This is the first installment of a four-part series.
They must be observed taking their daily medicine, at least in the beginning.
The clinician often wears a white lab coat and works behind protective glass. She’ll pour a dose into a small plastic cup – it’s often reddish and clear, like cold medicine – then pass it through a low opening. The patient, who may be fidgety or testy or dangerously late for work, may throw it back with a resentful snap, as if it were a shot of cheap whisky. It is appallingly bitter, often masked with an even more vile fruit flavoring.
The clinician watches all of this to be sure the stuff is actually swallowed. Methadone must not be “diverted” (that’s government-speak for “stolen”) and resold as a recreational drug on the black market.
This almost morbid fear of diversion – far more than any desire to help patients – has been a big part of America’s methadone clinic system, critics say. For more than half a century, that fear also has handed clinics an exclusive, nearly unbreakable iron grip on what remains a gold standard treatment for opioid addiction.
Methadone clinics are strictly regulated, federally sanctioned and primarily owned by for-profit corporate chains. Many are backed by private equity or publicly traded healthcare companies, which has attracted the ire of lawmakers.
Still, the system has changed little over the decades, even as opioids grew terrifyingly stronger, addiction became epidemic and overdose deaths skyrocketed.
“Coming off opioids is horrible,” one clinic regular told us. “You want to die, like your skin doesn’t fit anymore. You want to crawl out of it.”
Methadone makes that agony go away.
Yes, there are newer medications to manage opioid addiction – namely, buprenorphine – and those can be prescribed by doctors. But good, old-fashioned methadone is greatly preferred by many recovering users. It’s a synthetic opioid, with a chemical structure that allows it to bind more fully to the brain’s opioid receptors, so it excels at alleviating cravings and withdrawal symptoms, and at helping people get – and keep – a life.
But treating an opioid addiction with another opioid has always been a bitter pill for many to swallow.
The exclusive methadone clinic model was the brainchild of the Nixon administration, conceived when “hippies” dabbled with smack and glassy-eyed military veterans returned from Vietnam with raging habits. Methadone was conceived more as a tool for crime reduction than as a tool for healthcare, and restricting it to tightly controlled, government-regulated clinics – and only those clinics – reflected that era’s assumptions about criminality and morality as much as anything else.
It’s true that many methadone patients are forced to be there thanks to tangles with the legal system. Others, though, are getting treatment voluntarily, simply sick of being sick. A half-century has proven that methadone works, cutting the risk of overdose and death from other opioids by half. And the pandemic proved that methadone patients won’t necessarily run amok if entrusted with their own medicine; during lockdowns, when patients were allowed many more take-home doses, methadone overdose deaths actually fell.
But methadone is a narcotic and, under federal law, it remains a Schedule II drug, alongside beasts like oxycodone, fentanyl and methamphetamine. Healthcare workers outside the clinic system – even board-certified addiction medicine specialists – cannot prescribe methadone to manage opioid addiction.
Also, neighborhood pharmacies cannot fill methadone prescriptions. Unless, perplexingly, the methadone is for chronic pain rather than addiction.
Patients, most of whom use methadone as a key for their health and relative normalcy, wonder how much of that makes any sense.
‘Not reform, but demise’
The world of methadone matters to you, even if you can’t tell an oxycontin pill from an aspirin. You pay for a lot of it.
The federal government, through Medicaid, spent about $29 billion on opioid treatment in 2023, according to the Brookings Institution.
Unfortunately, officials can’t tell taxpayers precisely how much of that pays exclusively for methadone care at methadone clinics. Researchers estimate that about 800,000 people were enrolled at methadone clinics last year, and clinics estimate they spend about $6,550 per patient, so figure around $5 billion a year on methadone. That doesn’t include some money from states and private insurers.
But just a fraction of that money pays for the medication itself, researchers have found. The bulk of methadone billings are for counseling services, testing, record-keeping and regulatory costs. Critics say that’s where clinics make most of their money.
And money, critics add, is why clinic operators have so staunchly opposed methadone reform.
“Pharmacists are very accustomed to working with methadone in the space of pain management, but there’s this complete switch the minute it’s used outside the realm of pain management and in the realm of opioid use disorder,” said Jonathan Watanabe, chair of the clinical pharmacy department at UC San Francisco.
“Then, the level of scrutiny, the draconian measures, make it the most tightly regulated therapeutic drug in the United States.”
Dr. Walter Ling, founding director of UCLA’s Integrated Substance Abuse Programs, has an unusually intimate perspective on the issue. He worked at the Sepulveda Veterans Administration hospital back in 1971, as rattled soldiers returned from Vietnam and the nation’s first methadone programs mobilized to help them.
