The first big update to U.S. methadone regulations in 20 years is poised to expand access to the life-saving drug starting next month, but experts say the addiction treatment changes could fall flat if state governments and methadone clinics fail to act.
For decades, strict rules required most methadone patients to line up at special clinics every morning to sip their daily dose of the liquid medicine while being watched. The rules, built on distrust of people in the grip of opioid addiction, were meant to prevent overdoses and diversion — the illicit selling or sharing of methadone.
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Methadone patient Irene Garnett, 44, of Phoenix, leaves a clinic after taking her medication in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, 44, of Phoenix, prepares to leave a clinic after taking her medication in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, right, 44, of Phoenix, meets with counselor Melodie Reece at a clinic in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, 44, of Phoenix, waits for her medication at a clinic in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, 44, of Phoenix, holds her medication lock box at a clinic in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, 44, of Phoenix, meets with counselor Melodie Reece at a clinic in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, 44, of Phoenix, sits in the waiting room of a clinic in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, 44, of Phoenix, takes her treatment at a clinic in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
The COVID-19 pandemic changed the risk calculation. To prevent the spread of the coronavirus at crowded clinics, emergency rules allowed patients to take methadone unsupervised at home.
Research showed the looser practice was safe. Overdose deaths and drug diversion didn’t increase. And people stayed in treatment longer.
With evidence mounting, the U.S. government made the changes permanent early this year. Oct. 2 is the date when clinics must comply with the new rules — unless they're in a state with more restrictive regulations.
Alabama — where about 7,000 people take methadone for opioid use disorder — plans to align with the new flexible rules, said Nicole Walden, a state official overseeing substance use services.
“This is a step toward the country — and everybody — saying this is not a bad thing,” Walden said. “People don’t have to show up every day to get a medication that can help save their lives.”
Methadone, an opioid itself, can be dangerous in large amounts. When taken correctly, it can stop drug cravings without causing a high. Numerous studies have shown it reduces the risk of overdose and the spread of hepatitis C and HIV. But it cannot be prescribed for opioid addiction outside of the nation's 2,100 methadone clinics, which on a given day treat nearly 500,000 U.S. patients with the drug.
The new federal rules allow stable patients to take home 28 days’ worth of methadone. Colorado, New York and Massachusetts are among states taking steps to update their rules to align with the new flexibility. Some others have not, including West Virginia and Tennessee — the states with the nation’s highest drug overdose death rates.
“Where you live matters,” said University of Arizona researcher Beth Meyerson, who studies methadone policy.
Phoenix resident Irene Garnett, 44, would welcome more take-home methadone doses. Her clinic now requires her to come in twice a week, even though she's been a patient there more than 10 years, "which is just bonkers,” she said.
Garnett, who works as a grant manager for a harm reduction agency, lives 25 minutes away from the clinic. She said 28 days of take-home methadone, the maximum allowed under the new federal rules, would give her more freedom to travel and a “more normal quality of life.”
“This is the only medication where you have to disrupt your life by going someplace every day,” she said.
Under the new rules, which Arizona plans to embrace, clinics will have broad discretion about which people qualify for take-home doses. Ideally, such decisions will be made jointly between doctors and patients. But money will play a role too, experts said.
Frances McGaffey, who researches substance use treatments for the nonprofit Pew Charitable Trusts, said payments to clinics are sometimes tied to in-person dosing, which can discourage take-home treatment.
"States should be looking at their payment policy and see what kind of care they’re incentivizing,” she said.
In Arizona, clinics now get $15 per in-person dose from the state's Medicaid program vs. about $4 per take-home dose. The state is considering options including making those amounts equal or adopting what’s called “bundled payment,” a model that reflects the overall cost of treatment.
New York's Medicaid program uses a bundled payment model so there's no financial incentive for in-person dosing.
Longtime methadone patient David Frank, a 52-year-old New York University sociologist, gets four weeks of take-home methadone in wafer form from his clinic.
“I never in a million years could have gone back to school, got my Ph.D., done research or taught — any of that stuff — if I had to go to a clinic every day,” Frank said. “It’s night and day in terms of your ability to live a stable, happy, quality life.”
The methadone clinic system dates to 1974, when the U.S. saw fewer than 7,000 overdose deaths a year. Some longtime patients — including Garnett and Frank — are organizing a movement to “liberate methadone” as annual overdose deaths now top 107,000. They support legislation to allow addiction specialist physicians to prescribe methadone and pharmacies to fill those prescriptions.
The new federal rules don't go that far, but they include other changes, such as:
— In states that adopt the rules, methadone treatment can start faster. People will no longer need to demonstrate a one-year history of opioid addiction.
— Counseling can be optional instead of mandatory.
— Telehealth can be used to assess patients, improving access for rural residents.
