Oregon lawmakers are gathered in Salem, determined to address the state’s drug crisis.
Both parties appear poised to crack down – at least to some extent – on drug possession, which was decriminalized with the 2020 passage of Measure 110. And Democrats hope to remove some barriers for people in treatment while expanding treatment options, including clinics that offer an integrated approach to behavioral health, primary care and addiction treatment.
That expansion likely would include the use of medication to treat opioid disorders, Rep. Rob Nosse, D-Portland and member of the joint addiction committee, told the Capital Chronicle. Medication-assisted treatment, or MAT, relies on prescription drugs that replace opioids in the body, or block them, to keep withdrawal symptoms at bay and allow the person to become stable. The most powerful and most effective of the drugs is methadone, long considered the gold standard for treatment, John McIlveen, the state opioid treatment authority at the Oregon Health Authority, told the Capital Chronicle.
“We literally don’t have another modality of treatment that consistently shows a reduction in drug use,” McIlveen said.
Methadone has been used since the 1950s to treat heroin and other opioid addictions. It’s been heavily studied since then, and the research has shown that it works, McIlveen said.
And yet no state general funds have been allocated to expand clinics that offer methadone, known as opioid treatment programs, in at least the last 11 years, McIlveen said. A grant program administered by the Oregon Justice Commission, IMPACTS, has allocated funds to counties and nonprofits that offer medication-assisted treatment, but Ken Sanchagrin, the commission’s executive director, said it’s unclear whether any of that money has gone toward methadone. Clinics mainly rely on insurance payments – from Medicaid, Medicare and others – to fund operations.
Much more funding is needed to expand operations, providers say.
McIlveen said he’s called for years for the state to stand up more clinics, though Nosse, chair of the behavioral health committee, said he has not come to him.
That changed in December during a meeting between Nosse, McIlveen and the Oregon Health Authority officials to discuss methadone, which is regulated by the federal and state governments. Nosse said the Legislature needs to better understand how federal regulation of medications used in treating opioid misuse interact with state regulations, but he expects an expansion of methadone and other opioid treatment medications to be included in Democratic-backed bills on improving the state’s response to the drug crisis.
“I don’t understand the interplay between (methadone) and federal and state rules,” Nosse said. “But I do think we’re going to make this easier to get and more accessible.”
At the moment, the Democrat’s main proposal addressing addiction, House Bill 4002, calls for a study of expanding medication-assisted treatment, and includes tweaks to lift some barriers to treatment, but does not propose expanding methadone clinics even though they offer the gold standard of treatment that’s been well-researched by scientists for years. Another bill, House Bill 4120, would expand opioid medication treatment in jails.
Numerous providers across the state offer medication-assisted treatment but there are only 26 opioid treatment programs in Oregon, largely along the Interstate-5 corridor. There’s an eastern Oregon clinic in Pendleton, a central Oregon clinic in Bend and two on the coast, in Seaside and North Bend.
“In the face of this drug epidemic crisis, we don’t have enough,” McIlveen said.
McIlveen said the state could use up to twice as many opioid treatment programs to prescribe methadone to fight the fentanyl epidemic.
“Many Oregonians still have to travel unacceptable distances to access methadone treatment,” McIlveen said in an email. A more geographically robust network of clinics (would) allow more Oregonians to access (these) essential services closer to their own communities and families, and eventually begin to mitigate the most damaging impacts of the opioid crisis we are experiencing today.”
Unlike methadone, fentanyl is easy to access: The drug is cheap, powerful, plentiful and deadly. And overdoses are skyrocketing. State data shows overdoses from fentanyl and other synthetic opioids increased from about 80 deaths in 2019 to nearly more than 650 in 2022, while fentanyl-related emergency department visits jumped from about 260 in 2021 to 1,200 in 2022 alone.
In addressing the opioid crisis in Canada, the Ottawa government funded seven “rapid access addiction medicine” clinics in 2015 to give patients same day, walk-in access to addiction medications along with other services. The pilot program was so successful that the government funded about 50 more clinics. A recent study in the Journal of the American Medical Association said the clinics were associated with a reduction in opioid-related emergency department visits and hospitalizations and an overall reduction in deaths.
Canada has a state-funded medical system, while the U.S. does not. Building opioid treatment programs in the state have relied on the federal government.
“It’s mostly been federal monies that have come to the state,” McIlveen said.
Nosse said lawmakers have not pushed for their expansion in the past because no one lobbied for it though providers have discussed medication-assisted treatment in hearings as lawmakers continue to grapple with the opioid crisis. Fentanyl, in particular, has killed hundreds a year, led to open air drug markets, made it difficult to avoid public drug use in cities and fueled retail theft and other crime, according to police.
One of the problems with methadone, even though it’s been heavily studied and shown to be successful, is that it’s classified as a controlled substance by the Drug Enforcement Administration, meaning it has a relatively high potential for abuse and is heavily regulated.
Establishing a clinic to administer methadone requires jumping through a lot of bureaucratic hoops, and the clinics have to be federally licensed, according to Tom Sorrells, chief of substance use treatment at Adapt Integrated Health Care, a nonprofit that has methadone clinics in Roseburg and North Bend. Providers also face a lot of federal oversight, and they have to comply with myriad regulations, though the government recently made a rule change that will go into effect in April that should ease the regulatory burden for providers, Sorrells said.
Then there’s the money problem.
“They’re just not particularly well-funded compared to other kinds of approaches,” Sorrells said. “The other problem as well is that there’s a stigma attached to medication-assisted treatment.”
