Faculty Bibliography

BACKGROUND/UNASSIGNED:The potential of methadone maintenance treatment (MMT) to address the opioid crisis has been limited by restrictive federal and local policies that require frequent clinic visits for medication. Unprecedented federal regulatory changes started in early COVID-19 and were made permanent in 2024, allowing clinics increased flexibility in granting take-home medication to patients. Medicaid payment policies can profoundly shape provider behaviors but may not align with regulatory changes. METHODS/UNASSIGNED:We conducted a systematic synthesis of Medicaid MMT payment and billing policies among 40 states over March 2020-July 2025. RESULTS/UNASSIGNED:More than half of the states continued to adopt a per-dose or per-diem approach to paying for methadone dosing and a per-service approach to paying for addiction counseling, thus tying Medicaid revenue closely to clinic visits. More than one-quarter maintained a flat bundled payment dating back to prepandemic era that provided little incentive for granting patients more than 1 week of take-home medication. Adoption of a 2-tiered bundled payment modeled after Medicare's payment increased over time but remained limited. CONCLUSION/UNASSIGNED:Medicaid payment policies for MMT saw limited changes over the 5 years following initial federal regulatory changes. Practice changes toward more flexible and patient-centered care may be hindered without compatible changes in payment approaches.

The United States continues to grapple with the shifting substance use landscape among the emerging concurrent use of opioids and stimulants. Polysubstance use (PSU) of opioids and stimulants, whether intentionally or unintentionally, has increased substance use related morbidity and mortality. Changes at the policy level are needed to effectively curb overdose and other adverse outcomes. This article outlines 3 policy changes that are particularly relevant to opioid-stimulant PSU: (1) reforms in opioid agonist treatment policy, (2) reforms in payment for evidence-based treatment, and (3) reforms of drug paraphernalia laws. The current overdose crisis requires a multidimensional paradigm shift toward patient-centered and harm reduction focused policies that will expand access to comprehensive evidence-based treatments and services for individuals engaged in opioid and stimulant PSU.

PURPOSE/OBJECTIVE:Opioid overdose survivors are vulnerable to fatal overdose, particularly in the weeks following overdose, a period when health service use is often low. This study explores post-overdose health/medical services engagement among a diverse sample of survivors. METHODS:We conducted semi-structured interviews with 23 recent opioid overdose survivors across seven states. We asked about service utilization and drug use history, contextual factors related to the overdose, service use immediately after and in the months following, and the impact on wellbeing. RESULTS:Over half of participants described calls to 911 (n = 13), and one-third went to the hospital (n = 8). Six key themes guided by Levesque's patient-centered access to care framework emerged. Several themes explored why participants did not seek medical services following an overdose, including 1) the belief they could manage at home, 2) a lack of trust in responders, often based on prior negative experiences, 3) concern about unintended consequences such as legal issues, and 4) the financial, social, and opportunity costs associated with calling 911 or going to the hospital. Of those who did receive emergency services, some declined transport to the hospital for similar reasons, including potential repercussions from their treatment program if they were notified. A fifth theme focused on interactions with providers in the hospital, where individuals were rarely offered medications for opioid use disorder or connected to treatment. Interactions with providers were largely negative, though participants reported more positive experiences with social workers and peer support specialists. A few had early discharges, often due to feelings of vulnerability, unmanaged withdrawal symptoms, or poor interactions with providers. Last, the sixth theme focused on substance use treatment engagement. Treatment engagement was often delayed but was facilitated by factors like a social worker following up, longer hospital stays, or the participant seeking treatment on their own. CONCLUSIONS:Most of the sample did not engage with hospital or substance use treatment services after a nonfatal overdose. Negative prior experiences and fear of negative consequences were major barriers in this sample.

INTRODUCTION/BACKGROUND:State regulations governing opioid treatment programs (OTPs) vary widely in their restrictiveness, yet how state policies relate to the availability of services offered within OTPs remains understudied. In this study, we compare the availability of medication for opioid use disorder (MOUD) options, psychosocial services, and housing supports across OTPs operating in states with different levels of OTP policy restrictions. METHODS:We conducted a cross-sectional study of 1501 opioid treatment programs (OTPs) in the United States. Exposures included 11 state-level OTP policies that impose legal or administrative barriers to opening or operating OTPs or to patients' receipt of care (e.g., pharmacy licensure requirements, zoning restrictions, government identification requirements, and administrative discharge for positive drug screenings). Data on OTP service offerings-including buprenorphine, naltrexone, all three medications for opioid use disorder, mental health services, contingency management, trauma-informed counseling, and housing services-and organizational characteristics were obtained from the 2023 Mental Health and Addiction Treatment Tracking Repository, a national longitudinal database of licensed substance use disorder treatment facilities. These data were linked to a previously developed state policy typology using latent class analysis, which categorized states as having low or high OTP restrictiveness. Regression models adjusted for state- and organizational-level characteristics and accounted for clustering within states. RESULTS:In descriptive analyses, OTPs in highly restrictive states were significantly less likely (p < 0.05) to offer all three MOUDs and behavioral health services, including mental health services, trauma-informed counseling, and contingency management, compared with OTPs in low-restrictiveness states. In adjusted Poisson regression models, facilities in highly restrictive states were significantly less likely to offer naltrexone (ARR: 0.73; 95% CI: 0.54-0.97) and all three MOUDs (ARR: 0.70; 95% CI: 0.53-0.92). CONCLUSIONS:Given that OTPs are the only facilities in which methadone can be legally dispensed, these facilities are a critical point of access for individuals in need of evidence-based OUD treatment. However, our findings suggest that states that place additional restrictions on OTPs also offer less services within their OTPs.