— Nurse practitioners and physician assistants — not just doctors — can start people on methadone.
“It really is up to states to adopt these changes in order to increase access to care,” said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence.
Tennessee officials have drafted new rules that are stricter than the federal government's. The state's proposal would increase random urine drug screening, make counseling mandatory for many patients and obligate clinics to hire pharmacists if they want to dispense take-home doses.
The state's proposed rules "are duplicative, contradictory, prescriptive, rigid, and written in a way that seeks to punish versus heal people living with an opioid use disorder,” wrote Zac Talbott, who operates four methadone clinics in Tennessee, Georgia and North Carolina.
In states that do adopt the federal rules, the changes will be a heavy lift for some clinics, experts said. Some clinic leaders may disagree with the patient-centered philosophy behind the changes. Some may balk at the legal liability that goes with judgment calls about which people can safely take methadone at home.
“Not all opioid treatment programs are created equal,” said Linda Hurley, CEO of Rhode Island’s oldest methadone program, CODAC Behavioral Healthcare.
Clinics are used to operating within a highly restrictive environment, said Meyerson, the University of Arizona researcher.
“We have regulated them into a corner for years,” Meyerson said. The new rules allow the clinics to put the well-being of patients at the center of care.
“The question is," she said, "can they do it?”
The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.
Methadone patient Irene Garnett, 44, of Phoenix, leaves a clinic after taking her medication in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, 44, of Phoenix, prepares to leave a clinic after taking her medication in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, right, 44, of Phoenix, meets with counselor Melodie Reece at a clinic in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, 44, of Phoenix, waits for her medication at a clinic in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, 44, of Phoenix, holds her medication lock box at a clinic in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, 44, of Phoenix, meets with counselor Melodie Reece at a clinic in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, 44, of Phoenix, sits in the waiting room of a clinic in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
Methadone patient Irene Garnett, 44, of Phoenix, takes her treatment at a clinic in Scottsdale, Ariz., on Monday, Aug. 26, 2024. (AP Photo/Ross D. Franklin)
European heavyweights Real Madrid and Manchester City both suffered big defeats in the Champions League on Tuesday.
Defending champion Madrid was humbled 3-1 at home by AC Milan, while Erling Haaland missed a penalty and City squandered a fourth-minute lead as it lost 4-1 at Sporting Lisbon, whose coach will soon take charge of its crosstown rival.
It was a much better evening for Liverpool, as Luis Diaz scored a hat trick and Cody Gakpo grabbed another goal in a 4-0 win over German champion Bayer Leverkusen at Anfield that marred Xabi Alonso’s return to his old home.
The Leverkusen coach was given a warm welcome on his return to the club where he became a fan favorite as a player over five seasons between 2004-09. Alonso won the Champions League with Liverpool in 2005.
Liverpool moved top of the league phase table with four wins from four games, followed by Sporting and Monaco, both on 10 points after three wins and a draw. Under the new 36-team format introduced by UEFA this season, the top eight teams advance directly to the next round, and those from ninth to 24th enter a playoffs to reach it, while the bottom 12 are eliminated.
Before their game, Sporting fans displayed a huge tifo thanking Rúben Amorim in his last home game before he takes over Manchester United.
Phil Foden then got City off to a flying start in the fourth minute, only the second goal Sporting has conceded in four games of the competition.
But Swedish forward Viktor Gyökeres scored a hat trick as Sporting came roaring back. Gyökeres first equalized in the 38th after a perfect through ball from Geovany Quenda, before Maximiliano Araújo made it 2-1 right after the break. made it 3-1 in the 49th from the penalty spot after Joško Gvardiol was penalized for a shove on Francisco Trincão in the area.
Haaland’s penalty hit the crossbar, before Gyökeres showed the Norwegian how it’s done with another spot kick at the other end to complete the scoring.
It is the first time since 2018 that City has lost three straight games, coming off a defeat to Tottenham in the English League Cup and a loss to Bournemouth in the Premier League.
“In my seven and a half years at the club, I don't remember losing three games in a row,” City midfielder Bernardo Silva said.
In Spain, Christian Pulisic sent in a corner for Malick Thiaw to head Milan into a 12th-minute lead, ensuring Madrid trailed in a third straight game in the Champions League this season. The 15-time champion had already lost to surprise team Lille in their second game.
Vinícius Júnior equalized from the penalty spot in the 23rd after he’d been tripped, but Álvaro Morata pounced on the rebound after Andriy Lunin saved Rafael Leão’s shot to restore the visitors’ lead against his former club.
Morata had already been given a hostile reception from the home fans, who evidently remember the goal he scored to take Juventus through to the 2015 final at their team’s expense.
Tijjani Reijnders scored Milan’s third goal as the home fans made their frustrations known at Santiago Bernabéu Stadium.
