LAS VEGAS — Mark Parrino, the longtime leader of the U.S. methadone clinic industry, kicked off his organization’s conference here last week with a simple message: Allowing addiction doctors to prescribe the medication directly to their patients is “not a good idea.”
It was a revealing warning both in timing and tone. At no moment since Parrino founded the American Association for the Treatment of Opioid Dependence, a national advocacy group representing methadone clinics, has his industry faced such pressure to radically expand access to the medication. But amid record opioid overdose deaths, the clinics are facing calls for reform from major medical groups, politicians, and patient advocates, many of whom perceive the clinics as restrictive, punitive, or unwilling to provide patient-centered care.
One legislative proposal in particular stood out as a theme throughout the conference: A bill from Sen. Ed Markey (D-Mass.), with bipartisan backing in the House and Senate, that would wrest methadone from the strict control of specialized clinics and allow any board-certified addiction doctor or addiction psychiatrist to prescribe the medication directly to patients.
“We oppose this legislation,” Parrino said during his remarks at the conference’s opening session. “We’ve taken criticism for it. We think this is the wrong way to go.”
The gathering of several thousand methadone clinic leaders and staff, held roughly every 18 months, touched on a wide range of issues, including the highly toxic U.S. drug supply, increased use of methamphetamine and cocaine alongside opioids, and a rise in problem gambling. But even outside Parrino’s opening salvo regarding Markey’s bill, much of the conference centered explicitly on the ramifications of that proposal, or on methadone clinics’ shaky political footing more broadly.
The conference’s title — “So much more than medication” — mirrored the rhetoric of “Program, Not a Pill,” an ongoing lobbying campaign funded by AATOD and several for-profit methadone clinic chains. The advocacy effort is designed explicitly to fight efforts to make methadone available outside the context of specialized methadone clinics, which are also known as opioid treatment programs or OTPs.
Despite the emphasis on perceived threats from Capitol Hill, numerous presenters and attendees acknowledged the shifting landscape and welcomed recent efforts from clinics to better meet patients’ needs. One speaker framed the entire gathering as “an opportunity to rethink care.” But just as often, sessions focused on defending the status quo — at least when it comes to whether methadone should be prescribed by doctors and dispensed by pharmacies, like almost all medications.
One, titled “MAT Advocacy in an Evolving Political Landscape,” focused extensively on the legislation, which clinic representatives have warned would cause an increase in methadone-involved overdoses. Methadone’s effectiveness stems in large part from the fact that it is an opioid itself — and when administered properly, can help heroin or fentanyl users stop illicit drug use, remain clear-headed, and avoid the painful symptoms of withdrawal.
Methadone is seen as a critical component of the U.S. response to the addiction crisis, especially as opioid deaths have eclipsed 80,000 annually. People taking methadone are 59% less likely to die of an opioid overdose than those not using medication. For all the lives it saves, however, methadone also contributes to more than 3,000 overdose deaths per year, though it’s unclear what share of those also involve drugs like fentanyl, and which deaths stem from methadone used as an addiction treatment as opposed to methadone prescribed for pain.
Jason Kletter, the president of BayMark Health Services, a large for-profit clinic chain and the chair of AATOD’s legislative committee, lamented during the session that politicians and medical groups like the American Society of Addiction Medicine have increasingly blamed clinics’ historically restrictive culture for the country’s lackluster drug treatment outcomes.
“Sadly, instead of those folks acknowledging the great work that OTPs have done for 50 years and the hundreds of thousands or millions of patients who have benefited from OTPS … to this day, we instead hear lots of criticism, which is sad and unfortunate,” he said.
Ed Long, a contract lobbyist representing AATOD in Washington, also spoke at the session, accusing politicians of seeking a “quick fix” and giving pointers for how methadone clinic officials can most effectively lobby their congressional representatives.
“The No. 1 ask,” Long said, “is [to] oppose the Modernizing Opioid Treatment Access Act.”
Not all leaders in the methadone clinic industry are in lockstep, however. Nick Stavros, the CEO of the fast-expanding Community Medical Services, has said he is open to a system in which methadone is prescribed by doctors and dispensed by pharmacies. Some addiction clinicians like Ruth Potee, the medical director of several OTPs in western Massachusetts, have emerged as leading advocates not just for methadone clinic reform but also for allowing doctors to prescribe the medication directly to patients.