Many people in the community don’t want an opioid treatment clinic in their area because of that stigma, providers say. Residents don’t understand why providers would treat someone with an addiction with another opioid. They see addiction as a personal failure, not a chronic medical condition.
“There are enough people, whether they’ll say it or not, who are not really interested in whether or not somebody with a severe addiction lives or dies,” said Alison Noice, CEO of CODA, Inc., which runs opioid treatment clinics in Portland and Seaside.
Opioid treatment clinics also face the same workforce shortage as other addiction and mental health services.
“They need a full contingent of providers, nurses and counselors, certified alcohol and drug counselors,” Sorrells said.
Daily doses
Like the Canadian clinics, Adapt’s clinics offer opioid users walk-in services. Patients are assessed, diagnosed and undergo a medical exam, which means clinics have to employ a physician, nurse practitioner or physician’s assistant in-house. Most opioid users qualify for methadone or another form of medication-assisted treatment, Sorrells said. These drugs have to be taken every day, which means daily trips to the clinic at first. The more convenient the clinic, the easier it is for the patient to get on track in the beginning.
Opioid interact with opioid receptors throughout the body. An individual builds up a tolerance and needs the drug to maintain an equilibrium. Without it, the body goes into withdrawl.
“You have opioid receptors all over, so you get sick all over,” Sorrells said. “That’s a powerful motivation to continue to use.”
Buprenorphine, like methadone, is an opioid and a controlled substance, though it has a low potential for abuse. They both are used to replace the user’s opioid of choice. Methadone is the most effective because it’s a full opioid agonist that completely stimulates the opioid receptors in much the same way that fentanyl does. Buprenorphine is only a partial agonist, which means it partially stimulates the receptors.
Another opioid disorder medication, naltrexone, is not an opioid and is not a controlled substance. It works by blocking opioid receptors, but studies show it’s not as effective as methadone or buprenorphine.
As opioids, methadone and buprenorphine can cause an overdose if not properly dosed, though buprenorphine has a lower risk of overdose than methadone. That’s why government regulation is needed for methadone, Noice said.
“When you’re not prescribed methadone by somebody who is really adept at addiction medicine, there is an overdose risk. That’s why it’s been regulated through these opioid treatment programs for so long,” Noice said.
She said regulations are effective at ensuring that opioid medications are prescribed appropriately and patients are monitored. That limits the risk of methadone, in particular, being diverted to someone on the street.
When users try to get off illicit opioids without the medication, their tolerance quickly drops. If they relapse and use a similar amount as before, they risk overdosing. With proper prescribing, methadone – along with buprenorphine – prevents overdoses because the body no longer cycles through periods of craving and withdrawal.
“They’re not in that extreme danger of overdosing as soon as they relapse, and people relapse all the time,” Sorrells said.
Relapses are more frequent with fentanyl, Noice said. Fentanyl is a potent opioid like heroin and it’s short-acting, which means users have to take it every few hours to prevent withdrawal symptoms. The withdrawal is also prolonged: Symptoms can persist for several weeks.
On methadone, patients can establish a normal life, find a job, parent their children, go to school and improve their quality of life.
“If they’re coming back to the clinic and getting their maintenance dose of methadone or buprenorphine every day, the chances decrease that they’re going to be out on the street looking for some substitute because they’re kind of getting what they need in the clinic and they’re not suffering the same kind of danger to themselves and the same kind of impairment,” Sorrells said.
Studies have shown that methadone helps stem criminal activity, improves social interactions and reduces the spread of infectious diseases by getting patients back on their feet.
Methadone clinics – like Canada’s rapid access addiction medicine facilities – are required to offer a range of services, including counseling. Methadone allows patients to work on tackling their mental health problems that are linked to drug use.
“If folks are not sick and they’re not jonesing for the next fix and they’re not physically dependent on a harmful street drug that’s causing them impairment, which methadone when it’s administered correctly does not, then they can focus on the business of getting help and getting treated,” Sorrells said.
Removing barriers
Patients on any medication to treat an opioid use disorder are considered to be in recovery and their rights are protected. But individuals on methadone can face discrimination in housing and employment.
Democrats hope to remove some of those barriers with legislation this session. Their proposals include an extension of fair housing standards to cover patients on medication-assisted treatment, and they’d like to ban health insurers, including the coordinated care organizations that insure Medicaid patients in Oregon, from requiring prior authorization for addiction treatment. They also would like to allow pharmacists to prescribe and dispense emergency refills of addiction medications and require health insurers to reimburse costs associated with emergency refills. And their proposals include one that would boost medication-assisted treatment in jails to get suspects and criminals on a path to recovery.
Removing barriers could help remove the stigma associated with addiction and addiction treatment, advocates say.
Providers say the state needs to urgently expand care to fight the fentanyl crisis and give patients quick access to medication treatment to keep them alive long enough to benefit from it. Existing methadone clinics face high demand, but treating patients is not as straightforward as treatment for a physical condition. Addiction providers face more layers of state and federal regulations than in primary care.
Oregon’s behavioral health rules govern how providers obtain consent, assess the patient and collect information on their history of trauma, their past substance use, their family history and other relevant information. And they have to do it quickly.
“Our rules suggest we have to gather all of this information immediately and then get them in front of a medical provider who can prescribe the medicine,” Noice said.
She’d like some state rules modified to enable faster access to care, and she’d like clinics to receive more resources.
“We need a lessening of the administrative burden on specialty addiction providers,” Noice said. “But to be honest, we need incentives, and that means money.”
