This is the second installment in a four-part series.
Drug dealers know where to prowl. They often troll the shadows of America’s methadone clinics, tempting patients aiming to chase sobriety with one more mind-blowing high.
Two years ago, Sherry Lynn James was in such a space – the parking lot of a methadone clinic in Costa Mesa. Once, James herself was addicted to opioids, but she’d kicked that habit decades ago. On this day, she was riding shotgun to support her son, Lee, who was there for his “observed daily dose” of methadone.
She was in a festive mood when a dealer apparently approached the car.
We have no idea exactly what transpired after that. Perhaps she ignored him at first, or hesitated. Maybe she even told him to get lost.
But somehow, in the end, her answer was something different:
Why not?
The battle
When the pandemic hit, the festering rebellion against America’s decades-old methadone system exploded with a singular fury.
The first half of 2020 was an insane time for everyone: lockdowns, empty shelves, toilet paper hoarding, confusion. But the terror carried an extra-sharp edge for people who needed methadone and had to visit methadone clinics in order to keep their sobriety intact and their lives in working order.
Unlike other first-world nations, the U.S. kept methadone under perplexingly tight control. It’s considered a Schedule II drug, same as fentanyl, under federal law. That means it’s available only at federally sanctioned (and overwhelmingly for-profit) clinics. And that, in turn, means that patients had to show up in person as often as six days a week for “observed daily dosing” (to ensure they did not abuse the medication, or “divert” it to the black market).
In the best of times, many hated that protocol, feeling irrevocably, and resentfully, bound to the clinics by what some derisively dubbed as “liquid handcuffs.”
But after the national COVID-19 emergency was declared, panic ensued: Would the nation’s 400,000-or-so methadone patients be cut off from a lifesaving treatment? Would they defy lockdowns? Would they have to turn to the black market to stave off agonizing withdrawal?
All were terrifying prospects.
The clinic system was, in the eyes of many patients, already beyond infuriating. They called it degrading; racist, tyrannical. What sense did it make to say that drugs that often spark addiction — oxycodone, oxycontin, etc. — could be prescribed in a doctor’s office and picked up at a corner drug store, while a drug that combats addiction could only be prescribed and dispensed by a federally sanctioned clinic?
And the “observed daily dose” bit. That, patients said, was infantilizing; to not be trusted to administer your own medicine; to be watched as you swallow. Some patients, at some clinics, might earn take-home doses after stretches of exemplary behavior (including regular attendance at clinic counseling sessions, exhibiting no serious behavioral problems or criminal activity, producing clean urine tests, etc.). But that was at the clinic’s discretion, and very difficult for some to attain. Break abstinence with, say, a glass of wine, and you could lose your methadone take-home privileges and have to start “earning” them all over again.
The underlying assumptions were clear: Methadone maintenance patients could not, should not, be trusted. They were junkies, after all. Criminals.
And as the pandemic dragged on, a half-century’s worth of fury boiled over. Patients joined forces to compose a document known as the “Methadone Manifesto,” in which they demanded nothing less than the destruction of the clinic system.
“We are traumatized and mistreated as we try and access treatment because many people believe we are simply substituting one drug for another,” the Urban Survivors Union, which describes itself as “the American national drug users union,” declared in the “Manifesto.”
“We are watching our loved ones die and our community decimated. Our trauma demands that this collaborative living document detail the culture of cruelty that continues to shame, stigmatize and kill.”
Methadone saves lives, reducing the risk of overdose and HIV infection, they wrote. Yet even though more than 1.6 million people met the criteria for methadone treatment in the U.S., less than a quarter of them actually got it. And that, they charged, was the deadly fallout from America’s punitive, tightly controlled clinic system.
“While the rest of the world responds to the opioid crisis with safe supply options and evidence-based treatment, here in the US we have doubled down on drug war policy and coercive, abstinence-based treatment options, many of which increase our risk of death,” the “Manifesto” said.
Then came the real fighting words, rejecting a half-century of American drug policy: “Our goal requires the elimination of the clinic system.”
And it added a war cry:
“Liberate methadone!”
Unplanned experiment
This matters to you, even if you can’t tell an OxyContin pill from an aspirin, because you pay for a lot of it.
The federal government spent about $29 billion on opioid treatment in 2023, according to the Brookings Institution. Some $5 billion of that was poured into the 2,100-clinic methadone system, which is known federally as “Opioid Treatment Programs.”
The pandemic led the federal government to do the heretofore unthinkable: Methadone clinics would be allowed to let “stable” methadone patients receive up to a 28-day supply to take home, unobserved. “Less stable” patients could receive up to a 14-day supply.
Stability? That would be judged by the clinics themselves.
Some observers predicted catastrophe. Waves of methadone overdoses, mounting deaths, a flood of supply into methadone’s black market, where users beyond the clinic system would consume large doses to get high.
And so America found itself involved in a huge, unplanned drug-treatment experiment. Who was right? The patients who insisted they could be trusted with their own medication? Or the skeptics who predicted carnage and death?
Data from the California Department of Public Health shows that:
• Back in 2012, long before liberalized take-home policies, 339 Californians died of methadone overdoses. Same in 2013.