Throughout the conference, AATOD leaders and other featured speakers — including the right-wing megadonor, physician, and addiction researcher Miriam Adelson — extolled the virtues of methadone clinics specifically, which they argue entail a comprehensive approach to recovery that includes medication, counseling, peer support, drug testing, and other services.
Recently, however, patient groups have argued that requiring those services alongside medication may be, in at least some cases, more harmful than helpful. And in the wake of the Covid-19 pandemic, when emergency regulations led many clinics to issue weeks’ worth of “take-home” medication instead of requiring patients to attend in person each day, the culture has shifted significantly toward flexibility and liberalization.
In April, the Substance Abuse and Mental Health Services Administration codified flexibilities including take-home medication. It also warned against using drug testing “punitively” — in other words, punishing patients who don’t instantly achieve total abstinence.
Yngvild Olsen, a top SAMHSA official and former methadone clinic medical director, called for an industry-wide “culture change” while speaking at the conference’s opening session, even appearing to admonish providers whose practices remain restrictive, inflexible, or punitive.
“Some of it is going to take money, some of it is going to take regulatory change,” Olsen said. “But some of it is also that we can be kind to our patients, and that doesn’t take a whole lot of time. And we can trust our patients. We can talk to them, we can understand who they are as people, and work with them in fostering that trust and recovery.”
While the new regulations allow for more flexibility than ever, it remains unclear whether patients will truly benefit. Methadone clinics are also regulated even more stringently at the state level, and even in states where regulations don’t pose an obstacle, patient experience is often driven by the culture of individual clinics.
Moreover, many prominent lawmakers seem to view the regulations as insufficient. Rep. Don Norcross (D-N.J.), a co-author of Markey’s legislation, often refers to the methadone clinic industry as a “cartel.” Markey, meanwhile, has increasingly questioned the role of private equity firms, which a recent STAT investigation revealed now hold ownership stakes in nearly one-third of the roughly 2,000 clinics nationwide.
The methadone industry’s breadth and political clout were on full display in the exhibition halls of the Planet Hollywood Resort & Casino, located on the Las Vegas Strip — perhaps an unexpected venue for a conference about addiction and substance use, and the subject of frequent jokes throughout the week.
Multiple officials from both SAMHSA and the Drug Enforcement Administration gave presentations during the conference. SAMHSA and the National Institute on Drug Abuse, the federal research agency, were given special acknowledgement on the conference’s list of sponsors.
Promotional booths included advertising for several for-profit methadone clinic chains, a high-tech robotic system used to fill and track methadone doses, administrative software, billing services, a virtual interface for supervising patients as they take their doses at home, custom-designed bottles for storing take-home methadone doses, molecular drug testing, high-dose naloxone products, and more.
A large majority of the business present appeared to be marketed exclusively to methadone clinics, which, as the opioid crisis has accelerated, have become big business.
Last year, Acadia Healthcare, the country’s largest OTP chain, reported roughly $500 million in revenue from its over 150 methadone clinics nationwide. While it was once privately held and backed by private equity firms, Acadia has since gone public — making it the only major clinic chain that is obligated to publicly report revenue.
Given the financial implications of eliminating the clinics’ exclusive right to prescribe methadone, many critics have accused AATOD and clinic chains of prioritizing profits over patients. While industry leaders like Kletter and Parrino have rejected those assertions, there remains little doubt that the passage of Markey’s legislation or any similar proposal would cause an upheaval throughout the methadone treatment world.
At one point during the presentation on political advocacy, one attendee rose to ask whether AATOD had a plan in place if addiction doctors were to gain direct methadone-prescribing privileges. Kletter acknowledged that no such plan existed.
Another audience member then stood to offer, in his words, a different perspective. While he referred to Markey’s bill as a “disaster,” he argued that the methadone clinic industry bears much of the blame for the current political climate.
“Look in the mirror: We can do things better,” he said. “We need to be more involved with our patients. We need to love them.”
The crowded room of several hundred burst into applause. And with that, the session was over.
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.