Testimony in Support of Reducing California’s Regulation of Methadone to Improve Access

Testimony from:

Stacey McKenna, Resident Senior Fellow, R Street Institute

In SUPPORT of AB 2115, AN ACT that amends California’s regulation of methadone to more closely align with federal guidelines.

April 9, 2024

Assembly Committee on Business and Professions

Chair Berman and Members of the Committee,

Thank you for considering my testimony. My name is Stacey McKenna, and I study opioid harm reduction for the R Street Institute, a nonprofit, nonpartisan public policy research organization. R Street supports free markets and limited but effective government in a variety of policy areas. We believe that the government should not prevent people from accessing evidence-based tools that help them stay safer and healthier.^[1] Therefore, we support harm reduction, a practical approach that promotes access to risk-mitigating knowledge and resources, even for individuals who engage in potentially harmful behaviors such as substance use. This is why AB HB 2115 is of special interest to us: The bill will bring California’s regulation of methadone closer to harmony with federal guidelines, thereby improving patient access to a gold standard medication for opioid use disorder (OUD).

An estimated 2.7 million to 7.6 million Americans, including more than 200,000 Californians, are living with an OUD.^[2] Furthermore, thanks to the increasingly unpredictable and dangerous illicit drug supply, OUD is more dangerous than ever. In 2023, more than 112,000 Americans died of a drug overdose, almost 13,000 of them in California.^[3] 

Two FDA-approved medications drastically improve the lives of people with OUD: buprenorphine and methadone. By preventing withdrawal symptoms and cravings, they help people feel physically and emotionally well enough to reduce or stop using illicit substances and focus on piecing their lives back together.^[4] Compared to their counterparts in non-medication treatment, patients taking MOUD are up to four times more likely to stay in treatment, are less likely to use illicit substances, and are much less likely to die of a drug overdose.^[5] 

In the face of fentanyl—which leads to a very strong dependence and high opioid tolerance—methadone is increasingly recognized as the preferred medication.^[6] Nonetheless, only about 311,000 Americans take methadone for OUD in a given year.^[7] This is, in large part, the result of decades of overregulation that make this life-saving medication difficult to access and diminishes the associated quality of care.

Methadone access in the United States is currently available only through a system of “opioid treatment programs” (OTPs). Due to long wait lists, limited operating hours and the relative paucity of OTPs in the United States, once a person decides they want to access methadone, they often must wait 48 hours or more to receive it.^[8] For people who are dependent on opioids, that means choosing between debilitating withdrawals or returning to illicit opioids that will keep them at bay but come with a risk of overdose.

Once patients have access to an OTP, strict regulations make continued care challenging, especially for individuals who work and have family obligations or lack personal transportation. Many OTP patients must travel to the clinic up to six days per week to take their methadone under supervision.^[9] Drive times of 10 minutes or more are associated with a 33-percent reduction in likelihood a person will complete treatment; in California, the average drive time to an OTP is more than 11 minutes each way.^[10] Furthermore, OTP patients must submit to regular urine screenings (sometimes observed) to check for medication compliance and other substance use, and engage in mandatory counseling on a set—rather than individualized—schedule.^[11] 

These burdensome requirements prevent many people from starting or staying in treatment.^[12] In addition, they do not clearly represent best practices. Evidence suggests that take-home doses of methadone improve treatment retention and stability.^[13] Drug screening is more effective when it is based on patient-specific factors than based on a government-dictated schedule.^[14] Finally, not only is counseling unnecessary for many patients to benefit from methadone, but mandating it can cause harms.^[15] 

During the COVID-19 pandemic, the federal government relaxed restrictions on methadone access and found that it did not lead to increases in overdose deaths or diversion, as some opponents feared it might.^[16] Furthermore, the approach did not undermine treatment quality; in fact, in some cases it led to improved retention, higher satisfaction and better outcomes.^[17] 

Improving access to methadone is one of the best tools we have in the fight against the relentless overdose crisis. But current California law remains too restrictive. Although the federal government allows for hospitals and clinics to prescribe “bridge” methadone to prevent withdrawals in OUD patients awaiting treatment, current California law remains overly restrictive.^[18] And although the federal government has made many COVID-era methadone rules permanent—allowing for more take-home doses and a more flexible, patient-centered, provider-driven approach to treatment—California lags behind.^[19] By modernizing California law to align more closely with updated federal guidelines, AB 2115 would improve access to a medication that saves lives immediately and reduces demand for illicit opioids in the long-term. Therefore, we strongly urge the Legislature to pass AB 2115.

Thank you for your time.

Best regards,

Stacey McKenna

Stacey McKenna

Resident Senior Fellow

Integrated Harm Reduction

R Street Institute

970-443-8063

[email protected]