Addiction Doc Urges Lawmakers to Rethink Methadone Prescribing Restrictions

Could loosening restrictions around methadone prescribing improve treatment for patients with substance use disorder? Are survivors of traumatic brain injury getting the mental health care they need? Lawmakers discussed these issues during a hearing of the Senate Health, Education, Labor and Pensions (HELP) Subcommittee on Primary Care and Retirement Security on Wednesday.

Currently, methadone and buprenorphine are regulated under the Controlled Substances Act when used to treat pain, per a report from the Government Accountability Office, which notes that "methadone may generally only be administered or dispensed within an opioid treatment program (OTP), as prescriptions for methadone cannot be issued when used for opioid addiction treatment."

This limits an individual physician's ability to treat a patient with an opioid use disorder, said Stephen Taylor, MD, MPH, president-elect of the American Society of Addiction Medicine (ASAM), during the hearing.

"I, as an addiction specialist physician, board-certified in addiction medicine, and addiction psychiatry, would be committing a crime to prescribe a patient methadone in my office who needs methadone for treatment and stabilization of their opioid use disorder," he said.

Taylor shared the story of his patient, a college student, who became addicted to prescription opioids, and then progressed to snorting and injecting heroin.

Taylor started this patient on buprenorphine only to have him relapse. Because Taylor is not allowed to prescribe methadone, he had to refer the patient to another physician at a methadone clinic. "It was a tortuous process taking care of that young man because of the fact that he wasn't able to just have me work with him on a consistent basis, prescribing whatever it was that he needed," he noted.

The patient later transitioned back to buprenorphine under Taylor's care. He told the subcommittee that the patient's father wrote him a letter explaining that the same young man had recently graduated from law school. While that story had a happy ending, Taylor warned that "not everyone has the kind of outcome he had," and that restrictions on methadone prescriptions put an additional burden on that patient.

The prevalence of fentanyl, and its highly potent analogues, makes changes to methadone access even more urgent, he added.

Sen. Lisa Murkowski (R-Alaska) stressed the need for greater awareness on fentanyl's potency. "I think people need to understand that we're dealing with something at a higher, more intense level ... This is not something that you can engage in lightly. You will be poisoned and you will die," she said.

Taylor said that ASAM supports the bipartisan Modernizing Opioid Treatment Access Act as part of the push "to make it possible for us [physicians outside an OTP] to be able to prescribe methadone and have people get it from pharmacies because, for many patients, buprenorphine isn't the medicine that they're going to need for that transition. It's methadone."

"We need to have every tool available in the toolbox to be able to take care of people, particularly because of this extremely complicated, potent drug to which so many people are addicted," he said.

On the issue of care for traumatic brain injuries, Murkowski highlighted a front-page Anchorage Daily News article reporting that Alaska has the highest rate of traumatic brain injury deaths in the country. One in every four deaths among those under age 30 in her state is related to these injuries, she noted, although she acknowledged that many Alaskans engage in activities with a higher risk of injury -- snowmobile riding, four-wheeling, rock climbing.

She pointed out that roughly half of people with traumatic brain injuries report symptoms of depression, and that suicide attempts are also more common. "We recognize that this is a pretty tight correlation here ... if you've had a traumatic brain injury, is there follow-up then to help on the mental health side?"

Warren Ng, MD, president of the American Academy of Child and Adolescent Psychiatry, said that this issue illustrates why mental and behavioral health care need to be integrated within medical and other specialty settings.

"It's really important. It allows us to have this conversation but also when there are issues related to suicide ... we're able to address it directly and we're not having to refer to someone else," he said. "When you're talking within your trusted medical care team, and you're able to provide that level of identification, screening, assessment, and referral to treatment, I think that that's really key."

Access to Pediatric Mental Health Care

Murkowski also raised concerns about the lack of pediatric mental health providers in her state.

Along with Sen. Tina Smith (D-Minn.), Murkowski noted that she introduced a bill, the Mental Health Professionals Workforce Shortage Loan Repayment Act that would repay up to $250,000 in student loans for mental health professionals who agree to work in mental health workforce shortage areas.

But, she acknowledged, "I don't know that we can do enough fast enough and particularly when we're looking at suicide statistics for young people who are struggling and are just simply not able to get the mental health treatment that they need."

In Alaska, when services aren't available to young people, they are directed to care "outside," Murkowski said. "And when I say outside, it's not outside of a building, it's outside the state of Alaska."

Young people are having to fly to Seattle or Utah, where they're isolated from their family and their support systems. "This is not a tenable situation," she added.

Murkowski asked Ng what other supports, in terms of wrap-around services or other interventions, can happen at the community level while people are waiting to connect with a medical professional.

Workforce shortage issues are key in these scenarios, he said, but it's also important to be able to finance and support providers within communities and medical settings.

Earlier in the hearing, Ng also noted that poor reimbursement disincentivizes the recruitment of medical students into psychiatry. Pediatric mental health access programs that provide consultations to pediatric providers, particularly in "urgent settings" and telepsychiatry, can be leveraged to bridge gaps in care, he added.

"I totally agree that there isn't a quick fix to this because this problem existed well before, but at the same time," he said. "Loan repayment as well as trying to finance integrated behavioral health interventions, as well as leveraging telepsychiatry and continuing to fund those innovations that have been helpful during the pandemic, would be key."

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