Dr. Julio Nunes Discusses Addiction Treatment and the Modernizing Addiction Treatment Access Act

The MOTA act would allow addiction psychiatry specialists to prescribe methadone outside of OTPs, to be picked up at your local pharmacy.

On July 28, the The American Journal of Drug and Alcohol Abuse published an article describing the bipartisan Modernizing Opioid Treatment Access (MOTA) Act, a bill that is currently making its way through the house and senate that would allow board certified addiction psychiatrists to prescribe 30-day supplies of methadone to be picked up at your local pharmacy, instead of at an opioid treatment center (OTP). I spoke with first author of the article, Julio Nunes, MD, an addiction psychiatry resident at Yale University, and board member at the Doctors for Drug Policy Reform, about treatment for opioid use disorders, stigma, what the bill would do, and what we can all do if we want to support it.

You can listen to the recording of our conversation, or read the transcript below, which as been edited lightly for clarity.

Dr. Nunes

I'm Julio Nunes. I am a medical graduate from Brazil. I came to the United States as a research fellow at Stanford University, and now I am a final year psychiatry resident at Yale University, at the Department of Psychiatry. As of recently, I am also on the board of directors for Doctors for Drug Policy Reform. I got very interested in addiction—psychiatry in general—and that's why I mentioned Brazil before, because I used to work in one of the major favelas. These are highly impoverished regions in Rio that are in the middle of narco trafficking violence. So I would work as an emergency physician in the middle of that setting where the patients were victims of narco trafficking violence, people who are using substances, and family members of those folks. And frequently in that area, police officers receive money from narco trafficking and allow them to continue their work. So we were the safety spot. All this to say, I got interested in addiction before I was even thinking about psychiatry. And now as a psychiatrist, it only makes sense that, as I continued working with folks, that it's a different scenario, but I continue to care a lot about those folks.

Emma

That makes sense. So for people who are not aware of methadone, I know when I first started reading about addiction, suboxone would come up, but I didn't see a lot about methadone. Could you describe a little bit about what the system is like now and what a patient's experience would be like if they're taking methadone?

Dr. Nunes

Totally. And I'm not sure if everyone who is hearing us knows the difference between Suboxone, methadone and all of that. I have a nice metaphor that helps people understand that. It’s how I usually explain it to patients. When you're using opioids in general, we're going to call them the full agonists. It's like you're driving an out-of-control car on the highway. And if you're driving very fast at 150 miles per hour, that's dangerous. You can cause accidents. You lose control of the car, and that's the metaphor of addiction. Methadone is still a full agonist. It's still a medication that makes your opioid receptors go fast. We still call it a full agonist, but in many ways, it is much safer and easier for us to predict and use with patients, to allow them to use opioids in a recovery process. Then there is buprenorphine that you brought up. Buprenorphine gets all the attention because it's a partial agonist. Instead of driving your car at 100-120 miles per hour, which is dangerous, you're driving the car at a comfortable 50-60, miles per hour, you're still hitting those opioid receptors. Those are still opioids, after all, but in a much safer mechanism of action.

Emma

And why would someone benefit from methadone as opposed to buprenorphine?

Dr. Nunes

Yeah, and that's exactly the next point. There are several situations in which I see it happening, and fentanyl has really changed a lot of how we think about this. Recent studies have shown that adherence to methadone tends to be higher, slightly higher than buprenorphine. Part of the theory behind that is methadone is a full agonist, so it is more intensely targeting those opioid receptors. There are a couple of populations in which that becomes very special in my head: folks who have opioid use disorder and are also in pain, buprenorphine is used in chronic pain, but methadone has that extra edge for analgesia, especially if we're able to help folks divide that dose in two times a day, rather than once daily, like most people do.

