Jeffrey A. Singer
A new report from the Department of Health and Human Services Office of Inspector General (OIG) found only 19 percent of the 1.2 million Medicare enrollees who have opioid use disorder (OUD) have been accessing medications for opioid use disorder (MOUD).
Addiction medical specialists classify three medications as MOUD: methadone, buprenorphine, and naltrexone (Vivitrol). Methadone and buprenorphine are opioid agonists—they bind to and stimulate opioid receptors in the central nervous system. Naltrexone is an opioid antagonist. Like the overdose antidote naloxone, naltrexone binds to opioid receptors but does not stimulate them. Instead, it displaces opioids that are already on the receptors and remains bound to them for an extended period.
Comparative effectiveness research indicates that methadone and buprenorphine are the only treatment modalities not linked to opioid-related morbidity, such as relapse and overdose. In contrast, naltrexone, along with both inpatient and outpatient rehabilitation without MOUD, is associated with this morbidity. Naltrexone’s ineffectiveness is understandable: it represents a medically enforced abstinence-only treatment. While abstinence-only treatment approaches are popular with courts that mandate drug possessors to enter rehab, clinical evidence indicates that such programs are largely ineffective and associated with opioid-related morbidity.
According to the OIG report, among the 1.2 million Medicare enrollees with OUD, 13 percent are receiving buprenorphine treatment, almost exclusively in office settings. Six percent of enrollees are receiving methadone solely through government-licensed opioid treatment programs (OTPs), commonly referred to as “methadone clinics.”
In December 2022, Congress removed some of the barriers the government imposes on clinicians seeking to prescribe buprenorphine in the office setting to individuals with OUD. The new law took effect in 2023. The OIG report found the number of providers prescribing buprenorphine to Medicare Part D enrollees increased by 32 percent that year. Still, only 13 percent of Medicare enrollees with OUD receive the drug. The OIG report noted:
Despite these increases, fewer than one in five Medicare enrollees received medication to treat their opioid use disorder in 2023. This percentage is similar to those for past years and may indicate that enrollees are facing ongoing challenges accessing treatment.
That same year, it reported approximately 53,000 Part D enrollees “experienced opioid-related overdose.”
One reason more clinicians are not prescribing buprenorphine might be because they are afraid they may become targets of overzealous law enforcement. Numerous stories circulate about SWAT teams raiding the offices of doctors who provide buprenorphine treatment.
Law enforcement is concerned that doctors may be aiding in the “diversion” of buprenorphine into the black market for nonmedical users. However, research by Cicero et al. found:
The most common reasons for illicit buprenorphine use were consistent with therapeutic use: to prevent withdrawal (79%), maintain abstinence (67%), or self-wean off drugs (53%). Approximately one-half (52%) reported using buprenorphine to get high or alter mood, but few (4%) indicated that it was their drug of choice. Among respondents who had used diverted buprenorphine, 33% reported that they had issues finding a doctor or obtaining buprenorphine on their own. Most (81%) of these participants indicated they would prefer using prescribed buprenorphine, if available.
If cops stopped practicing medicine, perhaps more clinicians would be willing to use buprenorphine to treat people with OUD.
But buprenorphine doesn’t work for everyone. Studies show some people have better responses to methadone than to buprenorphine. Buprenorphine is a partial agonist, whereas methadone is a full agonist. Partial agonists activate the receptors to a lesser extent and have a ceiling effect. Full agonists can produce the full range of opioid effects. Therefore, methadone can more effectively reduce cravings. A 2024 retrospective cohort study of the comparative effectiveness between buprenorphine and methadone published in the Journal of the American Medical Association concluded:
Receipt of methadone was associated with a lower risk of treatment discontinuation compared with buprenorphine/naloxone. The risk of mortality while receiving treatment was similar for buprenorphine/naloxone and methadone, although the CI estimate for the hazard ratio was wide.
The OIG report stated in its conclusion:
The findings of this report show a continued need for CMS to work to ensure access to these medications and provide further support for prior OIG recommendations.
One way to expand access is by removing government barriers that prevent primary care clinicians from prescribing methadone to their patients in their offices and clinics, a practice that clinicians in Australia, Canada, and the UK have maintained for over 60 years (similarly, physicians in the US did so before 1972). Sofia Hamilton and I discuss this reform proposal in a 2023 Cato Institute policy analysis.
The Modernizing Opioid Treatment Access Act (MOTAA), which has had bipartisan support in Congress for several sessions, is a step in that direction. However, it has failed to advance.
Recently, a group led by the American Society of Addiction Medicine found that the methadone treatment regime, focused on DEA-approved OTPs, is based on regulatory decisions by the DEA and Health and Human Services, not statutory requirements. They have written a letter to Attorney General Pam Bondi and Acting DEA Administrator Derek Maltz requesting a review and revision of methadone treatment regulations. I wrote about their efforts in this blog post.
As I write in my book Your Body, Your Health Care:
Treating substance use disorder is complicated. Practitioners must commit to developing close relationships with their patients, taking the time for deep discussions, and monitoring them closely. Not every primary care practitioner will feel competent to treat patients with OUD and will refer those patients to appropriate practitioners. However, allowing all primary care providers to provide methadone treatment would significantly expand treatment options and access to care.
While recent reforms around buprenorphine are a step forward, methadone remains trapped in a system built for another era. Removing the regulatory barriers that keep methadone out of primary care settings won’t solve the opioid crisis overnight—but it will give more patients a fighting chance. The government doesn’t need to build a new system—it just needs to get out of the way and let doctors treat their patients.