Testimony in Support of a Remote Methadone Dosing Pilot Program in New Jersey
Testimony from:
Stacey McKenna, Resident Senior Fellow, R Street Institute
In SUPPORT of Senate Bill 1324, AN ACT that Establishes a “Remote Methadone Dosing Pilot Program.”
May 9, 2024
Senate Health, Human Services and Senior Citizens Committee
Chairman Vitale and members of the committee,
Thank you for considering my testimony. My name is Stacey McKenna and I am a senior fellow in integrated harm reduction for the R Street Institute, a nonprofit, nonpartisan public policy research organization that supports free markets and limited but effective government in a variety of policy areas, including those related to opioid use and opioid use disorder (OUD). We believe that governmental policy should not stand in the way of access to evidence-based tools that help people stay as safe and healthy as possible, even if they have previously or continue to engage in risky behavior such as using illicit substances.[1] This is why we are interested in Senate Bill 1324.
SB 1324 establishes a pilot program at a handful of New Jersey opioid treatment programs (OTPs) for remote supervision of methadone dosing. The proposal will improve patients’ access to an evidence-based medication for opioid use disorder (MOUD).
In 2023, more than 112,000 Americans died of a drug overdose, approximately 2,800 of them in New Jersey.[2] Because people living with an OUD are among those at highest risk of an overdose, the gold standard MOUDs methadone and buprenorphine represent one of the most effective ways to prevent these deaths. By preventing withdrawal symptoms and cravings, these medications help people feel physically and emotionally well enough to reduce or stop using illicit substances and focus on reclaiming their lives.[3] Patients taking MOUDs are up to four times more likely to stay in treatment, are less likely to use illicit substances, and are up to 80 percent less likely to die of a drug overdose compared to their counterparts who are engaged in non-medication treatment programs.[4] Because the current market is dominated by highly potent synthetic opioids that can cause very strong dependence and high opioid tolerance, methadone is emerging as the preferred medication.[5]
Nonetheless, of the millions of Americans who report living with an OUD disorder in the past year (at least 69,000 of whom are in New Jersey), only about 311,000 take methadone.[6] This is, in large part, because federal and state governments have long subjected methadone to uniquely strict regulations that create considerable access barriers and undermine patient experience and quality of care.
Methadone access in the United States is currently available only through a system of “opioid treatment programs” (OTPs), to which patients must travel up to six days per week to take their methadone under direct supervision.[7]
These restrictions in effect act as a barrier to helping individuals turn their lives around and end dependence on illicit opioids. Considering the average person in the United States lives about 20 minutes from the closest OTP, and people living in rural areas may have to travel much further, in-person dosing requirements present a major barrier to recovery. In fact, drive times of just 10 minutes are associated with a 33 percent reduction in likelihood a person will complete treatment.[8]
These requirements interfere with people’s work and personal obligations, and travel may pose a considerable cost burden, factors that prevent many individuals from starting or staying in treatment.[9] Furthermore, such strict requirements do not represent current best practices.
Although some critics of take-home methadone claim that supervised dosing at OTPs is key for guaranteeing adherence and preventing diversion, research shows that many methadone patients do not need supervised dosing to be successful in their recovery.[10] In particular, evidence suggests that patients who have access to appropriate take-home doses of methadone are often more stable and more likely to stay in treatment.[11] Additionally, COVID-era increases in access to methadone provide evidence that take-homes did not lead to an increase in diversion or overdoses.[12]
Nonetheless, as with all medical care, methadone treatment for OUD works best when it is individualized to patient needs, and some patients may benefit from supervised dosing. Fortunately, there is a small but growing body of evidence to support the role of remote options that provide the structure of supervised dosing while allowing patients the flexibility of taking their methadone at home instead of at the OTP.
Pilot studies of video observed methadone consumption have shown that patients were able to remain adherent and had a low risk of diversion, even when allotted greater-than-usual take-homes.[13] Furthermore, patients were more likely to stay in treatment, and reported improvements in their ability to meet obligations as well as saving on transportation-related costs.[14]
Improving access to methadone is one of the best tools we have in the fight against the relentless overdose crisis, and remote methadone dosing has the potential to help in that effort. By establishing a pilot program for remote dosing via OTPs, SB 1324 is a step toward extending the benefits of take-home methadone to patients who may otherwise struggle without the structure of supervision. As such, it is an important move that would ensure more patient-centered, evidence-based care for patients with OUD. Therefore, we strongly urge the passage of SB 1324.
Thank you for your time,
Stacey McKenna
Resident Senior Fellow
Integrated Harm Reduction
R Street Institute
970-443-8063
[1] Mazen Saleh and Chelsea Boyd, “R Street Integrated Harm Reduction Principles and Priorities,” R Street Explainer, Dec. 14, 2021. https://www.rstreet.org/research/r-street-integrated-harm-reduction-principles-and-priorities.