But then with fentanyl and those synthetic opioids folks nowadays use, the truth is, I can't predict anymore how much opioids my patients are actually using. We try to think of that in morphine equivalents. We get whatever opioid the person is using, oxycodone, for example, and convert that to what morphine looks like. With fentanyl and with street opioid use, there's no way for us to be sure. But those numbers, just for reference, in the past, we would use 80 to 100 milligrams of methadone. A lot of the psychiatrists learned to do that. Nowadays, after fentanyl, those doses are getting much higher. We have patients in 150, 200mg even of methadone. The truth is, buprenorphine, being a partial agonist, may not be the right choice for everyone, especially as they are in those very much higher doses of opioid use.

And there's another problem when you're using buprenorphine. Because it's a partial agonist, it's making your car reduce the speed from 120 to 50. If you just do that, you're driving at 120 and you slam the brakes and you make your car go slower, you're gonna spin. So if you give someone buprenorphine when they are recently actively using opioids, you're gonna send them into withdrawal. So for us to do what we call buprenorphine induction, you have to have the patient go into moderate withdrawal and then start the treatment. The car has to naturally slowdown from 120 to 50, and then you keep the car at 50 versus then making it sudden. Not everyone can tolerate that induction process.

Emma

That sounds difficult for sure. So you recently published this paper about the modernizing Opioid Treatment Access Act, and in it, there was a quote that I found pretty insightful. “Methadone entanglement with the criminal justice policies has long framed OUD through a punitive lens.” Can you elaborate on what that means, and what treatment looks like now?

Dr. Nunes

100%. Treatment today, and this is fluctuating, there are many regulations that go into this. So I don't want folks to necessarily hear what I'm saying and think that it applies to every place, everywhere. That's part of the problem. But in general, for you to access methadone, you have to go every day to an opioid treatment program that's a specialized, federally regulated facility that has permission to dispense methadone. Mind you, most hospitals, clinics, places that you normally go to receive care, are not allowed to dispense methadone for ongoing use. It has to be that specialized clinic and then—and this is where it changes from clinic to clinic—but most patients are going to start their recovery process having to go once every day to the methadone clinic to have a nurse observe them take the medication. You don't have to do that for buprenorphine. For example, you can just buy from any community pharmacy that is willing to stock it for up to 30 days at a time, 28 days at a time.

When I said it's entangled with the criminal system, it has to do with the origins of all this treatment. Right? The war on drugs is really how a lot of folks approach their attitude towards substance use. Opioid use is no different. We are more concerned about, historically, about the risk of medications that are used to treat patients being diverted than we are about making sure that patients receive those medications in the first place. So historically, we're more worried about keeping the medication safe, rather than the people who benefit from them safe. And in my opinion—we have another paper that is coming out that compares how it is in the United States and other countries—it leads to the US having less of 20% of people who should be on medications for OUD actually accessing them. It's a tragic number in comparison with other countries; France is at 85% of coverage rate. They can access methadone from community pharmacies. England is at around 50%. Australia is at around 50%. Iran is at around 50%. They completely revamped back in the 70s and 80s. They had a “substance use as a sin” kind of model, a moral failure, no treatment for it other than abstinence. And at some point, they reviewed their concept of addiction treatment and now they expanded a lot of the treatment options, including outpatient modalities. And nowadays their coverage is much, much higher, which is surprising, like for the historical context of that country.

Emma

Yeah, absolutely. I mean, I've heard comparisons with France and Portugal. I have not heard a lot of comparisons with Iran, so that's super interesting.

Dr. Nunes

Yeah, Iran uses something that a lot of people don't use. For example, they use tinctures. They use opium tinctures, and they will have that in community. It's a way of accessing opioids in a more controlled fashion with clinical work. Nowadays, it's not the mainstream, but that was the bridge between no treatment at all and now getting medications for OUD and their coverage rate nowadays, 50%.

Emma

Wow. Okay, so this latest paper you put out was about the act itself. So can you talk a little bit about what the act would do if it were passed.

Dr. Nunes

The act is a was submitted by by Senator Edward Markey (D-MA). He's from Massachusetts. What is very cool is that he has bipartisan support. It has, if I believe in the Senate, it's 12 co-sponsors. Half of them are Republican side. Half of them are Democrat side. And that's a very interesting point about the act.

