An analysis of 2023 transportation data in Connecticut has found that more than half of the state’s census regions lack sufficient public transit access to opioid treatment programs (OTPs), leaving vulnerable many of the residents who are most in need of methadone treatment. Administrators of OTPs point out, however, that this research took place prior to the 2024 enactment of dramatic federal regulatory changes that expanded use of take-home medication and other strategies for making methadone treatment more accessible.
Published February 3 in JAMA Network Open, the study reported a statewide median travel time of 41.7 minutes by public transit to the closest OTP (compared with 11 minutes by car). A total of 53% of the state’s census block groups (small subdivisions of census tracts) were found to have either no access to public transit or a travel time of more than an hour, posing a particularly difficult hurdle for individuals who don’t have cars but also don’t live in urban centers.
Researchers led by Benjamin A. Howell, M.D., M.P.H., assistant professor of medicine at the Yale School of Medicine, suggested that efforts to expand access to methadone treatment through new brick-and-mortar OTP sites or mobile units should focus on communities with poor transit access and high overdose rates. However, they also argued that even more could be accomplished at the federal regulatory level, citing the potential benefit of office-based methadone treatment as proposed in the federal Modernizing Opioid Treatment Act (MOTA).
That view comes under strict criticism from OTP administrators such as Linda Hurley, CEO of CODAC Behavioral Healthcare in Rhode Island. She told ADAW that while the Connecticut study’s findings are valid and reflect transportation challenges that all states have experienced, the researchers’ policy conclusions are flawed because they are based on an outdated regulatory environment that required daily in-person attendance for most OTP clients.
“The loosening of the regulations have made the reasoning behind MOTA anachronistic,” Hurley said. “There was required daily or almost daily criteria. Now we’re being supported in getting the medication to the people who need it, by the regulatory agencies.
”CODAC operates eight OTP sites in Rhode Island, but at present more than half of its methadone patients are now receiving six or more daily take-home doses at a time, Hurley said. This all has been made possible by the regulatory changes that the Substance Abuse and Mental Health Services Administration (SAMHSA) finalized in 2024 to expand access to take-home medication dosing and telehealth for supportive counseling.
The study’s researchers, two of whom received funding support from the National Institute on Drug Abuse (NIDA), stated that most prior studies on transportation access to OTP services focused on drive times with a personal automobile. This geospatial analysis compared access to Connecticut’s 29 OTP sites by personal vehicle and public transit.
The outcome of interest was an estimate of the minimum travel time from each of the state’s 2,702 census block groups to the nearest OTP, using a standard departure time of8 a.m. on a Wednesday to reflect typical travel during an OTP’s business hours. The researchers also collected data on each geographic area’s income level, racial composition, and opioid-involved overdose death rate.
The research team found that 53% of the census block groups in Connecticut either had no access to public transit or were subject to excessively long travel times. Median travel times in rural areas of the state were 19.4 minutes by car and 57.4 minutes by public transit, compared with 8.2 minutes by car and 32.3 minutes by public transit in rural areas.
“The study’s findings are relevant to other states,” Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA) and vice president of the West Midtown Medical Group told ADAW. “The findings regarding urban/suburban and rural travel certainly relate to what we see in New York state.”
Median travel times by either transportation method were shorter in census block areas with a higher proportion of Black or Hispanic residents, the researchers reported.Median travel times were longer in areas with lower fatal overdose rates. These data points reflect the greater concentration of OTP locations in those communities.
The study’s authors wrote that their research “demonstrates methadone treatment may be essentially inaccessible via public transit in many parts of Connecticut. Severe OUD is often associated with fewer financial resources and higher likelihood of reliance on public transit for daily travel. Incorporating public transit access provides a more comprehensive and accurate portrayal of the transportation barriers to OTPs."
In both the JAMA Network Open paper and an accompanying commentary, authors suggest that the access-expanding measures adopted so far are important but not sufficient. Howell and colleagues wrote in the paper that MOTA “would have changed federal statute to allow for office-prescribed, pharmacy-dispensed methadone. Several studies have shown comparable treatment outcomes for patients treated in these types of models and can extend methadone treatment access beyond fixed-location OTPs.” The referenced studies of methadone maintenance in primary care were published in JAMA in 2001 and the American Journal of Psychiatry in 2021.
Hurley and Schorr disagreed with this reasoning. Hurley said office based treatment would work only for otherwise well-situated individuals who are successfully meeting their goals. For the many patients struggling in early recovery, the expanded services that are becoming more common in the OTP community deliver whole-person care that primary care providers can’t match, she suggested.
“This is a highly complex disease,” Hurley said. “People who are struggling are not safe yet. They need counseling; they need help with housing; they need help with food stability.
”In the commentary accompanying the study, Noa Krawczyk, Ph.D.,and David Frank, Ph.D., both affiliated with New York University, wrote that uptake of take-home flexibilities and establishment of new mobile treatment units have been slow. They suggested that office-based treatment would reduce travel time and help integrate care across multiple settings, although they expressed doubt over whether policymakers will ultimately embrace MOTA.
Krawczyk and Frank, who serve on the board of a group called the Coalition to Liberate Methadone, wrote that “methadone still remains shackled by ineffective policies that devalue the time and needs of people who use opioids.” Schorr strongly disagreed, reiterating that the study on which they were commenting did not account for the 2024 regulatory changes.
“There’s no evidence that the proposed MOTA would have a positive impact on nonurban transportation issues,” she said. “The much-anticipated increase in access to buprenorphine as a result of the elimination of the DATA 2000 waiver failed to materialize. There are real risks to MOTA, and not much evidence that supports the commentary.
”Another co-author of the study paper, Yale Program in Addiction Medicine director David A. Fiellin, M.D., is chairing a newly formed National Methadone Access and Quality Commission. Yale received a $917,000 grant from the Foundation for Opioid Response Efforts to establish the commission.
A January 28 announcement of the commission’s launch stated that the effort will bring together leaders in addiction medicine, healthcare delivery, public health, and public policy to inform change and increase the public’s understanding of methadone treatment. The announcement gave little indication as to what direction the panel ultimately might take.
Fiellin said in the announcement: “The goal of the commission is not to promote a single viewpoint, but to elevate evidence, improve quality and ensure that people who need care can access it.”
Last week, the Department of Health and Human Services (HHS) terminated grants to Centers for Disease Control and Prevention (CDC) programs in fourstates: California, Minnesota, Illinois, and Colorado. The targeted states were all Democratic, reporters noted. The terminated grants encompass those relating to HIV, sexually transmitted diseases, Racial and Ethnic Approaches to Community Health (REACH) — which includes a focus on tobacco prevention,the Public Health Infrastructure Grant, and the Behavioral Risk Factor Surveillance System. The total amount of the eliminated grants is about $600 million. The cuts got little mention in the press. •
“The loosening of the regulations have made the reasoning behind MOTA anachronistic.”
The research team found that 53% of the census block groups in Connecticut either had no access to public transit or were subject to excessively long travel times.
“The goal of the commission is not to promote a single viewpoint, but to elevate evidence, improve quality and ensure that people who need care can access it.”
