For years, Sommer Nolette has taken an Uber every week to a methadone clinic in Washington, Pa., often heading there before sunrise to make it to her job by 8:30 a.m. She estimates a monthly expense of $80 in commuting fees to secure the drug that has kept her heroin-free for seven years.
That expenditure of time and money in seeking methadone is not unique to Ms. Nolette, 29. Nationwide, hundreds of thousands have faced challenges in accessing a drug approved by the Food and Drug Administration decades ago to treat opiate addiction.
An estimated 111,877 people died of drug overdoses in the U.S. between June 2022 and June 2023, up 2.5% from the year prior, according to the National Center for Health Statistics.
Amid the country’s worsening opioid crisis, a bill introduced this year is meant to help knock down such hurdles. The Modernizing Opioid Treatment Access Act, or MOTA, calls for expanding who can prescribe methadone to address gaps in availability that disproportionately impact those in less populous areas.
The U.S. Senate will take up the bill on Tuesday.
While harm-reduction experts applaud the bill’s intent, researchers at the University of Pittsburgh studying the legislation’s potential impact say it doesn’t go far enough in improving the accessibility of a drug that has been shown to reduce the risk of a fatal overdose by more than 50%.
“Despite the fact that we know methadone is effective, it’s very hard to access in the U.S.,” said Paul Joudrey, an assistant professor at the Pitt School of Medicine and first author on a paper published last month in the journal Health Affairs Scholar.
“This means that for many suburban and rural communities, there are really no treatment options for them,” he said.
MOTA was introduced in March as a bipartisan bill. Reps. Donald Norcross, D-N.J., and Don Bacon, R-Neb., brought it to the House; Sens. Ed Markey, D-Mass., and Rand Paul, R-Kentucky, brought it to the Senate.
The bill would allow addiction medicine specialists to prescribe methadone from a larger network of clinics. Current regulations say only federally recognized opioid treatment programs may do so, and there is a dearth of such facilities compared to demand.
In addition to methadone, two other drugs — buprenorphine and naltrexone — are FDA-approved as medications to treat opioid use disorder.
“It’s so important to have methadone in communities to give people options,” said Dr. Joudrey, also a certified addiction medicine specialist at Pitt.
Were MOTA to pass, patients living outside of urban areas would likely still struggle to procure methadone, the Pitt study found. It calls for expanding methadone services beyond the bill’s asks by allowing any trained clinician, such as an informed primary care provider, to prescribe it.
“One of the only reasons I am still here is because of methadone,” said Ms. Nolette, who grew up in Schoharie County, N.Y., 50 miles west of Albany.
Rural communities have suffered disproportionately from opioid overdose deaths compared to urban areas.
Looking at national census tracts — subdivided county regions of about 4,000 inhabitants determined by the U.S. Census — the Pitt study found more than half did not have an opioid treatment program that prescribed methadone. Researchers further discovered that those tracts overlapped areas where more than half of all drug overdose deaths occurred from 2009 to 2019.
And fewer addiction medicine specialists practice in rural areas.
Even such specialists outside of rural areas and with robust financial and social support can experience the challenges of accessing methadone.
Following an addiction to Percocet that led to heroin, Samantha, 40, a native of an affluent Pittsburgh suburb, has been taking methadone since 2012. For years, she’s driven 60 minutes round trip for it.
To maintain her anonymity, Samantha is being identified by a pseudonym, as some family and friends remain unaware of her recovery and methadone prescription.
While noting her advantages compared to many — “Just being able to attend the same methadone clinic for the past 11 years, being able to get there every single day. Being able to afford the gas, the treatment, the child care” — accessibility issues highlight a tethering aspect of the prescription.
A visit to her parents out of state, Samatha said, felt like wearing “liquid handcuffs,” as she nervously awaited what’s known as “guest medication” when traveling.
The Pitt researchers, in looking at the impact if all trained clinicians were able to prescribe, found it would increase the hypothetical availability of the treatment in 58% of rural census tracts, 53% of suburban tracts and 30% of urban tracts. Under the MOTA proposal, only 16% of rural census tracts would see increased access.
Those involved with the study also included faculty from the University of Gothenburg Institute of Medicine in Sweden, the University of Illinois, and the Pitt School of Public Health.
A prevailing argument against creating more methadone clinics is what those in the field call NIMBY-ism, the “not in my backyard” sensibility in which people hypothetically support social services for the underserved until those services show up in their neighborhood.
Dr. Joudrey said the MOTA bill — as well as his team’s suggestion to expand prescribing to all trained clinicians — could tackle such reluctance in a new way.
“If you allow methadone to be prescribed at pharmacies, you can kind of skirt around this NIMBY issue,” he said. “You could get methadone at the same place you get your blood pressure medication. It gets around this siloing and othering of methadone by the health care system.”
Not everyone supports even the less-extensive MOTA proposal. The American Association for the Treatment of Opioid Dependence, a trade group representing more than 1,300 opioid treatment facilities, released a fact sheet in response to the bill, stating that the organization opposed MOTA, including allowing methadone access via pharmacies.