What it does—the main thing that I'm raving about, and so many people are raving about, including the American Society for Addiction Medicine—is it lets physician specialists, in this case, it's not general psychiatrists or general internal medicine doctors, you have to be a psychiatrist who specializes in addiction psychiatry, to prescribe methadone for up to a month from community pharmacies. That's the biggest thing it does. It also makes the language very clear that telehealth is integrated into this. So I, as an addiction psychiatrist, I could allow patients to access the same treatment, even if I'm seeing them virtually. It also has a couple other things in there. For example, each state gets to opt in or opt out of that rule, but we will talk more about that later. The essence is those 30 days of prescription. What is very important about this is that those opioid treatment programs that I was bringing up before, they're not widely available. For most counties in the country, it's a 45 minute average drive to get to an OTP. Many counties don't have an OTP within one hour. And we know that a lot of the hardest hit counties, the counties that were hit the hardest by the opioid epidemic, they are rural counties. West Virginia comes to mind, for example. So if you can only access the treatment by going every day to a clinic, and that clinic is one hour away from your house, something is not working properly, and no wonder we have less than 20% people engaging in treatment.

Emma

When a doctor would prescribe 30 days of methadone, would the people have to go daily to a local pharmacy or do they get 30 days at a time from the pharmacy?

Dr. Nunes

The bill would allow for up to 30 days from a pharmacy. You don't have to do daily prescribing. You don't have to have a nurse see you do it and this is important. You asked me before about that, the mention that I made about like the criminal entanglement, and this is what a lot of patients expressed. I even mentioned in the paper, many patients will say they feel like methadone is like having liquid shackles. They feel like prisoners of a clinic. And also, there is a lot of stigma. This is the one treatment, not benzodiazepines, not stimulants, not all sorts of other substances. This is the one treatment that you have to go to a special facility that just serves that purpose, and now everyone in your life knows exactly what you're doing in there. So it's hard to preserve any sense of privacy when you are being supervised daily, watched and at the eyes of everybody in your community.

Emma

And one of the things I've heard people complain about before, and this isn't every clinic, but the supervised urine screens in particular, are one of the things that people have often said, just make them feel like they're in prison.

Dr. Nunes

And what's most interesting about the supervised urine screen, and that's also like going to go from OTP to OTP. Many OTPs don't do that, and there are many OTPs that do, and that's a big problem with OTPs. They have been essential in providing access to those medications for decades, but as wonderful in many ways as they have been, they are clearly not doing everything that we could be doing, and we need something different. The big problem is that each OTP policy comes down to their own clinical decisions. So there are studies that show that certain OTPs will give immediate or very quickly, take-home dosing privileges. Other OTPs will have most of their patients having to come every single day. There are studies that show that there are racial and ethnic disparities, for example, in who gets those take home dose privileges versus who doesn't. There are OTPs that are going to make patients be seen as they are doing the urine screens, most others won't. In my head, personally, even if your urine screen is positive, that's just giving me information that my treatment is not at the right dose and you're still having cravings. So for me, I'm going to use that as information to optimize your treatment and make you feel better. I'm not going to use that information to hold against you. There's no point in observing you do the urine screen, because the urine screen, in my practice, is to help you.

Emma

That makes sense.

Dr. Nunes

And nobody would stop someone's methadone because the urine screen came positive for something else. So it's so arbitrary.

Emma

So what would happen to the OTPs if this bill were passed? Would they go away? Would they be optional?

Dr. Nunes

They wouldn't go away. Truth is, we have, I don't know, I think like 1000 addiction psychiatrists in the entire country. I don't know how many addiction medicine board certified specialists, either. It's not a lot of us, and there are definitely not enough to completely fill in these blanks and replace OTPs. That's not at all the goal. The bill just adds options. The bill adds a possibility that maybe someone connected well with an addiction specialist, and they want to move into this different phase of their treatment, that physician feels comfortable prescribing the medication. I have patients who wouldn't want to do it. They love going to the OTP every day. It's a source of community and observation and accountability, and for them, the OTP daily attendance model works. I have patients whose OTPs allow them to take take-home doses, and they still want to go and take it every day in person, because it serves them better. This is not about removing options. It's about increasing them.

