It was below freezing when Billy stepped outside of his home in Newark, Ohio. He tried to start his girlfriend’s car, but it wouldn’t start. He tried again. Nothing.
Somehow, though, they both needed to get from Newark to a methadone clinic in Columbus. Normally it’s a 45-minute drive, but with the snow, the wind and the roads, it was hard to tell how long it would take.
But they had to get there; the withdrawal was starting already. Sometimes, Billy said, when he’s driving to the clinic, it can be so bad. Despite the cold, he’ll have his windows rolled down, his shirt off. People passing him think he’s lost it.
So, just two days before Christmas, his mom came over and they all piled into her 2007 Ford Fusion.
From Newark to Columbus, the roads were treacherous – icy, barely plowed. The wind blew snow across the flat stretches before New Albany’s white fence began to cordon off the highway from clusters of townhomes. Billy’s mom could hardly see the road in front of her and white-knuckled the steering wheel at 25 miles per hour.
She was amazing, Billy said. It was the other drivers he worried about, like the pickup with an empty trailer that kept sliding around on I-670.
With the snow and ice and arctic temperatures, Billy’s trip that day, and the next two days, was epic – the lengths he had to go to get life-saving medicine. It’s not usually this intense, he said, but it’s a grind driving every day back and forth.
His situation isn’t unusual. For people using methadone to treat opioid use disorder (OUD), there are many hurdles. It’s the most regulated medicine in the United States. It must be dispensed at special clinics that are regulated not only by the state but by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Agency. Patients must attend counseling and have regular drug screens. It is unique, too, in that it is tied to a physical space, a clinic, which many users must visit every day.
Typically, clinics will allow one take-home dose a week (usually to cover the day a clinic is closed). When patients have been in treatment long enough, they may be eligible for more take-home doses.
If Billy misses a visit, besides experiencing withdrawal, it can set him back in his treatment. To receive take-homes he must have two months of negative drug screens and attend all doctor and counseling appointments.
That’s why he was on the road during a Level 3 snow emergency.
It’s not perfect, but for him methadone is the best medication for addiction treatment he has tried. It has a long “half-life” which means it is longer acting, so patients using it to treat opioid use disorder are able to stabilize their lives in ways they might not be able to otherwise.
“It’s better than the alternative,” Billy said, “better than doing dope.”
Medication for Addiction Treatment
The COVID-19 pandemic presented a serious problem for the clinic model – all of those patients crowded into offices could spread the virus.
But in March of 2020, SAMSHA issued new rules allowing for more take-homes. Public insurers covered telemedicine visits, while some clinics waived urine screenings. Others allowed patients to designate a person to deliver take-homes. These were the first changes to the methadone model since the 1970s and it was, in a sense, a vast national experiment that revealed that extra take-homes didn’t lead to an increase in negative treatment outcomes, overdoses or diversion.
A Cochrane review from 2009 – considered one of the highest bars for research – concluded that methadone is effective because it keeps people in treatment and helps decrease illicit heroin use, lessening the risk of overdose. In a time when people are dying because of a poisoned drug supply, this is no small thing.
Jason (a pseudonym) uses methadone to treat opioid use disorder and to alleviate the pain that comes from complications related to his Type 1 diabetes. In an interview with his mother, she told me that he had tried other medications in the past – including naltrexone (Vivitrol) – but so far methadone has been the best fit.
Things were going well for Jason. He loved the clinic which, unlike Billy, is close to his home. And then the storm hit. On Christmas Eve, he was five minutes too late to the clinic. Everyone had left and it wouldn’t be open the next day. He wouldn’t be getting his Saturday or Sunday dose.
Jason worried that he would go into withdrawal, that he would get dehydrated and end up back in the hospital. So, he made some phone calls. It got him through until Monday.
But for someone who hadn’t been using illicit fentanyl for a while, it was a risky calculation.
Low-Barrier Care
In Spring 2021, the Urban Survivor’s Union, a national drug-user led organization advocating for harm reduction and an end to the Drug War, published a Methadone Manifesto created by current and former patients, activists, healthcare professionals and researchers. It offers the perspectives of people with lived experience and points out the limits of the current regime.
They advocate for person-centered, low-barrier care with a harm reduction approach – meeting people where they’re at. This would mean clinics that are open longer and greater access to take-homes. But more importantly, an end to the clinic-based system. They point to Canada, Europe and Australia, where pharmacy and primary-care dispensing has existed for years.
What stands out, though, is that they frame the clinic model as a violation of human rights. They note that drug screenings, mandated counseling and stringent dosing rules, in addition to barriers of access to medication and to the clinics, would hardly be considered for most medications. People are being deterred from healthcare, they assert, at a time when they most need it.
They offer a variety of solutions including permitting dispensing through primary care physicians or pharmacies. According to the Centers for Disease Control, nine out of 10 Americans live within five miles of a pharmacy – and pharmacies already dispense methadone if it’s prescribed for pain. The UK and Australia have successfully used pharmacy-based methadone dispensing of OUD for decades.
Mobile methadone clinics might also be a short-term solution for Ohio. They already exist in other countries and states.
Anthony Bonifonte, assistant professor of Data Analytics at Denison University (where I also teach), has studied the problem of access to methadone closely.
In a study published in the Journal of Substance Abuse Treatment, he and co-author Erin Garcia argue that because daily access is required, geographic access is central. They found that “18.2 percent of the United States population does not have geographic access to a methadone clinic and estimate 77,973 individuals in these areas would attend a clinic if geographic access barriers were removed.”
“We estimate 3,800 people in Ohio would attend a methadone clinic but are prevented by geographic access limitations,” Bonifonte said. “Central Ohio accounts for 630 of these people, with one-way drive times up to 70 minutes each way to the nearest clinic.” In another study of which Bonifonte was a part, he mapped out possible routes for mobile methadone clinics that included multiple locations to make it more financially viable.
In mid-December, SAMHSA announced some proposed rule changes that could help ease restrictions on people who take methadone. They hope to codify rules governing telehealth and greater access to take-homes that began during the early days of the pandemic. In addition, the
Opioid Treatment Access Act, sponsored by Sen. Ed Markey and Rep. Donald Norcross, proposes similar changes, with the addition of allowing pharmacies to dispense methadone.
But right now, it’s still a hassle, Billy said. It’s a challenge to get there every day. Even in cities, where most of Ohio’s methadone clinics are clustered, if you don’t have a car, travel back and forth on a bus can take up a day.
“It feels like it consumes the whole day,” said Billy, who wishes he could just go to CVS and be done with it. He points out the window – there’s one less than a mile from his house.