BACKGROUND:Methadone is a highly effective treatment for opioid use disorder (OUD). Yet its impact is constrained by low rates of treatment initiation and retention, driven in part by geographic inequalities in the availability of methadone-providing opioid treatment programs (OTPs) and restrictions on the types of clinical settings where methadone can be dispensed. In response, in July 2021, the Drug Enforcement Administration released a new rule allowing OTPs to dispense medications for OUD-including methadone-through mobile medication units (MMU) without the need for additional treatment waivers. METHODS:We conducted interviews with 11 participants living in a residential substance use treatment facility in NYC and receiving methadone treatment (MT) from an MMU. Interview data were coded using Dedoose software based on a combination of inductive and deductive coding strategies, and guided by a thematic approach to explore patient's treatment experiences and perceptions. RESULTS:Participants described MMU as substantially reducing the logistical burden of treatment while also allowing patients to avoid problems associated with brick-and-mortar OTPs. Some raised minor complaints (i.e., additional waiting time on medication delivery days), yet participants framed these concerns within the context of their overall preference for MMU. Participants also expressed uncertainty about how methadone treatment would continue after leaving residential care, highlighting potential challenges in transitioning from mobile services to traditional clinic settings. DISCUSSION/CONCLUSIONS:Our findings provide qualitative evidence from patients' perspectives on how mobile methadone delivery can potentially reshape the logistical demands, treatment environments, and continuity-of-care challenges associated with methadone treatment in residential settings.

BACKGROUND:Methadone is the gold standard treatment for opioid use disorder (OUD). In the U.S., methadone is usually only available through licensed opioid treatment programs (OTPs), but a 2021 federal rule provided an opportunity for OTPs to provide methadone on mobile medication units (MMUs). MMUs operate under the license of an OTP and are subject to complex regulatory requirements. New York State provided grant funding to support OTPs to adopt MMUs, aligned with the broader goal to improve methadone access statewide. This study explored barriers and facilitators to MMU implementation across New York State from the perspectives of treatment staff and administrators. METHODS:We conducted semi-structured interviews between June 2024 and June 2025 with 16 staff from four OTPs that adopted MMUs and one residential treatment program served by an MMU. Interviews were audio-recorded, transcribed, and analyzed using a hybrid deductive-inductive thematic analysis approach to identify implementation barriers and facilitators. RESULTS:Staff described a variety of potential models for using MMUs to expand access. In New York City, MMUs were used to serve a residential substance use program. In upstate NY, MMUs were deployed to reduce travel distance in counties with few OTP options. Key facilitators of MMU implementation included leadership persistence in the face of community pushback, creativity and workarounds in the face of logistical hurdles, and support from the state agency. Key barriers included community resistance to MMUs, unclear or inconsistent guidance from the Drug Enforcement Administration, and a variety of operational challenges, such as vehicle maintenance and workforce shortages. Staff generally were positive about the opportunity to use MMUs to address access challenges. CONCLUSIONS:MMUs provide a novel approach to expand methadone access, particularly to populations not currently served by brick-and-mortar OTPs. Early implementers can provide important lessons about how to manage start-up challenges, which can guide later adopters.

Methadone is a highly effective treatment for opioid use disorder. However, its public health impact in the U.S. has long been constrained by strict regulations requiring dispensing through specialty opioid treatment programs (OTPs). In 2021, the U.S. Drug Enforcement Administration authorized mobile medication units (MMUs) to dispense methadone in community settings, raising hopes that mobile delivery could expand access for underserved populations. This commentary examines New York State's early experience implementing MMUs as a case study of both the opportunities and persistent challenges associated with this care delivery model in the U.S. We discuss how burdensome methadone requirements, high start-up and operating costs, complex staffing and logistical burdens, community opposition, and a continued emphasis on diversion control over patient access have limited the ability to effectively scale MMUs as a low-threshold treatment option. Although MMUs have and will continue to improve convenience and access for some patients, their potential to substantially improve geographic access, provide lower-threshold care, and deliver comprehensive OUD services is inhibited by the broader U.S. "methadone exceptionalism" framework, which silos methadone as a separate and more restrictive treatment modality requiring excessive vigilance and oversight . We argue that without greater regulatory clarity, flexibility, and alignment with patient-centered care goals, MMUs may likely remain a welcomed but modest, rather than transformative, innovation in addressing methadone gaps in the United States.