• In 2020, after more patients were allowed to take methadone home, the death toll fell to 259. It rose slightly in 2021, to 264, but still remained below the earlier totals.
• In 2024, after federal regulators made the looser take-home policies permanent, methadone deaths in California plunged even further, to 185.
That’s just 2% of the 9,018 overdose deaths statewide that year. It was the same story nationally, data from the U.S. Centers for Disease Control found.
“Evidence from numerous studies has shown that increases in take-home methadone doses … have not been associated with higher overdose rates, worse treatment outcomes, increased health care utilization, lower adherence to treatment, increased use of illicit opioids or significant diversion of doses among patients on methadone maintenance therapy,” researchers reported in 2023.
One study actually found that even as take-home doses went up — nearly tripling in the span of a few years — methadone-related visits to emergency rooms dropped significantly.
“(P)atients had predominantly positive views of policy changes resulting in increased take-home doses, and identified themes of reduced travel time permitting increased recreation and employment, reduced exposures to triggers or individuals less stable in recovery, and feeling trusted with increased responsibility,” the study said.
Folks from the Urban Survivors Union, the group representing patients, felt both vindicated and furious. Even though data showed that liberalized take-home rules could work, some clinics resisted fully embracing them, it charged.
“(W)e must not allow fears of overmedication and diversion to outweigh the health risks caused by patients … being driven to an adulterated illicit drug supply,” the Union said.
Board-certified addiction medicine doctors — a group of treatment specialists that, under federal law, remain frozen out of the methadone clinic system and cannot prescribe methadone for addiction treatment — shared that outrage. What sense did it make that they were forbidden from prescribing one of the best tools in the fight?
Cries of “Free the methadone!” grew louder. It seemed that America’s restrictive, paranoid methadone policy was wrong.
‘Reduce stigma … save lives’
An unlikely political duo — Sen. Ed Markey, D-Mass., and Sen. Rand Paul, R-Ky., a doctor — were listening.
Their bipartisan answer was the Opioid Treatment Access Act of 2022, which, according to their bill announcement, was intended to “improve access to life-saving methadone treatment for opioid-use disorder.”
The legislation “would revise outdated regulations on methadone treatment … by reducing the time in treatment required for patients to receive take-home doses of medication and allowing pharmacies to dispense methadone for (opioid use disorder) treatment for the first time,” they said.
The senators argued that more permissive take-home policies, and new rules to let pharmacies sell prescribed methadone, would “make it easier for patients who work, have kids, or live far from opioid treatment programs, to adhere to treatment regimens and stay in recovery.”
In 2023, the Markey/Paul bill morphed into the Modernizing Opioid Treatment Access Act. Not only would pharmacies be allowed to dispense methadone for maintenance, but the new rules also would finally allow board-certified addiction medicine physicians to prescribe it.
“As a physician, I know the value of the doctor-patient relationship,” Paul, an ophthalmologist not without his own controversies, said at the time. “This bipartisan legislation will return treatment decisions to healthcare providers, who know their patients best. Doing so will be another important step toward combating the opioid epidemic that has caused so much harm in Kentucky and our nation.”
Change was long overdue, the lawmakers argued. In both 2022 and 2023, overdose deaths in the United States, from all types of drugs, ran at about 110,000 people a year.
“Parents are losing their children. Children are losing their parents,” Markey said. “Yet, we are still making recovery harder, with outdated rules that burden the very people we need to be providing care for.
“If we want to beat these crises, we have to meet people where they are at with the resources they need,” he added. “The Modernizing Opioid Treatment Access Act will reduce stigma and save lives.”
For many methadone patients, justice seemed within reach. The effective elimination of the hated clinic system finally seemed at hand.
Then, methadone clinics began to punch back.
“The Modernizing Opioid Treatment Access Act is dangerous,” wrote officials with the American Association for the Treatment of Opioid Dependence, a group that represents more than 1,400 clinics, or roughly two-thirds of all U.S. clinics.
“It proposes to eliminate laws that create a safe framework for the use of methadone in treating Opioid Use Disorder. (The bill) would allow board-certified physicians to prescribe methadone … outside of the (clinic) setting with no safeguards or oversight. There is significant evidence over the past 20 years that demonstrates that such practices result in increased diversion, overdose and death.
“Methadone is a very effective medication when used properly. When used improperly, methadone can be lethal.”
Mark Parrino, founder and president of that association, said people were taking the wrong lessons from the pandemic-era plunge in methadone overdose deaths, and using that data as justification for radical change is a bad idea.
The real reason there were so many methadone overdose deaths in the early 2000s? That was because doctors — non-clinic doctors — were prescribing methadone for patients complaining of pain, not drug addiction. And that was happening outside the existing clinic system, outside of its careful oversight.
And the real reason methadone overdose deaths declined? That was because the government tightened the rules. Doctors weren’t writing nearly as many methadone pain prescriptions. The clinics again became the main gatekeepers.
Soon, a trade group representing the clinics launched a campaign to defeat methadone liberalization. They called it “Program, not a Pill.”
Next: Reform? Clinic operators hire Danny Trejo to push “Program, Not a Pill.”