Emma

And this bill was introduced about two years ago, 2023, why was now the right time for you to publish this paper about it?

Dr. Nunes

That question has a funny answer and a serious answer. The funny answer is that I am quite young, so by the time the bill actually came out, I was early in my psychiatry training, barely exposed to addiction treatment in the United States, so it wasn't a problem that I was aware of to begin with, because I was early in my training. So I got to write about it as soon as I learned more about it and I got more involved in it, that's the honest answer. Now what shocks me is that it took us two years to have a first peer reviewed publication on the topic in a scientific journal, in a scientific manner. The American Society of Addiction Medicine and the American Society of Emergency Medicine have been wonderful and really supportive of the Modernizing Opioid Treatment Access Act. They have published several statements.

I do want to say, the Doctors for Drug Policy Reform, that's the organization that I'm joining their board of directors right now. It's an organization that has been actively supporting these and other measures to expand treatment access and fight the criminalizing motto of addiction care. But it's surprising that it took two years for the scientific community in the traditional peer reviewed model, to actually put something out there. I'm just surprised that I even had the chance to. I thought there would already be a paper about it.

Emma

My hope was that your answer was going to be something about it gaining new momentum currently.

Dr. Nunes

That's something good should be hopeful about. If anything, I hope my paper helps with the momentum. It is also coming with a companion opinion editorial at Psychiatric News, where the call to action of that op-ed is, please call your representatives. This is a bipartisan problem. We all want to have those patients have better access to their treatments, because that makes our communities better for all of us. So you don't even have to know someone who has an opioid use disorder. Calling your representative and advocating for this bill to be highlighted is important. The bill passed a couple like major break points. It was referred to this to the Subcommittee on Health in the Senate, and then it passed from that. Now it's stuck in the house, waiting for it to be discussed there and then to continue the discussion in the Senate. It really helps if people share their stories and actually call the representatives, which is what I'm trying to do with these publications.

Emma

Okay, that makes sense. That is one of the questions I had planned to ask. If anybody hears this or reads this and they want to advocate, what should they do?

Dr. Nunes

Senator Ed Markey has a web page entirely dedicated to methadone stories. So if you're hearing this and you want to Google “Ed Markey methadone stories”, it's going to be the first link that's going to show up. You can call them. You can send it via mail. You can write a letter. They are collecting stories from people who directly live the experience of going through an OTP, family members of people who have that experience, and also maybe healthcare workers and people who work with those folks to share your stories of you know how limiting OTPs can be. Now, after sharing your stories with them, calling your representative, I can't stress this enough. This is a bill that has to go through all the House and the Senate and et cetera. So if you find out who the house officer is for your state and who the senator is, call those people. Let them know that you support this bill.

Emma

All right, so you said it's got bipartisan support. So who doesn't support it? Is there anybody who's against this bill?

Dr. Nunes

I wish there wasn't. If there wasn't anybody, maybe this would be accepted already. So historically, there are a couple organizations that try to see addiction research and addiction policy together from a scientific perspective. Some of those organizations that come to mind are the American Academy of Addiction Psychiatry and the American Society of Addiction Medicine. For OUD, in particular, we have the American Association for the Treatment of Opioid Dependence. That's AATOD, and frequently, those associations will hold hands on many issues. The MOTA act is one particular instance in which AATOD, the American Association for Treatment of Opioid Dependence, disagrees with ASAM. Historically, the people who are a part of AATOD, they are very closely related to the opioid treatment programs, so there is significant lobbying on their end, through something called the “Program, Not a Pill” campaign. And what they argue is that the treatment for opioid use disorder is much more than just a medication. You need groups, you need supervision, you need psychotherapy, you need all sorts of things, care management. You need all sorts of things that come with it. And I agree. Treating any medical disease is not just about a medication. It's about the whole lifestyle change and infrastructure that comes with it.

