I am a physician who specializes in the treatment of addiction and my patients are dying. Among them, a sweet legally blind kid with thick glasses, barely in his twenties, who used heroin and then fentanyl. He needed treatment with methadone, but federal regulations intentionally limit access to that lifesaving medication. So, he died instead. Another patient: a sixty-year-old woman hooked on pain pills. I started her on a medication called buprenorphine that has an excellent track record of treating opioid addiction. She stopped using drugs and moved to rural Oregon to reunite with her children. But near her new home, there was only one doctor who would agree to continue her prescription, and when he retired, she lost access to the medication. She started using again. And then she died.
Yes, my patients chose to take the drugs that eventually killed them, but before they died, they also tried to take evidence-based medications that could help them stop. Unfortunately, they discovered it is much, much easier in this country to find a fentanyl dealer than to find a way through the multiple, unconscionable barriers limiting access to these essential medications.
Methadone and buprenorphine are opioids themselves. Unlike other opioids, however, methadone and buprenorphine save lives. They decrease cravings, decrease use, and decrease deaths. Methadone is what is known as a “full agonist” at the opioid receptor, which means it sits on the receptor and activates it fully, just like morphine, oxycodone, or fentanyl. The difference with methadone is that it builds up slowly and sticks around, so there are no rapid highs and few deep dives into withdrawal. At the right dose, it activates the receptor just enough to remove cravings and stem withdrawal, helping patients focus on other, valued parts of their lives.
Buprenorphine is a “partial agonist,” meaning it occupies the opioid receptors but only partially activates them, decreasing cravings and withdrawal without an accompanying high. Because it is a partial agonist, it is very difficult for anyone to overdose on buprenorphine. It doesn’t have the potency necessary for complete respiratory depression. Also, because it binds the receptors tightly, it keeps other opioids from binding on the receptor, which means that when it is in a person’s system, it protects that person from overdosing on any other opioids as well.
Both are excellent medications, but methadone is stronger than buprenorphine. For users of fentanyl, it is sometimes the only medication strong enough to stem cravings. However, federal rules can make it near impossible for some patients to access methadone to treat their addiction. The rules stipulate that patients may only obtain methadone from an opioid treatment program (OTP), and, for the first three months of treatment, they must attend the OTP in person daily to receive their medication. They receive just one dose a day. It doesn’t matter if the OTP is hundreds of miles from their home, if a job or childcare makes it impossible to pick up the medication on time, or if they have no car to get there.