Methadone and the need for radical reform

Recently, the National Coalition to Liberate Methadone released its report on the liberation of methadone from the clinic system. This report is based on a conference held last year by the NCLM, National Survivors Union, and the New York University Center for Opioid Epidemiology and Policy. (https://tinyurl.com/4j78jman)

With the goal of highlighting the importance of liberating methadone from the current system and to improve access to methadone for people living with chaotic drug use, the “Liberating Methadone: Building a Roadmap and Community for Change Conference” was held on Sept. 21 and 22, 2023 in New York City. This writer attended the conference virtually.

The event started with a reminder that without science-based treatment modalities, thousands of people have died due to opioid overdoses. The beginning of the event established the setting: thousands gone, people who could have been treated with methadone rather than failed abstinence-only approaches to the drug problem. This conference was driven by drug users and methadone patients and supported by researchers. Aaron Ferguson, one of the driving forces behind this conference, highlighted the fact that drug user activism is reaching the shores of the United States, a country that has abandoned drug users historically.

Ferguson said, “If you’re going to call something treatment, the first goal should be to keep the patient alive.” He explained that methadone treatment — scientifically proven to be the gold standard of opioid use disorder treatment — is often gatekept and locked behind doors. According to Ferguson, “Every breath that you and I take is an act of defiance,” making the battle for methadone a radical fight. 

Conference speakers mentioned buprenorphine as a miracle, but noted that many chaotic drug users need methadone, because it’s far more powerful. Methadone, like buprenorphine, attaches to the opioid receptors in the brain. Buprenorphine is an imperfect fit for the receptors; methadone is a better fit, because its ability to block opioids and stop opioid cravings is stronger.

Methadone system needs radical reform

While safe supply has been in place around the world, the United States has failed to embrace this important movement, so our second-best approach is to radically reform the methadone system. We start this process by centering those with direct personal and lived experience in the methadone treatment system. The importance of this cannot be overstated. By including the voices of people on methadone — and to a lesser extent, buprenorphine — we can establish how to best help chaotic users of opioids like fentanyl and fentanyl analogues, the nitazene family of chemicals (isotonitazene, etonitazene) and heroin. 

An important message of the conference was that while buprenorphine could be helpful, methadone could do even more for people with dependence on stronger opioids.

The first panel at the conference was about research possibilities and gaps in   methadone treatment. One example of the research has to do with the effectiveness of office-based methadone — meaning methadone dispensed via prescriptions and pharmacies — versus buprenorphine, which is already dispensed this way. One of the goals is to see the effectiveness and implementation of office-based methadone. The other is to see how long people remain in treatment.

A major point brought up was the need for expansion of methadone treatment into every prison and jail in New York State. Many people in prison are incarcerated for a drug offense, with Black and Brown people being shepherded and railroaded into prison for having what amounts to a disease. A goal of the conference was to use public dollars to help fight the opioid epidemic and help people improve their outcomes in treatment. An important policy change being advocated is to meet chaotic drug users where they’re at, meaning that they get help no matter what they might be doing in their lives.

One part of the important research being done on methadone is to see how to better serve people in different populations, such as those who are homeless. In this research, we see that providing both methadone and housing helps people improve themselves and their lives. Unfortunately, the regulations regarding methadone have stunted progress, science and innovation in the field of Opioid Use Disorder treatment. The stigmatization of methadone treatment has also held back patients.

Importance of direct experience

An important part of the conference surrounded the relationship between research and direct, lived experience. We demolished the lines between researchers and community members. People who had direct and lived experience in drug use and treatment have been participating in the conference and the field of drug use research as both “experts” and patients.

The second part of the conference was dedicated to explaining the role that peer research and activity had on research into the drug problem. Drug users were playing the important role of researcher and specialist on the subjects of drug tainting, fentanyl and xylazine. They also played the important role of saving lives via their work.

While the entire contents of the conference would take many volumes, these two panels set the tone for the entire program. The summation of the conference can be found in the Liberating Methadone report. Establishing the facts of methadone treatment and its possibilities; the full report comes in at 51 pages. A conference attendee stated: “Every overdose death that we have is a policy failure. It’s a failure of our treatment system. It’s a failure of our regulations.” 

No truer statement could have been said. The report indicates that only 650,000 people are on methadone treatment, a fraction of the number who would benefit from it. Deep misunderstandings and biases against methadone exist, showing that even a very effective tool — and methadone can be shown to be an effective tool in chaotic opioid use treatment — can be mismanaged and misused — not misused on the end of the patient, but on the provider end.

Opponents of liberating methadone believe myths and outdated views, such as the necessity of abstinence for recovery treatment. While abstinence is an admirable goal, it’s not necessarily needed for methadone treatment to be successful, and enforcing it as a mandatory goal actually does more harm than good.

Called the “culture of cruelty,” when abstinence from drugs is enforced as a rule, it results in one of several possibilities: a stripping of “take home” doses (doses of methadone prepared for home use), a requirement that one goes to the clinic every single day (and since it often requires going to the clinic at early hours in the morning, it creates an insurmountable barrier for some), and, at worst, complete ejection from methadone programs, which often results in eventual overdose and death for patients who return to complete drug use. 

The reform of the methadone patient regulatory system is needed in order to make the treatment model centered around the patient and around human dignity. We need providers to acknowledge that a return to controlled use is not incompatible with recovery and that a return to chaotic use only symbolizes that the patient needs more support.

What needs to change

The fifth and final panel was about this particular question: What can we do to change the methadone system to make it human-centered and patient-centered? We need to educate politicians, methadone patients and the loved ones of patients how the current system is centered around making profits and sticking to norms of old recovery culture, such as abstinence-only requirements. Poverty and criminalization among drug users runs rampant in society, and this includes at methadone clinics.

We must end this, or else these failures in policy will kill drug users who seek help or recovery.

The main findings and recommendations of the conference are easy to digest. First, we center lived experience in policy making surrounding methadone and other medication assisted treatment. Second, we must normalize methadone treatment as health care and as a valid medical pathway to treating chaotic opioid use disorder. Third, we must change the “culture of cruelty” and make person-centeredness the focus in all methadone policies. This means that we prioritize evidence-based models of treatment, abandon anti-person policies and frame treatment around personalized goals for each person.

Fourth, we must improve opioid treatment program practices by removing barriers to treatment, such as requiring patients to fail with naltrexone or buprenorphine before trying methadone. Fifth, we create alternatives to the methadone clinic system, such as office-based physicians prescribing as with other medications. Lastly, we must change the public perception of methadone as inherently “replacing one drug with another.”

The National Coalition to Liberate Methadone successfully held its first Liberating Methadone Conference in order to meet the needs of people who use drugs and who use methadone and other medication assisted treatments. We — the activist and radical communities, whether we ourselves are chaotic drug users or people in recovery or not — need to understand these demands and these findings in order to best commit to activism around chaotic drug use. We need to study the revolutionary and progressive demands being made by people with lived experience.