“What the methadone regulations need is not reform, but demise,” said Ling, who laments the symbiotic relationship between clinics and the government.
“Providers are allowed to run clinics as businesses, which provide justifications for the need to regulate. Just ask what the government regulators would do if they didn’t have the clinics to regulate: They’d be out of jobs.
“Without the regulations, methadone clinics would have to operate as medical practices, and the current providers would be out of business,” Ling added.
“Over the years, methadone regulation reform has been talked about but never carried out. Except for patients, who have little power, no one wants any change.”
The clinics argue that’s nonsense. Methadone is a narcotic. It must be carefully controlled to prevent abuse.
“Treating this disorder effectively is about much more than just giving the medication,” said Mark Parrino, founder and president of the American Association for the Treatment of Opioid Dependence, which represents owners of 950 methadone clinics in the United States and Mexico.
“That, in itself, is not treatment. That’s why the regulations exist. Effective care is medication combined with other clinical services. Keep in mind we’re often treating people with a number of other comorbidities – hepatitis, HIV infection – and holistic care is really what works best.”
In addition to meds, clinics provide the strong social support system that supporters say is vital to sustained recovery. Methadone clinic counselors have been there, done that, and lived to tell about it. Outside doctors just can’t provide the same support.
“I understand the view that we need to do something more to increase access, and we’re doing something more,” Parrino said.
“The system is expanding. We’ve added mobile vans. There are medical clinics associated with OTPs (Opioid Treatment Programs, the official name for methadone clinics). We’re working on partnering with federally qualified health centers and community-based organizations” that provide care to underserved communities.
“There’s a reason we support federal oversight,” Parrino said. “We think those regulations are very well thought through. They serve as protection.”
Parrino’s experience in the methadone system is as long as Ling’s. And, during his career, has been called all the names, from monopolist to cartel defender.
“Cartel, that’s a little bit extreme,” he said. “People say, ‘You’re protecting the financial interests of the industry you represent.’ What I’m doing is protecting the integrity of treatment.”
After death and destruction failed to materialize following a general easing of the methadone rules during the pandemic – when clinics were allowed to use telehealth to track patients, and patients were allowed more take-home doses – the government made those rules permanent in 2024. Clinics agreed it was the right thing to do.
But one bill now in Congress seeks to eliminate those changes entirely, and return the system to full lockdown.
A competing bill seeks to bust it open much further.
As it stands, the greater freedoms can be agonizingly slow to trickle down to methadone patients. Taking doses at home remains an earned privilege, bestowed at the discretion of clinic operators. And beyond the regular visits and oft-despised “observed daily dose,” patients – even those with long-standing sobriety – must participate in counseling sessions that may or may not be helpful, and submit to regular urine testing.
Those urine tests can be particularly degrading. Some states – though not California – require methadone patients to be observed by a clinician as they pee into the cup (to prevent cheating where patients sub in “clean” urine for their own). Sometimes, that observation is done in person, sometimes via camera, according to research from Pew.
And, sometimes, test results can be painfully punitive. Toasting a grandchild’s graduation with a glass of champagne? Indulging in a beer? Take-home rights have been curtailed and dosages reduced in the wake of such breaches of abstinence.
Can you imagine a diabetic being denied insulin after eating chocolate cake?
Treasure maps
There are some 2,100 methadone clinics in America, including more than 150 in California. Many are located in rougher parts of town.
One patient described clinics as “finishing schools for drug junkies” because they’re rarely far from where dealers and users gather. For poison peddlers eager to make money, the clinic addresses can function as a veritable treasure map. They prowl the edges, just out of sight, eager to tempt former opioid users with one more cheap, mind-blowing high.
And so it was for Sherry Lynn James, 77.
James lived in Grass Valley, a picture-postcard-perfect Gold Rush town nestled in the Sierra Nevada Foothills north of Sacramento. She was visiting her son and his wife in Huntington Beach on March 22, 2024, and in festive spirits. She had a long-ago history with heroin, but she’d been clean since 1986, according to her family and police reports.
Addiction is known to run in families. Her son, Lee, was weaning himself off his own opioid addiction.
On that day, James accompanied her son to the Costa Mesa methadone clinic – dubbed by some patients as “the Hilton” for its comparably squeaky-clean environs – to get Lee’s observed daily dose of methadone.
Lee parked the car in an adjacent lot, but James declined to join him inside, deciding instead to wait in the car.
While Lee was inside, getting his methadone, a man appeared in the parking lot, the police report said, where he made contact with James.
You can imagine him leaning in the car window, ticking off his inventory. James maybe trying to ignore him at first, then listening to his pitch.
Something like, “You want some?”
Next: Part 2: “Liberate Methadone!” A drug inspires patients to write a manifesto.