These findings provide an in-depth examination of the many ways that restrictive take-home dose policies negatively impact the lives of people on MMT. They describe a situation whereby the organizational approach to take-home doses almost guarantees that patients will encounter significant life disruptions that result in impediments to their ability to maintain employment, travel and respond to important life events.
Very few people in any walk of life would be able to show up to a non-work appointment at 6am every single morning and even less so when administered in the rigid, top-down and punitive manner described by patients. Indeed, it is only because the first author was able to find one of the few clinics that does offer 28 days of take-home doses, that he was able to attend graduate school and pursue a professional career. Had Dr. Frank been required to attend clinic every day, or even a few times a week, for years on end, graduate school and a career would have been entirely impossible.
By revealing how poorly people on MMT are often treated, the study findings also reveal the extent that they are marginalized. Patients’ descriptions evoke Giorgio Agamben’s socio-philosophical work on “bare life”, which highlights that certain (marginalized or oppressed) populations are seen by others as being outside of, or a “state of exception” to, the boundaries of human citizenry and thus not deserving of basic human rights [37, 38]. Agamben developed this set of concepts to help explain how certain groups, such as prisoners in Guantanamo Bay, are treated with little regard to standards of decency. Descriptions by MMT patients of being forced to stand in line after clearly going into labor or being denied the opportunity to attend a family members’ funeral—particularly when done in the context of the biological power that clinicians wield over patients through their dependence on methadone [39, 40]—show a particular cruelty and dismissiveness of this populations’ human rights, as though they are undeserving of the same standards of ethical humane consideration and respect that are generally and appropriately expected in patient-provider, and indeed -most, relationships.
Similarly, the literature on medicalization describes how medical personnel derive power through the socio-cultural framing of behaviors, particularly those activities seen as deviant, like substance use, as medical problems [41, 42]. Not surprisingly, treatment providers often rely on addiction-as-disease narratives that position PWUD as inherently disordered and in need of the clinics’ firm hand, to justify such polies. Yet, Frank’s previous work has contended that this is a mischaracterization of the reasons that PWUD use and benefit from MMT. Rather he has argued that MMT is better understood as a survival strategy that PWUD use in a variety of ways to maintain their use of opioids and reduce the harms of criminalization of drug use [9, 43]. In other words, whether patients pursue abstinence or not, MMT provides them with a shelter from harms stemming from the criminalization of drug use. Similarly, Frank & Walters have problematized the notion of consent in MMT by pointing out the ways that structural, legal, and cultural forces constrain the decisions of people who use illegal opioids [29]. In this light, restrictive take-home policies, and those who enforce them appear as yet another structural barrier preventing PWUD from obtaining safe access to opioids.
The solutions to this problem are, in many ways, not complicated. Programs must be made tolerable to patients, otherwise they will not use them. This is borne out by the consistently low rates of use and retention and correspondingly high rates of patient dropout in MMT [44]. However, since restrictions are tied to an institutional structure that disincentivizes take-home dose provision, part of the solution requires creating an institutional reimbursement system or health care delivery model that supports, and at a minimum does not structurally disincentive, increased take-home doses. Advocates from the Urban Survivors Union, a harm reduction and drug-user rights organization recently published a “Methadone Manifesto” that also recommends abandoning requirements that limit take-home dose provision to those with long records of attendance and negative drug tests, and similarly, that peoples’ take-home doses not be suspended or rescinded for positive drug screens [5].
In addition, changes should be made that allow for the provision of methadone in a manner similar to buprenorphine, another maintenance-based medication for people that use opioids. Because they are regulated differently, buprenorphine providers have far more latitude to determine the most appropriate take-home schedule for their patients and generally provide take home doses more often than MMT clinics [45]. In fact, research shows that some PWUD choose buprenorphine over MMT, despite a preference for methadone, because of the access it provides to take-home doses, and that—since buprenorphine is only a partial agonist and methadone is a full-agonist—such choices could lead to negative healthcare outcomes [29].