Now for opioid use disorder in particular, several studies have shown that the addition of those other elements is particularly important for people who are underdosed on their methadone. So that's why we run away from saying “medication assisted treatment”, because it's not assisting treatment. Medication is treatment. Those other things are treatment too. But if I have to choose between not having access to anything and just having access to methadone, my choice here is very clear. So they really argue in favor of keeping everything in the OTP structure. Maybe there is a conflict of interest, because a lot of them are involved in the leadership of those organizations, and therefore they're very interested in keeping their patients within their structure. But as I said, this bill should just be adding options, and it shouldn't be taking away from anyone.

Emma

Okay, you mentioned this idea of being underdosed. What does that feel like for somebody if they are taking methadone, but it's just not quite enough?

Dr. Nunes

My patients will complain that they are still actively craving. And craving here can have many meanings. Sometimes patients will tell me that they can't stop looking at the clock and thinking about the next dose that they have to take, and that's a horrible feeling to have.

Emma

So that's not a craving the drug of choice, though, that's like, “I can't wait to take more methadone.” That's interesting.

Dr. Nunes

Yeah, but there's that sense that it's not enough, and I can't wait to get that next dose to complement what I'm having right now, which is not ideal. That happens to lot of folks who have chronic pain and are on prescribed oxycodone every four hours, and then they are timing their clock, and it's like three hours 56 three hours 57. That's no way of living. Then there are other patients were using unprescribed opioids, and they're actively thinking about it. They're thinking about, we have things called unconscious cues. So someone goes to do blood work, and that experience of having a needle, someone taking blood out of them, and they see the needle that can trigger that, that need for the substance that they have been using. And scientific literature will describe that feeling, that craving, will significantly go down as the medication dose is more adequate. Of course, some craving is a part of a chronic disease. Patients will return to use. Patients will think about the substance. It's the effect of the substance on the brain, but when it's still uncontrollable, and the patient comes to me and says, “Doc, I need help. I can't stop thinking about it.” That's a sign we should be increasing their medication.

Emma

Yeah, that's interesting. I actually, I'm setting up an interview in two weeks. The researcher is on vacation right now. He just did a study about cravings with methadone, and I thought that was really interesting, because a lot of people say if you're not having physical withdrawal symptoms, it's enough.

Dr. Nunes

A lot of it comes from the from how methadone was originally prescribed in the past. You would have a hard cutoff of 100 milligrams, never more than that. Then the synthetic opioids came out, and they really changed the math on the morphine equivalents. People are using way more opioids than they were ever exposed to back in the 90s because of the availability of the highly potent synthetic opioids. So it doesn't make sense to recommend the same 80 milligrams today for someone who's using double, triple the amount of intensity of opioids.

Emma

Okay, so you touched on this a little bit before there's this provision in the bill that would allow states to opt in or opt out. You also touched on the fact that there's a lot of variability already between clinics. So why is that provision important?

Dr. Nunes

To allow it to pass. That's a question that I asked, I worked with the with the health officer for the office of Senator Ed Markey, and that's one of the things that she explained. That provision was not originally there. Actually, at the embryonic phase of this act, it wasn't just restricted to addiction specialists. It would have allowed more professionals to be eligible to prescribe the medication. But to allow the bill to even have a chance to pass, they had to be more strict about it, and give states the agency to opt out, which is going to create a further cascade of disparities. It's interesting. I'm always coming back to that question of the of the criminal sense of treating substance use disorder. There's a study, they looked at large amount of data in New York, and the focus was how the COVID pandemic changed treatment flows. But their baseline data is very interesting. This is a large, large, large data set of Medicaid patients in New York, and when you look white patients, they were much more likely to be on buprenorphine at baseline, and then Black and Hispanic patients were much more likely to be on methadone at baseline. So it is interesting to me, and this is very understudied, I would like to understand more and more how those things influence those changes. But there are certain populations that we're allowing to get the medication, or we are referring more often to the medication that you can take 30 days at a time, and then there are certain populations that are more likely to be put in the strict system that you have to be observed every single day to receive it. And that speaks about not the medical need, because I'm sure there are patients on buprenorphine who might think that methadone is the right choice for them, but they don't get that choice because it's so inconvenient. And maybe there are patients on methadone who would rather have the freedom of buprenorphine, or it would be so much better for their lives overall, but they're kind of tied to that being watched every day kind of structure, and that's what's offered to them. All of this is preliminary thoughts. I don't think we have good science to back any of that up, but it does come to mind.

