With all of the discussion about methadone by pharmacies, methadone by increased take-homes, and methadone by less regulation in general, we decided to ask Robert Lubran, former director of the Division of Pharmacologic Therapies at the Substance Abuse and Mental Health Services Administration (SAMHSA), what he thinks about medication only – in other words, methadone without comprehensive services. Mr. Lubran is no stranger to controversy, as we know from many years of interviews.
“If by medication-only you mean, ‘gas and go,’ I certainly hope not,” Mr. Lubran responded. “But maybe that’s what we already have?”
We asked if it is safe for physicians to prescribe methadone to patients with opioid use disorder (OUD), without comprehensive care. “There is enough research on this topic to move cautiously toward a model like the hub-and-spoke,” said Mr. Lubran, referring to the model first established by Vermont (see https://atforum.com/2016/10/vermonts-hub-spoke-system-model-otps/).
“In the hub and spoke model induction can be done by a specialized treatment provider and once a patient has been determined to be stable, as assessed by the specialized treatment provider, why not allow the patient to transfer to the care of a trained medical professional?” asked Mr. Lubran. “Why not let the patient get his medication at a local pharmacy? Why not give patients more choices in their treatment? Being tethered to the OTP, in the case of methadone, is unique in American medicine and it stigmatizes patients.”
However, the hub and spoke model is based on the first assessment being done by an OTP, which then determines whether the patient gets methadone or buprenorphine. If buprenorphine, the patient goes to a “spoke,” which is an office-based physician. Or, if the patient is going to be prescribed buprenorphine but needs more monitoring and treatment, he or she will go to the hub (OTP) for treatment. If the patient needs methadone, the patient will go to the OTP hub, under the Vermont model. This model has been misinterpreted over the years to mean that everyone getting buprenorphine is in a spoke, and everyone getting methadone is in a hub. In fact, the question for clinicians is more about the need of the patient.
We asked Mr. Lubran whether buprenorphine is not, in fact, safer as a drug to be prescribed, compared to methadone. “Yes, buprenorphine is inherently safer from a pharmacological standpoint,” he said. Then why is there a call to prescribe methadone from physician offices? “When the model was established for buprenorphine it was clear that certain interests did not want it to be stigmatized along with methadone,” said Mr. Lubran, whose historical knowledge about this issue runs deep. “There are certainly problems for sure with buprenorphine prescribing, but overall I’d say many barriers remain, and there is stigma against OUD among physicians.” Mr. Lubran added that reimbursement for medical and counseling professionals is problematic, there is a shortage of highly trained workforce to provide counseling services. “There are not enough prescribers in rural areas,” he said. “I’ve complained before that the SAMHSA locator is of no help, that some pharmacies won’t carry the products, and many communities don’t have recovery supports that are welcoming to individuals with OUD who are in medication treatment.”