Biden drug czar: ‘All options are on the table’ for expanding methadone access

WASHINGTON — The federal government is aggressively exploring ways to increase access to methadone, a key Biden administration official told STAT.

Methadone, a common addiction medication, is the most effective drug currently used to treat opioid use disorder. But it is only available in the context of specialized methadone clinics, making it nearly impossible for many patients to obtain.


As opioid overdose deaths have skyrocketed in recent years, a growing number of doctors, patient advocates, and public health experts have pushed to allow patients to receive methadone the same way they receive any other medication: at a doctor’s office or pharmacy.

The Biden administration appears to be moving in a similar direction. When it comes to expanding methadone access, “all options are on the table right now,” Rahul Gupta, the director of the White House Office of National Drug Control Policy, told STAT in an interview.

Gupta said the federal government has convened conversations between two key agencies with jurisdiction over methadone: the Department of Health and Human Services and the Drug Enforcement Administration.


Gupta touted the administration’s existing policies favoring expanded methadone access, like allowing longer supplies of take-home doses and legalizing “methadone vans,” or mobile centers where patients can receive the medication.

He also floated an option that the federal government has not formally proposed: Allowing patients to pick up methadone at a retail pharmacy even when it’s prescribed at a specialized clinic known as an opioid treatment program, or OTP.

“We’re looking into whether people could be prescribed at an OTP but be dispensed at a pharmacy,” he said. “Methadone vans [are] another piece, take-home methadone is another piece. … We’re working within the interagency process right now, we’re bringing in HHS and DEA together to figure out what can we do to expand access.”

Gupta’s comments came during a wide-ranging interview with STAT last week at ONDCP’s headquarters in Washington.

His stance represents the latest sign of a remarkable shift in national attitudes surrounding methadone. The drug remains controversial in some circles, because methadone is itself an opioid used to treat pain and, if prescribed improperly, can contribute to sedation or even overdose.

As recently as the 1990s, national political figures like Sen. John McCain (R-Ariz.) and Rudy Giuliani, then the mayor of New York City, were forcefully advocating to add intense restrictions on methadone treatment — or eliminate it altogether.

Recently, however, prevailing opinion has shifted. Sens. Ed Markey (D-Mass.) and Rand Paul (R-Ky.) have introduced legislation that would let board-certified doctors prescribe methadone directly to patients, who could then pick up the medication at a pharmacy. Numerous advocacy groups, including the American Society of Addiction Medicine, have announced their support.

The debate over methadone access is one of several policy disputes in Washington regarding access to addiction medications. Beyond voicing his support for increased methadone access, Gupta applauded a separate decision from the DEA to delay a proposal that would have added new restrictions on buprenorphine, another medication often used to treat opioid use disorder.

The proposal would have required all patients who receive buprenorphine via telemedicine to receive an in-person examination within 30 days to receive a refill.

After widespread outcry, however, the DEA announced that it was delaying its decision six months, leaving in place Covid-era emergency rules that allowed providers to issue buprenorphine prescriptions via telemedicine.

“There should not be an extraordinary burden on people suffering from the disease of addiction to be forced quickly into treatment or to be brought in [in person],” he said. “The extension by six months, and 38,000 comments, is proof that we’re not in a rush to force things upon people, especially when life and death is the issue.”

Still, Gupta argued that people with addiction often have other untreated health conditions, both physical and mental. Requiring an in-person visit “at some point,” he said, gives health providers a chance to evaluate patients’ other needs beyond just addiction medication, such as routine vaccinations, cancer screenings or diabetes care.

“I’ve been on the other end of this, where I’ve had patients die of heart attacks and cancer because we were all treating their HIV and we ignored everything else,” he said. “And then we recognized, as people are surviving longer, they’re also having other conditions and their other health is being ignored. So I do think that’s a good standard of care, but we have to be cognizant that when people are going through addiction, they need the help of treatment for addiction first and foremost.”

Gupta also expressed optimism with regard to harm reduction — the public health philosophy that aims to help people avoid the worst consequence of drug use, like disease transmission and death, while recognizing that demanding instant abstinence is often impractical.

Several state governments have recently stymied proposals to expand supervised consumption services, the controversial practice of providing medical supervision to people who use drugs.

Despite harm-reduction defeats in states like California, Pennsylvania, and Colorado, Gupta said he thinks support for the philosophy, generally speaking, is still growing.

“I remember very clearly the time when naloxone was controversial, just about 10 years ago,” he said. “People really thought that this was going to enable people to experiment with drugs. … That’s just not panned out. The evidence has not suggested that. And Republicans and Democrats have understood the evidence, and we’ve seen more and more schools putting naloxone in schools.”

He also cited the increased popularity of test strips used to detect the presence of fentanyl in illicit drugs, which were illegal in most states until recently thanks to decades-old drug paraphernalia laws.

Most states have now passed legislation to legalize test strips, however, including several that are traditionally conservative, like Texas, Tennessee, and Kansas.

“It pleases me that more and more states are now accepting testing of drug supply,” Gupta said. “Because they recognize this is about saving lives, not about passing judgment.”

STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.

Source: STAT