BACKGROUND:The illicit drug landscape in South America is going through a major shift. The appearance of Tusi (or "pink cocaine"), a mixture often containing ketamine and MDMA, along with the growing presence of synthetic opioids like fentanyl and nitazenes, signals a new chapter in the region's drug use, which has been traditionally dominated by alcohol, cannabis, and cocaine. MAIN BODY/METHODS:Drawing on data on seizures, forensic analyses, warning systems, and surveys from Brazil, Chile, and Colombia, this perspective highlights three movements of the drug supply: non-prescribed and synthetic opioids, ketamine, and Tusi. We also elaborate on their unique public health challenges. Brazil and Chile have seen an increase in non-prescribed opioid use, some of them diverted from healthcare, accompanied by seizures of illicit fentanyl and the discovery of nitazene production in Brazil in May 2025. Colombia, while historically experiencing low opioid use, has documented fentanyl analogs in ketamine and MDMA/Ecstasy samples, mixed with various other contaminants, thus increasing risks among people who use them. Concurrently, ketamine and Tusi use are expanding rapidly across all three countries, particularly among nightclub attendees and youth with criminal-legal involvement. Tusi's unpredictable composition poses heightened overdose risks, especially in settings lacking drug-checking and overdose-prevention education and programs. Furthermore, South America has minimal opioid agonist therapy coverage, limited naloxone access, and underdeveloped harm reduction systems. CONCLUSION/CONCLUSIONS:The emergence of synthetic opioids, ketamine, and Tusi signals a new synthetic drug phase in South America's supply. The convergence of traditional drugs with potent new substances poses important health-related harms. Strengthening regional surveillance, toxicological monitoring, and harm reduction services are urgently needed. Coordinated international research and public health responses will be essential to prevent a drug crisis.

OBJECTIVES/OBJECTIVE:Policy reforms are being considered to increase methadone treatment (MT) access for opioid use disorder in the United States. Proponents of more structured MT reference risks of diversion, including non-prescribed use or redistribution of methadone, and overdose as arguments for limiting access to specialty settings. However, the scientific evidence behind these claims has not been thoroughly reviewed. METHODS:We conducted a narrative review of studies on methadone diversion, diverted methadone-involved overdoses, and how these compare in countries with specialty-care-only policies (methadone dispensed only through regulated treatment programs) versus general physician-prescribing policies (physicians prescribe methadone in office-based settings). A narrative approach was chosen, given substantial heterogeneity in study designs, diversion definitions, outcome measures, and data sources. We synthesize and discuss findings from international papers published before October 2025. RESULTS:We identified 29 articles studying methadone diversion or diverted methadone-involved overdoses in 7 countries. Lifetime methadone diversion occurrence varied between 6% and 68%, and using diverted methadone occurrence varied between 22% and 88%. Diverting methadone was most often done to help sick friends/partners. Common reasons for using diverted methadone were preventing withdrawal and avoiding opioid use. Three studies found no association between self-reported diverted methadone use and increased individual-level risk of overdose. CONCLUSIONS:The link between specialty-care-only policies and lower diversion and overdose risk is not supported by the reviewed literature. Policymakers should weigh diversion risks against benefits of lives saved through expanded MT access. Further research is needed to better understand the circumstances related to diverted methadone and inform policy-making that appropriately mitigates risks.

INTRODUCTION/BACKGROUND:A 2021 federal rule permits opioid treatment programs (OTPs) to provide methadone through mobile medication units (MMUs), creating an opportunity to provide medication for people in residential care facilities. We used simulations to quantify the potential of MMUs to expand methadone access to people residing in residential substance use treatment facilities (RTF), skilled nursing facilities (SNF), and nursing facilities (NF) in New York State under different scenarios. METHODS:For each facility (RTF, SNF, and NF), a need score was created using three items: facility opioid use disorder (OUD) population, driving distance to nearest OTP, and county overdose mortality rate. We then demonstrated potential patient reach following the launch of 50 hypothetical MMUs making one stop per day to the highest need facilities. In refinements, we examined three additional scenarios involving more daily stops and prioritizing rural areas. RESULTS:Our sample included 3214 people with OUD estimated to be housed in 1052 facilities in New York, with the majority in RTFs (51.5%). The demonstrated percentage of OUD population served ranged from 23.5% to 35.8%, and the percentage of facilities served ranged from 23.8% to 37.4%. Each scenario reached a large percentage of rural facilities (73-76%). Prioritizing rural facilities decreased the proportion of OUD population served (10% reduction) but did not substantially increase driving time. Allowing multiple stops increased the proportion of OUD population served (32-36% vs. 24-26%). CONCLUSIONS:Using methods based on location information and spatial relationships, state officials can develop priorities and assess tradeoffs of MMU deployment and distribution strategies.