P.A., president of the American Association for the Treatment of Opioid Dependence (AATOD). “There are also a number of other additional reforms being considered so the next several months will certainly be an active time for OTPs and the regulatory environment.”
Having buy-in from OTPs and, in particular, patients, is very important for any methadone reform bill.
From Mr. Parrino on the Better MAT Act:
The AATOD Board discussed this proposed legislation. We certainly support the conceptual idea of the bill, which seeks to provide greater flexibility in treating patients in OTPs.
We learned a good deal about how patients would use their expanded take-home opportunities during the height of COVID-19. I believe that SAMHSA is also evaluating what can and should be changed with regard to regulatory oversight of the OTPs. We have continually recommended that any changes in rulemaking must be aligned with federal and state third-party reimbursement. That was certainly identified as a challenge during COVID-19 and exemption opportunities.
We are working with a number of parties to increase the use of telehealth services in OTPs including audio only capabilities since many of our patients do not have access to devices that have video/telehealth capabilities.
Additionally, changes in federal oversight need to work in conjunction with the fact that some states are increasing their oversight of OTPs. In this instance, as federal agencies reduce some operating requirements for OTPs and DATA 2000 practices, a number of states have their own trajectory of increasing regulatory oversight. This will require coordination among federal and state authorities, including Medicaid authorities.
I understand that there are some studies on the way, especially at John Hopkins, in working with pharmacies to provide medication to stable patients. This model was used in New York City many years ago and would require careful coordination among OTPs, medical personnel and pharmacists.
We agree with the recommendation that these matters must be carefully studied to avoid any unanticipated negative consequences.
Ultimately, while we find ways to provide greater flexibility in treating our patients, we also need to be mindful that there are significant workforce challenges in OTPs especially during and after COVID-19. We are also in a timeframe where the debate of how we treat our patients grows in significance.
The Better MAT Act needs to be evaluated in context about how these policy issues should move forward at a time when we are working with partners in the justice system to connect with our treatment systems.
Finally, the determination of providing take-home medication to the patient, rest with the clinical determination of providing greater flexibility and care against the inherent risk of providing take-home medication to people who will clearly benefit in having significant support from clinical personnel.
Additionally, we found that more stable patients preferred greater flexibility in receiving take-home medication and telehealth counseling as opposed to less-stable patients, who preferred onsite counseling with a greater connection to treatment staff.