Opponents to providing increased access to take-home doses most often cite fears of diversion [46]. However, research suggests that this consideration is both exaggerated and mischaracterizes the complex risk environment that MMT addresses [47,48,49]. First, studies show that diversion is uncommon and happens more often among people using opioids for pain than for substance use [48, 50]. Recent studies examining expanded access to take-home doses during Covid-19 also found that diversion was rare [11, 22]. Second, concerns over diversion ignore the more significant risks of not providing take-home doses. As our findings demonstrate, the lack of take-home dose provision incentivizes patients to obtain opioids illegally where they will be exposed to the much greater risks associated with illegal and unregulated opioid use [51,52,53]. Restrictive take-home policies also encourage treatment discontinuation and discourage PWUD from engaging in MMT. In short, the risks of diversion, even when it happens, are far less than those produced by the current approach to MMT.
Further, the common clinic policies of using random drug testing or pill/bottle count spot checks and ‘call backs’ to assess if patients are potentially using illicit substances between visits, or potentially diverting methadone, should be reconsidered. While current US Federal guidelines require random urine checks as part of “diversion control plans [14], quantitative data to ascertain the degrees to which these practices either actually improve relevant outcomes or contribute to non-retention in treatment are scarce [54]. Our data demonstrate the extent to which these practices function as ‘part of the handcuffs’ and serve as barriers to job attendance and other social responsibilities. Further data to assess the holistic outcomes of random callbacks and spot checks are needed to soundly inform the design of truly evidence based, effective and humane, clinic policies.
Individual clinics can also make changes that would help to improve the burden on patients. For example, using a better organizational approach to scheduling patient appointments would improve many of the difficulties patients face. Similarly, clinicians can be more respectful of patients’ time commitments and outside-of-the-clinic responsibilities, and avoid using punishment, or the threat of punishment, as a response to scheduling issues.
Finally, there is a need for more detailed, publicly-available information on MMT clinics’ take-home dose policies and practices. SAMHSA should collect clinic-level data on how many patients receive take-home doses and according to what schedules. Similarly, clinic level data on individual clinics’ take-home policies, such as the maximum amount of take-home available and what kinds of metrics are used to ascertain whether a patient qualifies for addition take-homes, should also be made more readily available. This would help researchers and policymakers to develop a clearer picture of take-home provision and better determine which policies are working and which are not.
This paper has relevant limitations. It is based on a relatively small sample size. Similarly, and as with all qualitative research, results can not necessarily be generalized to the larger population of people on MMT. Additionally, as noted in the Methods section, it utilized an insider’s perspective which informed the data collection and analysis. Lastly, we would have liked to include demographic information about participants’ race and age in the interview quotations and explored its role in this issue. However, partly because of data collection difficulties that arose as a result of COVID-19, we were unable to collect this information for all of the participants and thus, decided to not include it for any of the quotations.
In conclusion, these data clearly demonstrate that take-home dose policies in MMT are not working for a substantial number of patients, are reasonably seen by participants as degrading and dehumanizing, and directly contribute to both non-engagement in MMT, MMT non-retention, and to significant difficulties with patients’ employment and in their lives. MMT’s many benefits are well known and supported by decades of evidence, and recognized by many PWUD (55). Yet, if MMT is made so onerous, degrading, and difficult that patients conclude that they cannot remain, or that it is not worth remaining, in treatment and live a ‘regular’ stable, fulfilling life, then they will not. Rather, and has been seen for decades, they will continue to simply ‘remove their liquid handcuffs’ and disengage from MMT, and return to obtaining opioids solely through the riskier illegal market. Revision of MMT regulations and policies regarding take home doses, drug testing and pill/bottle counts, and general operations are essential to improve patient satisfaction and the quality and effectiveness of MMT as a key evidence-based treatment and harm reduction.