[2] Brian Mann et al, “In 2023 fentanyl overdoses ravaged the U.S. and fueled a new culture war fight,” NPR, Dec. 28, 2023. https://www.npr.org/2023/12/28/1220881380/overdose-fentanyl-drugs-addiction#:~:text=In 2023 the overdose death,for Disease Control and Prevention.&text=Biden administration officials say they have “flattened” the upward curve; “Provisional Drug Overdose Death Counts,” National Center for Health Statistics, Centers for Disease Control and Prevention, March 13, 2024. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
[3] “How effective are medications to treat opioid use disorder?” Medications to Treat Opioid Use Disorder Research Report, National Institute on Drug Abuse, December 2021. https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/efficacy-medications-opioid-use-disorder.
[4] Ibid.
[5] Lev Facher, “Fentanyl isn’t just causing overdoses. It’s making it harder to start addiction treatment,” STAT, Nov. 16, 2022. https://www.statnews.com/2022/11/16/fentanyl-isnt-just-causing-overdoses-its-making-it-harder-to-start-addiction-treatment.
[6] National Survey of Substance Abuse Treatment Services (N-SSATS): 2020, Substance Abuse and Mental Health Services Administration, Department of Health and Human Services, June 2021. https://www.samhsa.gov/data/sites/default/files/reports/rpt35313/2020_NSSATS_FINAL.pdf; “Opioid Use Disorder,” Centers for Disease Control and Prevention, Aug. 30, 2022. https://www.cdc.gov/dotw/opioid-use-disorder/index.html#:~:text=About 2.7 million people in the United States report suffering from OUD; Noa Krawczyk et al., “Has the treatment gap for opioid use disorder narrowed in the U.S.?: A yearly assessment from 2010 to 2019,” International Journal of Drug Policy 110 (December 2022). https://www.sciencedirect.com/science/article/pii/S0955395922002031; “Individuals Reporting Past Year Opioid Use Disorder,” Kaiser Family Foundation. https://www.kff.org/other/state-indicator/past-year-opioid-use-disorder/?currentTimeframe=0&sortModel={“colId”:”Location”,”sort”:”asc”}.
[7] David Frank et al., “It’s Like ‘Liquid Handcuffs’: The Effects of Take-Home Dosing Policies on Methadone Maintenance Treatment (MMT) Patients’ Lives,” Harm Reduction Journal, 18: 88, (2021). https://doi.org/10.1186/s12954-021-00535-y.
[8] Abdullah Alibrahim et al., “Disparities in expected driving time to opioid treatment and treatment completion: findings from an exploratory study,” BMC Health Services Research, 22: 478, (2022). https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-07886-7; Robert A. Kleinman, “Comparison of Driving Times to Opioid Treatment Programs and Pharmacies in the US,” JAMA Psychiatry, 77: 11, (July 15, 2020). Pp. 1163-1171. https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2768026.
[9] Olivia Randall-Kosich et al. “Comparing Reasons for Starting and Stopping Methadone, Buprenorphine, and Naltrexone Treatment Among a Sample of White Individuals With Opioid Use Disorder.” Journal of Addiction Medicine, 14: 4, (July/August 2020), pp. e44-e52. https://journals.lww.com/journaladdictionmedicine/Abstract/2020/08000/Comparing_Reasons_for_Starting_and_Stopping.26.aspx.
[10] Jessie Hellmann, “Methadone access becomes flashpoint in fight over opioid crisis,” Roll Call, Nov. 2, 2023. https://rollcall.com/2023/11/02/methadone-access-becomes-flashpoint-in-fight-over-opioid-crisis; Rosella Saulle et al, “Supervised dosing with a long-acting opioid medication in the management of opioid dependence,” Cochrane Database of Systematic Reviews, (April 27, 2017). https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011983.pub2/full.
[11] Frank et al., https://doi.org/10.1186/s12954-021-00535-y.
[12] Stacey McKenna, “Improving Access to Medications for Opioid Use Disorder: Lessons from the COVID-19 Pandemic,” R Street Policy Study No. 285, May 9, 2023. https://www.rstreet.org/research/improving-access-to-medications-for-opioid-use-disorder-lessons-from-the-covid-19-pandemic.
[13] Kevin A. Hallgren et al., “Acceptability, feasibility, and outcomes of a clinical pilot program for video observation of methadone take-home dosing during the COVID-19 pandemic,” JSAT, (Oct. 4, 2022). https://www.jsatjournal.com/article/S0740-5472(22)00178-7/fulltext.
[14] James B. Darnton et al., “’Sign Me Up’: a qualitative study of video observed therapy (VOT) for patients receiving expedited methadone take-homes during the COVID-19 pandemic,” Addiction Science & Clinical Practice, 18: 21, (March 29, 2023). https://ascpjournal.biomedcentral.com/articles/10.1186/s13722-023-00372-3.