“The last two defeats are inexplicable. We have to analyze and react quickly," Lunin said, referring to Madrid's 4-0 loss to Barcelona in its previous Spanish league game.
It's the first time since 2009 that Madrid has lost two successive games at home with at least three goals conceded in each, according to Opta.
“We have to get back on track,” Lunin said.
German forward Nicolas Kühn scored twice as Celtic defeated Leipzig 3-1 at home, and Juventus drew 1-1 at Lille.
Lille midfielder Edon Zhegrova eluded two defenders before playing a perfect pass for Jonathan David, who fired inside the far post, but Dušan Vlahović equalized with a penalty for the Italian club.
Donyell Malen scored late for Borussia Dortmund to beat Sturm Graz 1-0 at home, and Thilo Kehrer did likewise for Monaco to win at Bologna 1-0.
United States midfielder Malik Tillman scored one goal and set up another as PSV Eindhoven beat Spanish team Girona 4-0.
Dinamo Zagreb dealt Slovan Bratislava its fourth straight defeat in the competition as the visitors came from behind to win 4-1 in Bratislava.
AP soccer: https://apnews.com/hub/soccer
Sporting players toss coach Ruben Amorim into the air during the UEFA Champions League opening phase soccer match between Sporting and Manchester City in Lisbon, Portugal, Tuesday, Nov. 5, 2024. (AP Photo/Armando Franca)
Sporting players celebrate after a goal during the UEFA Champions League opening phase match between Sporting and Manchester City in Lisbon, Portugal, Tuesday, Nov. 5, 2024. (AP Photo/Armando Franca)
Manchester City's Erling Haaland reacts after missing a penalty kick during the UEFA Champions League opening phase match between Sporting and Manchester City in Lisbon, Portugal, Tuesday, Nov. 5, 2024. (AP Photo/Armando Franca)
Sporting players toss coach Ruben Amorim during the UEFA Champions League opening phase match between Sporting and Manchester City in Lisbon, Portugal, Tuesday, Nov. 5, 2024. (AP Photo/Armando Franca)
Sporting's head coach Ruben Amorim leaves the pitch after the UEFA Champions League opening phase match between Sporting and Manchester City in Lisbon, Portugal, Tuesday, Nov. 5, 2024. (AP Photo/Armando Franca)
Real Madrid's Kylian Mbappe, right, and AC Milan's Yunus Musah battle for the ball during the Champions League opening phase soccer match at the Santiago Bernabeu stadium in Madrid, Spain, Tuesday, Nov. 5, 2024. (AP Photo/Manu Fernandez)
Real Madrid's Jude Bellingham, front, and AC Milan's Emerson Royal battle for the ball during the Champions League opening phase soccer match at the Santiago Bernabeu stadium in Madrid, Spain, Tuesday, Nov. 5, 2024. (AP Photo/Manu Fernandez)
AC Milan's Tijjani Reijnders, right, celebrates after scoring his side's 3rd goal against Real Madrid during the Champions League opening phase soccer match at the Santiago Bernabeu stadium in Madrid, Spain, Tuesday, Nov. 5, 2024. (AP Photo/Manu Fernandez)
AC Milan's Tijjani Reijnders (14) celebrates with teammates after scoring his side's 3rd goal against Real Madrid during the Champions League opening phase soccer match at the Santiago Bernabeu stadium in Madrid, Spain, Tuesday, Nov. 5, 2024. (AP Photo/Manu Fernandez)
AC Milan's Alvaro Morata celebrates after scoring his side's 2nd goal against Real Madrid during the Champions League opening phase soccer match at the Santiago Bernabeu stadium in Madrid, Spain, Tuesday, Nov. 5, 2024. (AP Photo/Manu Fernandez)
PSV's Malik Tillman, left, and Girona's Silvi Club fight for the ball during the Champions League opening phase soccer match between PSV Eindhoven and Girona at Philips stadium in Eindhoven, Netherlands, Tuesday, Nov. 5, 2024. (AP Photo/Peter Dejong)
PSV's Malik Tillman, center, scores his side's second goal during the Champions League opening phase soccer match between PSV Eindhoven and Girona at Philips stadium in Eindhoven, Netherlands, Tuesday, Nov. 5, 2024. (AP Photo/Peter Dejong)
PSV's Malik Tillman, foreground, celebrates after scoring his side's second goal during the Champions League opening phase soccer match between PSV Eindhoven and Girona at Philips stadium in Eindhoven, Netherlands, Tuesday, Nov. 5, 2024. (AP Photo/Peter Dejong)
PSV's Malik Tillman, left, scores his side's second goal during the Champions League opening phase soccer match between PSV Eindhoven and Girona at Philips stadium in Eindhoven, Netherlands, Tuesday, Nov. 5, 2024. (AP Photo/Peter Dejong)