Eight investigators from medical centers in the U.S. and Canada recently looked into methadone access in the U.S., and evaluated the current availability of methadone treatment for opioid use disorder (OUD).

The current situation within the U.S. wasn’t encouraging:

In 2017, drug overdose deaths in the U.S.—most of them related to opioids—totaled 70,237. Yet there are only 14,000 facilities for treating substance use disorders—not nearly enough. And fewer than half these facilities offer medications for opioid use disorder (MOUD).

As for opioid treatment programs (OTPs), the life-saving programs that dispense methadone for OUD, the U.S. has only 1,500. Most counties do not have any OTPs. The number of OTPs is increasing far too slowly to keep up with the need.

What about buprenorphine? It’s widely available, but some patients need a full opioid agonist for symptom control, and some prefer methadone to buprenorphine. According to The National Academies of Sciences, Engineering, and Medicine, all approved medications should be offered wherever OUD is treated.

Clearly, it’s not a good situation. What to do about it?

The team, including two investigators from Canada, looked into the possibility of pharmacy-based methadone dispensing in the U.S.

A pre-proof version of their study, “Pharmacy-based methadone dispensing and drive time to methadone treatment in five states within the United States: A cross-sectional study,” has just become available. The study will be published in Drug and Alcohol Dependence after additional editing and review.

The Rationale for Pharmacy Distribution Systems for Methadone

Pharmacy-based systems are working well in Canada and Australia. With residents of rural areas in the U.S. having “disproportionately long drive times to methadone,” the team wrote, the current situation in this country could very well be mitigated—if pharmacies could dispense methadone.

“Within the United States, primary care prescribing of methadone for OUD within Federally Qualified Health Centers could reduce long drive times to the nearest OTPs . . . but would require partnerships with local pharmacies for observed methadone dispensing,” they commented. Federally Qualified Health Centers are community-based health care providers that provide primary care services to people in underserved areas.

Federal Regulations Pertaining to Methadone and Local Pharmacies

Local pharmacies can currently serve as “satellite medication units for observed methadone dispensing”—but only if an OTP initiates the arrangement, Dr. Joudrey explained, in an email correspondence with AT Forum. But so far, this option has not been utilized, he added, despite the ongoing drug overdose epidemic.

In contrast, pharmacies in Canada can dispense methadone for OUD daily, if a physician has prescribed it. The situation is similar in the United Kingdom and in Australia.

According to the study:

Almost 9 of every 10 people in the U.S. live within five miles of a pharmacy, indicating that pharmacies are “valuable sites for healthcare delivery,” the team notes.

Services that many pharmacies already provide include vaccinations “in private areas set apart from the medication pick-up window.” These invaluable services help raise immunization rates and help lower the incidence of vaccine-preventable illnesses.

Pharmacy-based dispensing would increase “existing pharmacy initiatives to reduce opioid overdose, such as naloxone distribution.”

The team began gathering data to answer this question: What effect would pharmacy-based methadone dispensing, as available internationally, have on methadone access in the U.S.?

The Study

The investigators chose, as study sites, urban and rural neighborhoods (census tracts) in the five states with the highest death rates from opioid overdose: Indiana, Kentucky, Ohio, Virginia, and West Virginia.

Because patients are allowed to travel across state lines to reach the nearest facility that dispenses methadone, the team also included all OTPs and chain pharmacies in bordering states: Illinois, Maryland, Michigan, Missouri, North Carolina, Pennsylvania, and Tennessee. To be included, OTPs had to be identified as providing methadone “within the SAMHSA Behavioral Health Treatment Services Locator” (see the article for details).

The team used sophisticated tools and designs to compare drive times to the nearest OTP with drive times to the nearest chain pharmacy.

Outcome

The primary outcome the team sought was the minimum drive time, in minutes, from the center of the neighborhood to the nearest methadone-dispensing facility. This facility could be either an OTP or a chain pharmacy.

To measure distance, the team used a sophisticated tool that “simulates automobile movement between two points along a national street network based on historical average speeds.” Their procedure was as follows—

Calculate minimum driving times from the center of the neighborhood to the nearest OTP Calculate minimum driving times from the center of the neighborhood to the nearest chain pharmacy—CVS, Rite Aid, Walgreens, or Walmart Calculate drive times to the nearest CVS pharmacy (for intake limited to the area’s largest chain pharmacy) Answer, with a Yes or a No: Was the drive time to the closest dispensing facility greater than 60 minutes? (An hour is considered a long daily commute.)

(See the published study for details of the statistical analysis that followed.)

Driving Times

Driving time to nearest OTP:19.6 minutes, median; range, 1 to 161.5 minutes. (Median is the middle value in a list of numbers arranged from smallest to largest.) The driving time increased as the study area became more rural.

The median driving time to OTPs was greater than the median driving time to chain pharmacies (19.6 versus 4.4 minutes). This was true in both urban and rural areas of the study.

The median difference between OTPs and chain pharmacies in drive time: 13.9 minutes. (This difference became greater as the study area became more rural.)

Driving time to the nearest CVS was less than the driving time to the nearest OTP for all rural or urban commuting areas.

Implementation: Some Key Points

The authors listed several points to keep in mind:

Implementing a pharmacy-based program will require “further research into the potential barriers and facilitators of adoption.”

“Unlike primary care prescribing of methadone, dispensing from pharmacies does not require passage of new federal regulation.”

Planning the distribution location will improve efficiency. But “even dispensing methadone from CVS alone would result in a median reduction in drive times of over 20 minutes.”

Although existing federal regulations allow pharmacists to administer urine drug tests to screen for drug use and to supervise methadone dispensing, state regulations may need to be modified.

The Authors’ Conclusion

“Long drive times to the nearest OTP disproportionately impact people with OUD in rural census tracts, creating a barrier to life-saving treatment with methadone in these communities. Drawing from policies to increase methadone access in other countries like Canada and Australia, the geographic disparity observed in methadone access could be mitigated through implementation of pharmacy-based methadone dispensing in the United States.”

Reference

Joudrey PJ, Chadi N, Payel R, et al 2020. Pharmacy-based methadone-dispensing and drive time to methadone treatment in five states within the United States: A cross-sectional study. Drug Alcohol Depend. Pre-proof. doi:https://doi.org/10.1016/j.drugalcdep.2020.107968

