US will let more people take methadone at home

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.

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)

Hezbollah pounded northern Israel with 140 rockets Friday, a day after the militant group’s leader vowed to retaliate against Israel for a mass bombing attack, the Israeli military and the militant group said.

Israel’s military said the rockets came in three waves Friday afternoon targeting sites along the ravaged border with Lebanon.

In Gaza, Palestinian authorities said 15 people were killed overnight in multiple Israeli attacks.

An airstrike early Friday morning in Gaza City hit a family home, killing six people including an unknown number of children, Gaza’s Civil Defense said. Another person was killed in Gaza City when a strike hit a group of people on a street.

Israel maintains it only targets militants and accuses Hamas and other armed groups of endangering civilians by operating in residential areas. The military, which rarely comments on individual strikes, had no immediate comment.

Gaza’s Health Ministry says more than 41,000 Palestinians have been killed in the territory since Hamas’ Oct. 7 attack. The ministry does not differentiate between fighters and civilians in its count but says a little over half of those killed were women and children.

Israel says it has killed over 17,000 militants, without providing evidence.

Meanwhile, the leader of Lebanon’s Hezbollah is promising to retaliate for deadly attacks on its communication devices after Israel’s defense minister announced a “new phase” of the war. Fears are increasing that 11 months of exchanges of fire between the two sides will escalate into all-out war.

Hezbollah began striking Israel almost immediately after Hamas’ Oct. 7 attack that sparked the Israel-Hamas war. They have come close to a full-blown war on several occasions.

Here's the latest:

Palestinian authorities say 15 people were killed overnight in the Gaza Strip in multiple Israeli attacks.

An airstrike early Friday morning in Gaza City hit a family home, killing six people including an unknown number of children, Gaza’s Civil Defense said. Another person was killed in Gaza City when a strike hit a group of people on a street.

In Beit Hanoun, north of Gaza City, another person was killed and several others injured when a vehicle was hit by an Israeli strike, the Civil Defense said.

Late Thursday, six more people were killed in a strike that hit a home in the center of Gaza City, while another was killed in Beit Lahya, north of Gaza City.

Israel maintains it only targets militants and accuses Hamas and other armed groups of endangering civilians by operating in residential areas. The military, which rarely comments on individual strikes, had no immediate comment.

The war has caused vast destruction and displaced about 90% of Gaza’s population of 2.3 million.

Israel's foreign ministry said Friday it submitted two legal briefs in response to the International Criminal Court prosecutor’s request for arrest warrants against the country's leaders.

The court’s prosecutor is seeking arrest warrants for Israeli Prime Minister Benjamin Netanyahu and Defense Minister Yoav Gallant, as well as top Hamas leader Yahya Sinwar and other Hamas leaders. One of them was since assassinated in what was believed to be an Israeli strike.

The foreign ministry said it has submitted two legal briefs challenging the court’s jurisdiction to arrest Israeli leaders and claiming the court did not provide Israel the opportunity to investigate itself before requesting the warrants.

“No other democracy with an independent and respected legal system like that which exists in Israel has been treated in this prejudicial manner by the Prosecutor,” wrote Foreign Ministry spokesperson Oren Marmorstein on the social media platform X. He said Israel remained “steadfast in its commitment to the rule of law and justice” and would continue to protect its citizens against militancy.

Israel is not a party to the court. Rights groups say the country has struggled to investigate itself in the past. Netanyahu has brushed off calls for a state investigation into the failings that led to the Oct. 7 attack.

BAGHDAD — A leader of an Iranian-backed Iraqi militia was killed Friday in a strike in Syria, a war monitor and a militia official said.

Iraq’s Kataeb Hezbollah group — which is different from the Lebanese militant group Hezbollah — said in a statement that Abu Haidar al-Khafaji was killed “while performing his duties as a security advisor in Damascus.”

The UK-based Syrian Observatory for Human Rights had earlier reported that a leader in Iraq’s Kataeb Hezbollah group was killed and another person injured in a drone strike on the car they were traveling in on the road to the Damascus airport.

An official with an Iraqi militia confirmed that a car carrying a group of militia members was struck in Damascus, killing one person and injuring three others. The official spoke on condition of anonymity because he was not authorized to speak to the media.

There was no comment from Israeli officials on the strike. Israel frequently strikes Iranian and Iran-linked groups in Syria but rarely acknowledges the strikes.

Tensions have heightened in the region following a wave of apparently remotely detonated explosions in Lebanon targeting pagers and walkie talkies belonging to the Lebanese Hezbollah. The attacks, widely blamed on Israel, which has not commented on them, killed at least 37 people - including two children - and wounded about 3,000.

— By Qassim Abdul-Zahra in Baghdad

BEIRUT — Israel’s military killed two Hezbollah members who were planting explosives along the border over the weekend, Israel’s military and an official with a Lebanese group said.

The official with a Lebanese group said the two members of the militant group were killed Sunday and their bodies were taken by Israeli troops because they were too close to the fence along the tense frontier. The official spoke Friday on condition of anonymity because he was not authorized to speak to the media.

On Thursday, Israel’s military released a video it said was taken by one of the fighters showing the militants coming under fire. The military said that the two fighters were killed by Israeli troops as they tried to plant an improvised explosive device near a military post.

In the days following the tense border interaction, thousands of devices exploded in different parts of Lebanon and Syria, killing 37 people and wounding around 3,000 others. The attack was blamed on Israel, and many of those killed or injured were members of Hezbollah.

Associated Press writer Bassem Mroue contributed to this report.

Hezbollah members carry the coffin of their comrade who was killed when a handheld device exploded, during a funeral procession in the southern suburbs of Beirut, Thursday, Sept. 19, 2024. (AP Photo/Hussein Malla)

Right-wing Israelis with relatives held hostage by Hamas in the Gaza Strip, and their supporters, rally against a hostage deal, in Jerusalem, Thursday, Sept. 19, 2024. The placard in Hebrew reads: " To bathe in his blood." (AP Photo/Maya Alleruzzo)

Houses are engulfed in fire as the Israeli army raided the northern West Bank town of Qabatiya on Thursday, Sept. 19, 2024. (AP Photo/Majdi Mohammed)

Palestinians duck for cover as the Israeli army raided the northern West Bank town of Qabatiya on Thursday, Sept.19, 2024. (AP Photo/Majdi Mohammed)

FILE - Hezbollah fighters carry one of the coffins of four fallen comrades who were killed Tuesday after their handheld pagers exploded, in the southern suburb of Beirut, Wednesday, Sept. 18, 2024. (AP Photo/Bilal Hussein, File)