IF YOU PROVIDE IT THEY WILL COME: THE QUANDARY OVER METHADONE CLINICS

Volume 29, Issue 514 April 28, 2008

Matthew Gever

A tried-and-true method for treating opiate addiction is coming under increasing scrutiny from lawmakers as they confront an increase in methadone-related deaths and respond to long-standing community concerns about methadone clinics in their neighborhoods.

Methadone has historically been the safest and most effective means for treating people with an addiction to heroin and other opiates. The drug relieves cravings and reduces the symptoms of withdrawal, so that those who are committed to recovery can resume work, raise families and conduct their daily lives free from the constant hunger for heroin.

However, the synthetic opiate has been the subject of negative press recently, as it has been linked to a rising number of overdose deaths. The number of methadone-related poisoning deaths has increased 468 percent since 1999, compared to a 66 percent increase in overall poisoning deaths, according to a recent report from the National Center for Health Statistics (NCHS).

While some of the deaths are linked to diversion—using drugs for non-medical purposes—many are not. Instead, methadone has become increasingly popular as a pain killer for non-substance abusing patients. Methadone has less potential for abuse—and is far cheaper because it is not patented—than many other painkillers.

Many of the problems occur, experts say, because few doctors—especially physicians who practice in non-methadone settings—are trained in how to dispense methadone as a pain killer. “With the drug's half-life significantly longer than its effect on pain, the initial proper dosing of methadone is difficult and not all physicians are aware of its varying equivalence to other opioid medications,” said the NCHS report. In other words, some doctors over-prescribe the medication and a large dose can be deadly for those who have not developed a tolerance to opiates.

Moratoriums and Regs

Nevertheless, the increase in deaths has intensified some communities’ opposition to methadone clinics, and some lawmakers are responding by renewing moratoriums on new clinic construction and publishing regulations that deter patients from receiving treatment.

For example, in 1999, Indiana enacted a moratorium that forbade any new clinics in counties that had fewer than 40,000 residents, already had a clinic or was contiguous with a county that already had a clinic. The moratorium was extended every year but was temporarily lifted in 2006. In 2007, the Legislature passed another moratorium (SB 450) that will expire at the end of 2008. “This moratorium will give us the time we need to [review the issue] while responding to immediate community concerns about new clinics being considered now,” said Senator Connie Sipes.

With the moratorium expiring at the end of this year, the Legislature recently passed SB 157, which increases the amount of regulations for methadone clinics.

Part of the justification given is to keep out-of-staters away. “Opioid clinics in southern Indiana are flooded with patients from Kentucky and other neighboring states because we have very few regulations governing their behavior,” said Indiana Representative Steven Stemler. Often, clinics will set up shop in border areas to encourage out-of-state clients to come in, if the neighboring state is more restrictive or has a lack of clinics.

"Because of the number of patients traveling to Indiana to receive care, Indiana residents and legislators believed—inaccurately—that Indiana’s methadone regulations were particularly lax," said Kathleen Kane-Willis, interim director for the Institute for Metropolitan Affairs at Roosevelt University.

One of the key new provisions enacted was drug testing of new patients, specifically looking for non-opiate drug use such as cocaine and marijuana. New patients who fail a test will not be eligible for take-home doses and would instead have to ingest while at the clinic. The bill also restricts overall access to take-home methadone doses, reducing that amount to 14 days from 30. The take-home restriction had historically been one of the key differences between Indiana and the rules in Ohio and Kentucky—the latter two states having significantly more restrictive policies, according to Mark Parrino of the American Association for the Treatment of Opioid Dependence. The bill also increases the number of on-site visits of clinics and sets up a central registry of patients. “Enacting these restrictions will discourage opioid patients from crossing state lines,” said Stemler.

These restrictions, however, may adversely affect Indiana’s patients, said Chris Kelly, director of the Washington, D.C. chapter of Advocates for Recovery Through Medicine, a methadone advocacy group. Specifically, he said that the lack of new clinics is swelling patient count at existing clinics to unsustainable levels. “It’s a classic supply/demand imbalance,” he said.

In 2007, West Virginia enacted a hold on new clinics, mostly because clinics were opening at an incredibly fast rate—faster than the state could keep up with from a regulatory and patient safety standpoint. “We put a moratorium on the development of new clinics until rules are provided that are acceptable to the legislature,” said Delegate Don Perdue in a recent NCSL interview. Additionally, state officials were concerned about the increases in methadone-related deaths and were hoping to develop an educational component on proper use. "Because the number of methadone clinics was growing so rapidly, it became difficult to educate the public about the problems," said Delegate Perdue.

Louisiana instituted a moratorium in 2003 which is scheduled to last until July of this year. That would change if the Legislature passes HB 1062, which would extend the ban until July, 2010. However, the bill does provide the Department of Health and Hospitals the discretion to license a new facility if it determines a need exists.

In addition to moratoriums, states restrict new clinics through the “Certificate of Need” process, which limits construction of new health-care facilities based on community need. Currently, 22 states have CON provisions for substance abuse facilities, according to NCSL’s website on the topic. The CON process can have the same effect as a moratorium. “Here in DC, up until a few months ago we had a certificate of need process that almost prohibited any new providers, so there are only 4 right now—we could easily support 10,” said Kelly.

For more information on methadone and other treatments for opiate addiction, please visit http://www.ncsl.org/programs/health/forum/mat.htm or contact one of NCSL's substance abuse experts:

Allison Colker

202-624-3581, Allison.colker@ncsl.org

Matthew Gever

202-624-3576, matthew.gever@ncsl.org