Today, seatbelt use in the United States tops 90 percent. In 1983, only 14 percent of Americans wore seatbelts, due in part to the “persistent myth” that they could trap the user in a vehicle fire or submersion. In reality, fire and water factor into only 0.5 percent of all crashes, while seatbelts save nearly 15,000 lives a year and reduce the risk of fatal injury by 45 percent. This is a classic example of individuals rejecting a lifesaving tool because they place too much weight on unlikely risks and not enough on widespread, proven benefits.

We see the same phenomenon in the debate over who should have access to methadone, a medication for opioid use disorder. Here, the relatively small risk of people misusing prescribed methadone gets outsized weight in policy discussions, creating a status quo in which many people cannot access this lifesaving medication.

Taking methadone daily can help people with opioid use disorder (OUD) stay away from the dangerous illicit drug market and get back to living healthy and rewarding lives. It is also more effective for long-term recovery than abstinence-only approaches. It quadruples a person’s likelihood of continuing drug treatment and cuts overdose risk by up to 60 percent. But extremely strict government regulations prevent the majority of people with OUD from accessing methadone.

Federal and state regulations present enormous barriers to treatment, requiring methadone patients to visit a clinic called an opioid treatment program (OTP) up to six days a week to take their dose under strict supervision. A quarter of Americans live in a county with no OTP, and many patients face short clinic hours, long commutes, and onerous rules that can disrupt their care. Between 400,000 and 600,000 patients utilize OTPs, while between 3 million and 7.6 million people have OUD. While not everyone with OUD wants to or should take methadone, the access gap is huge—leaving many people at heightened risk of overdose and death.

Policy conversations about expanding methadone access hinge on two competing arguments about relative risk. One proposal would allow addiction specialist physicians to prescribe methadone for OUD outside of OTPs. (This is the premise of the Modernizing Opioid Treatment Access Act.) Opponents say access to methadone beyond OTPs is too dangerous because patients might sell, share, or misuse doses (known as “diversion”), which could result in overdose from methadone itself.

As with seatbelts, the question is whether wider access to methadone would increase or decrease the total number of overdose deaths.

Let’s start with the numbers. In 2023, 80,719 people in the United States died from opioid overdose, primarily from fentanyl, a drug for which methadone can be particularly effective. Only 4 percent of those opioid overdose deaths involved methadone. It’s unclear how many of these deaths involved other opioids and whether the methadone involved was diverted or prescribed.

But what if increasing methadone access causes a spike in methadone-involved overdoses? Data does not support that concern, especially in comparison to the potential number of lives saved by expanding methadone access. In fact, evidence suggests that reducing methadone misuse versus increasing access to the medication does not represent a binary choice. COVID-19 gave us a real-world experiment in that changes to federal regulations allowed some patients to receive days or weeks of “take-home” methadone doses from their OTP. Those take-homes have not been associated with any increase in methadone overdose deaths. What’s more, when methadone is shared or sold, it is often because people struggle to access the treatment they want and need. The primary form of methadone diversion is when one person gifts their medication to another. This often happens when someone misses a dose from their OTP (often due to access barriers), leading to extremely painful withdrawal. Without gifted methadone, they might return to the illicit drug market to ease their symptoms, putting them at greater risk of overdose. In other words, it’s possible that some diversion of methadone, while illegal, saves lives.

Although misuse is a consideration with any medication, the relatively rare occurrence of methadone overdose can’t compare to the potentially huge lifesaving impacts of expanded access to the medication. People who identify methadone diversion as the more risky problem reject this lifesaving tool because they place too much weight on relatively rare risks—just like those who opposed seatbelt use. forms of risk misperception can converge, using opposition to syringe services programs as an example.

We’re Chelsea Boyd (cboyd@rstreet.org) and Jessica Shortall (jshortall@rstreet.org), the lead authors of this Safer Solutions newsletter. Please reach out to us if you have comments or suggestions for future topics we can cover.

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