For every other medical condition, we treat people respecting their autonomy and we do shared decision making, but for addiction, we just don't give people the option. That’s why I like the MOTA act so much. Maybe it's gonna give these folks a little bit more participation.

Emma

So when you're talking to your patients, other healthcare providers, even families, are there common misconceptions you hear about methadone or buprenorphine, either one?

Dr. Nunes

Yeah, yeah. From patients always, but that's expected. That's what we are here for. It's very disheartening how often I do hear it from healthcare professionals. The truth is, most doctors will finish their training without ever being exposed to any addiction curriculum. There are major changes in the country that try to make up for that fact, but in practice, most doctors have no idea what they are doing when it comes to patients with addiction. And just the other day, a new study shared that a lot of healthcare professionals, over 30% they have reservations about treating people with addiction. Now they compare that with other stigmatized diseases, one of them being HIV. It was 39% or something like that for substance use disorder and 9% for HIV, which I still think is too high. But back in the 80s and 90s, nobody wanted to take care of those folks, and now we see kind of the same. It's almost 40% of doctors are not willing to see someone with addiction. That's really shocking to me.

Many of the misconceptions that come up are buprenorphine and methadone are opioids, so you are replacing one addiction for another. That's just not fair to the patients or the evidence behind those treatments. Yes, they are opioids in their formulation, but they're specifically designed to treat that dependence. Here is the core issue with that, and that's how I approach a lot of physicians, healthcare workers, and the families, we are only bothered by the fact that methadone and buprenorphine are also opioids, because our goal, internally, that's how we've been educated to believe, is that someone with an addiction must be abstinent from any and all substances at all costs. Now, when we kind of revisit that expectation that the goal is for happiness, well-being, reconnecting with family, reconnecting with friends, being able to work again, being able to take care of your children, not being arrested. That completely shifts the aim of what we're doing, and who cares if they are opioids? What matters is the outcomes. And the outcomes are obvious. These medications should be offered to 100% of the patients who need them.

Emma

Absolutely okay. I think those are all the main questions I had. Is there anything you want to add or emphasize that we haven't talked about?

Dr. Nunes

Yeah, I am sorry if I sound like a broken record, but it's been my experience, even in some of the like ivory tower institutions, where all the knowledge comes from, and where you'd hope everyone has access to information, that even in those places, there's so much misconception. There are so many people. For example, there was a question that I think we didn't touch on about other potential acts or bills that might change how methadone is accessed. And one of those is back in 2020 actually, there was a bill that was passed that allows for the 72-hour rule. What it does, is it lets emergency units to prescribe up to three days of medications, including methadone, to bridge patients until they get the care that they need. Now on Psychiatric News, five days ago, four days ago, a very interesting news piece came out discussing how it's been so poorly implemented. And when I try to discuss that in some of those ivory tower institutions, frequently I get the answer that, “do we really want to start giving opioids to opioid addicts in the emergency room? They're not going to stop coming.”

Emma

No, we would just want to watch them suffer.

Dr. Nunes

That’s what we'd rather do, like that's what we'd rather do. And it breaks my heart. That's why I'm writing this paper. That's why I'm saying these things for those patients, because it's just heartbreaking knowing that we have the medications to make people's lives better, and we're not using them. We're not allowing them to use them.

Emma

That's great.

Resources:

Methadone Stories, submit your experiences to Senator Ed Markey, the bill’s sponsor here.

Find your representatives and their contact information here.

Read Dr. Nunes’ article here.