When I began my career as a hospital pharmacist at Tufts Medical Center 22 years ago, the discussion surrounding pain and addiction was quite different than today. The debate then was over whether we were adequately treating pain in our patients.
This single-minded focus on eliminating pain gave rise to a significant increase in the number of prescriptions written for opioids, including oxycontin. From 2000 to 2010, prescriptions for opioids increased fourfold nationwide. A tragic unintended consequence of this wider availability of opioids was unfortunately a threefold increase in the number of overdose deaths in the country.
While opioid prescribing has decreased over the last decade, the introduction of potent synthetic opioids, such as fentanyl, which is 50 times more powerful than heroin, are now driving the rise in overdose deaths. The most recent numbers from the Centers for Disease Control indicate there were 107,622 deaths nationwide in 2021 from drug overdoses. This represents a roughly 50% increase over the 70,630 overdose deaths in 2019, before the pandemic.
As a pharmacist, my interest in this issue is multifold. This is a crisis partially exacerbated by the medical community through the over-prescription of opioids. We were part of the problem; I believe we need to work to be part of the solution. I’m also distressed by a system of care for addiction treatment that is stigmatizing, results in unnecessary barriers to care, and sets patients up for failure.
I believe we can and must do better.
One of the ways we could do dramatically better is by expanding access to methadone, a long-acting opioid used to treat both pain and opioid use disorder. After over 50 years’ experience using it to treat addiction, we know it is highly effective. It is also highly underutilized.
This medication cuts the risk of overdose nearly in half compared to those not receiving treatment. It also reduces drug cravings, prevents the unpleasant symptoms of withdrawal, and decreases use of dangerous illicit drugs. So why is it underused?
One of the primary barriers is an archaic distribution system instituted in the early 1970s. Methadone, when used to treat opioid use disorder, according to federal regulations, can only be prescribed and dispensed out of a methadone clinic, and patients must travel to a clinic every day to receive this lifesaving medication.
Imagine if patients with diabetes had to travel to their doctor’s office every day to get their insulin. It’s an unreasonable expectation, and for most people, it would be unsustainable. Our emergency rooms would be overrun with patients in a diabetic crisis, much like we are today with overdoses. In fact, there is no other chronic condition for which this would be considered an acceptable practice.
In our region, most of the methadone clinics are situated along the Interstate 91 corridor, leaving significant areas without any easily accessible treatment, particularly in rural communities. These are known as treatment deserts, and where I live on the eastern shore of the Quabbin Reservoir is one such desert.
The nearest methadone program is probably a 45-minute drive. For someone without a vehicle, that clinic may as well be on the moon, because there’s very limited public transportation in those rural communities. This eliminates one of the most highly effective treatments as a potential option for many patients. There are probably 70,000-plus people from Belchertown to Barre living in such treatment deserts.
Ironically, there aren’t the same restrictions in place when using methadone to treat pain. Your primary care doctor can prescribe it, and it can be picked up at your local pharmacy.
The fastest way to expand access to treatment for opioid use disorder is by eliminating the requirement for prescribing and dispensing to be out of a methadone clinic. When France removed similar training and prescribing requirements for buprenorphine, another effective treatment for opioid addiction, the number of patients receiving treatment went up by a factor of 10, while overdose deaths went down by 80%.
In 2020, more than 2,100 Massachusetts residents died from a drug overdose.
The latest numbers for 2021 aren’t available yet, but it’s a good bet the death toll will be even higher. If we don’t fundamentally change the way we treat addiction, we can anticipate thousands more grieving families by the end of this year.
Methadone is not a silver bullet, but loosening restrictions on its prescribing and distribution can make this important medication more widely available to help address the current epidemic.
Treatment for addiction should be as easy as receiving care for other chronic conditions. You should be able to go to your primary care doctor for care and pick up your medication at a local pharmacy. Access to treatment needs to be easier, not harder.
Mark E. Klee is a clinical pharmacist at Baystate Medical Center and a member of the Hampshire HOPE opioid prevention coalition run out of the city of Northampton’s Health Department. Hampshire HOPE members contribute to this monthly column about local efforts addressing the opioid epidemic.