In part, the group expressed concerns about the potential for methadone abuse.
“The legislation is a Trojan horse for a medication-only approach in treating a very complex illness. Medication alone is not sufficient in treating opioid use disorder,” association President Mark Parrino said via email.
Dr. Joudrey, countering that the association had cited outdated studies (up to 20 years old) to back up its claims, said the assertion that medication treatment alone doesn’t work is “factually inaccurate.”
A professional organization, the American Society of Addiction Medicine, has offered unequivocal support for MOTA.
For Ms. Nolette, methadone has provided the stability she sought after multiple stints at rehabilitation facilities and unsuccessful attempts at finding medication options that she said didn’t exist in her rural New York county.
She and her partner landed in Pittsburgh in 2017, detoxing at a hospital then walking a mile to a North Side treatment facility to start methadone. They were homeless for two months that summer, sleeping in parks and walking to the clinic.
“(We had) a suitcase each and $20 in our pocket, and no plan really, except that we wanted to do something different with our lives and not do this anymore,” said Ms. Nolette.
Eventually the pair moved to Washington, Pa. For two years, Ms. Nolette took the bus to the clinic daily, until she was cleared to go weekly, which requires constant negative drug screening and counseling.
Getting to the clinic became more complicated after she was hired at UPMC Magee-Womens Hospital to be a peer navigator, advocating for pregnant people on methadone to be able to stay with their babies. Studies show that pregnant people can take methadone safely under certain guidelines.
“Having to go to the methadone clinic limits the shifts you can take,” said Ms. Nolette, who has two children of her own. “It limits the places you can work.”
Local groups that work with people with opioid use disorder support MOTA and, if the logistics work out, would be interested in potentially adding methadone to their available medications for Pittsburgh patients.
Even in more populous Pittsburgh, the need exists. At the handful of clinics in the city, hours are limited.
Second Avenue Commons, the Uptown shelter and clinic that celebrated its one-year anniversary in November, currently prescribes the buprenorphine-naltrexone hybrid Suboxone via pharmacies. It is not legally allowed to do the same with methadone.
Being able to prescribe methadone “would be great,” Second Avenue medical director Anita Leon-Jhong said, adding that she would have to learn more about the feasibility of doing so if MOTA were to pass.
About 20 Second Avenue Commons clinic patients are taking Suboxone, she said, adding that many request it after missing the Prevention Point Pittsburgh van, a mobile option stopping at various locations around Pittsburgh Mondays through Thursdays that can write prescriptions for buprenorphine.
“As someone who has been working to reduce overdose deaths for the past 20 years, I applaud MOTA as a step in the right direction,” said Alice Bell, the overdose prevention project coordinator at Prevent Point Pittsburgh.
Regulations surrounding methadone prescription make things difficult, she said.
“I’ve talked to people who drive an hour and a half every day to get methadone,” said Ms. Bell. “It would greatly reduce barriers if people could go to their regular doctor. It would also help with continuity of care.”
When Samantha found methadone, it was the first time in years she could think about something other than acquiring drugs, she said.
“It is like a mental health medication that I take every day that keeps me feeling completely normal,” she said, adding that she has been slowly tapering off the medication. She now works as a recovery specialist at a local hospital system, giving others the help she needed in the past.
“This medication works incredibly well,” she said. “It’s like magic. It’s so liberating. … This normalizes my life.”
Methadone opposers have argued that people who use substances are simply swapping one drug for another, that taking another medication with potential for abuse is not getting them out of the cycle. Some cite deaths related to methadone as a reason to keep the drug under tight wraps.
While methadone does not create the feelings of euphoria that other opioids do, it does hold a potential for abuse because it can lead to chemical dependence. Experts suggest tapering as opposed to cutting someone off methadone for this reason.
And research also shows not being on methadone if a person has an opioid use disorder is more dangerous than the risks its poses. A report published by the National Academies of Sciences in 2019 found that while there is an increased risk of opioid overdose within the first two weeks of starting methadone, the overdose risk is still higher for people with an opioid use disorder who are not on medication management.
Prescription drug monitoring programs — electronic databases that track the flow of controlled substances — as well as an increase in U.S. Drug Enforcement Administration oversight of controlled substances have all come into the picture in recent decades as a response to the methadone-related abuse and deaths that did occur.
Addiction medicine specialists counter that medications for opioid use disorder, or MOUD, are treatment medications, similar to managing any other chronic disease, and that MOUD is one part of a coordinated approach, which should also include counseling and the bolstering of social supports.
“You wouldn’t tell somebody who finally has perfect blood sugars with their diabetes medication that now they should get off of it,” said Samantha. “It’s a process, and it takes time for everybody.”
Dr. Joudrey, the Pitt researcher, said his study puts methadone availability in stark terms.
“Real people are dying in communities where we’ve failed to do the simple thing — make sure a treatment we already know works is available.”
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