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After years of stigma, the conversation around methadone has long needed change

The way we talk about methadone often does not communicate the treatment offerings and efficacy of Opioid Treatment Programs. It’s time we update public perceptions

By CARF International

Replacing one drug for another at a ‘pill dispensary.’ This is often the perception when someone talks about methadone. But this is a deeply unfortunate attitude built upon long-held misconceptions of what methadone is and what it is used for.

Worse, this type of thinking adds barriers for people needing treatment services, such as feelings of shame when someone seeks treatment, perceived lack of safe treatment choices, and community pushback when a new program is opening.

It is time to update public understanding of methadone treatment and the Opioid Treatment Programs that offer it.

First, what is methadone?

Methadone is one of three FDA-approved prescription medications used in medication-assisted treatment for opioid use disorder (buprenorphine and naltrexone are the other two). Methadone is one of the most widely studied substances in the United States and has been shown to be safe and effective when used as a component of holistic treatment for opioid use disorder.

Methadone typically is administered daily and in front of a medical professional as part of an individualized treatment plan. This practice is designed to minimize the risk of misuse of the medication by the patient (including diversion) or accidental ingestion by others.

Patients eventually may be permitted to take a certain number of methadone doses off site under certain circumstances, but they first must meet eight federally-regulated readiness criteria for take home doses. A clinical team in partnership with the patient determine if and when these criteria are met.

In the United States, the only setting in which methadone can be prescribed to treat opioid use disorder is an Opioid Treatment Program. These programs must be certified by the Center for Substance Abuse Treatment, a division of the Substance Abuse and Mental Health Services Administration (SAMHSA).

What is an Opioid Treatment Program?

Opioid Treatment Program, or OTP, is the modern name for settings previously called Methadone Clinics or Methadone Maintenance Treatment Programs. The name shift reflects an industry and regulatory movement at the turn of the century to improve care quality and outcomes for methadone treatment. It also acknowledges the availability of other FDA-approved medications, as many OTPs offer two or all three of the approved medications: methadone, buprenorphine, and naltrexone.

OTPs offer medication-assisted treatment for opioid use disorder. Today, they are highly interdisciplinary, involving a team of medical professionals that pair use of methadone or other medications with individualized behavioral health services to address substance use, mental health, experienced trauma, and family needs.

In addition, OTPs offer group and individual counseling and many offer family services, peer services, and other recovery services. Often, the services also incorporate relevant community resources, cultural or linguistic preferences, and even integrated primary care.

In acknowledgement of the therapeutic and medical factors involved in treating people with opioid use disorders, in 2001 the Department of Health and Human Services transferred oversight of OTPs to the Center for Substance Abuse Treatment from the Food and Drug Administration (Federal Regulation 42 CFR Part 8). This followed a two-year pilot project that began in 1999.

CSAT now works with the Drug Enforcement Administration, individual states' opioid treatment authorities, and independent accrediting bodies to regulate and oversee OTPs. It also communicates with OTP professionals to help them improve treatment outcomes and meet regulatory criteria.

Outcomes and efficacy of Opioid Treatment Programs

Part of CSAT’s oversight and certification of OTPs includes a requirement that those programs be accredited by a SAMHSA-approved accrediting body, of which CARF is one.

CARF accredits more OTPs than any other accreditor. This gives CARF a unique perspective on the trends in service quality at OTPs. Since 1999 when CARF became involved with the CSAT pilot, we have observed a trend toward improved practices and accountability among OTPs applying for CARF accreditation. We have witnessed a higher level of first-time accreditation decisions, indicating higher levels of standards conformance.

For example, originally about 20 percent of OTPs undergoing accreditation review received a nonaccreditation outcome. That figure now is down to approximately 5 percent. CARF also has observed the evolution of a more conscientious approach to both dosing and monitoring in CARF-accredited OTPs over time since the accreditation requirement began.

SAMHSA had similar findings after it commissioned a study in 2006 to examine the impact of accreditation as an oversight framework for OTPs. The study found the model had a positive overall impact on OTPs and the field. Specifically, it found a positive impact on tracking patient outcomes and increasing patient involvement in determining appropriate dosing levels.

In addition, over the past 20 years, multiple external studies have explored the effectiveness of methadone maintenance treatment for opioid use disorder. A summary of this research is published by the National Institute of Drug Abuse. Some of the most interesting findings show improvement in specific outcome measures, such as criminal activity, suicide, employment status, and HIV infection rates.

Even with the clinical and outcomes data to back it up—and the support of major health agencies like the Centers for Disease Control and Prevention, the National Institute on Drug Abuse, and the World Health Organization—some people remain skeptical about methadone and Opioid Treatment Programs. It is time to change the narrative and rethink unjustified perceptions.

2/5/2019
(Behavioral Health,Opioid Treatment and Recovery)


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Shirley, thank you for your comments and reading the blog! Thank you for your work and commitment in ensuring quality care to persons served!

Posted by: Debbi Witham, Managing Director of Public Policy at 3/1/2019 7:03:35 AM



Hello, Candice, and thank you for taking the time to comment. I serve as CARF's managing director of public policy. We completely agree! This is why CARF standards call for an individualized approach to dosing, a community relations plan, and a person-centered approach to recovery planning. Thank you for your passion in reducing stigma and improving access to care!

Posted by: Debbi Witham, Managing Director of Public Policy at 2/28/2019 12:08:01 PM



As a professional treating individuals with opioid use disorders it is extremely important to recognize personal bias with regards to treatment/ medication options recommended for those diagnosed with OUD. I continue to experience first hand medical and mental health providers perpetuating misinformation about methadone in particular. Patients need accurate information without personal bias when making decisions regarding healthcare needs. Patients are vulnerable for exploitation especially by those they are supposed to trust. Secondly, Opioid Treatment Programs perpetuate stigma, when the treatment environment itself reinforces shame, judgment and misinformation. It's difficult to advocate the value of OTP when the surrounding community experiences the consequences of a mismanaged program.

Posted by: Candice Bender-Dee at 2/28/2019 10:28:30 AM



Excellent review of impact of methadone and alternate treatments in the handling of opiod abuse situations. Great to see the number, and effectiveness of CARF accreditation in service areas.

Posted by: Shirley McBride at 2/24/2019 2:22:21 PM

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