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New federal rules make it much easier to expand access to treatment

July 28, 2022

Jason Brian Gibbons is a postdoctoral fellow in the Department of Health Policy & Management at the Johns Hopkins School of Public Health. He is currently working on a multidisciplinary team evaluating state-level opioid policy reform as a part of the Bloomberg Overdose Prevention Initiative. We talked to him to better understand one of the strategies to increase access to evidence-based treatment: Mobile Methadone. 

What is mobile methadone?

Mobile methadone is the practice of providing methadone–one of the evidence-based treatment options for people with an opioid use disorder–to patients through a vehicle known as a mobile unit. The mobile unit is effectively a moving satellite methadone treatment center that operates under the license of an existing brick-and-mortar opioid treatment program. The mobile unit can travel to any location to treat patients and is often sent to treat patients in historically underserved communities. This includes rural communities, jails and prisons, residential treatment centers, halfway homes, and more.

Mobile methadone units are typically operated by one or two staff members from the brick-and-mortar opioid treatment program eligible to provide methadone and other behavioral health care services like drug testing. They are often partitioned internally into different sections that serve different purposes (e.g., front desk, treatment room, bathroom, etc.) and usually have complete indoor plumbing. In some cases, external providers offer telehealth for counseling within a separate section of the mobile unit.

The standard federal, state, and local methadone laws that apply to brick-and-mortar opioid treatment programs similarly apply to mobile units. Methadone must be stored in secured safes onboard the mobile unit, and all distributed doses must be carefully accounted for with reporting of utilization directly to the Drug Enforcement Administration (DEA) for review. The unit itself must receive inspection and approval by DEA auditors before any operations can begin.

Mobile units must be stored at the brick-and-mortar opioid treatment program it is affiliated with at the end of each business day so that all medications taken out for the day can be returned. This means that each mile a mobile unit travels to a service location must be retraversed at the end of each day. Waivers to allow mobile units to be parked in gated areas may be obtained from the DEA under exceptional circumstances.

The federal government just loosened rules regarding mobile methadone. Tell us what they did and why it was so noteworthy.

In July of 2021, the DEA created what is now known colloquially as the mobile methadone rule. The mobile methadone rule allows existing brick-and-mortar units to establish mobile units under their treatment waiver. This rule represents a significant shift in previous policy around mobile units. Historically, mobile unit licenses were separate from brick-and-mortar opioid treatment programs and were only granted under extreme circumstances such as natural disasters that directly cut off people’s access to opioid treatment programs (e.g., Hurricane Katrina). Although allowing opioid treatment programs to operate satellite locations such as mobile units has been advocated for years, the COVID-19 pandemic created an additional precedent for the DEA to increase its flexibility around mobile methadone.

Unfortunately, since the policy was rolled out, very few brick-and-mortar opioid treatment programs have chosen to begin operating a mobile unit. There are many challenges to setting up a mobile unit, most notably the operation costs. The mobile van with the necessary infrastructure has been estimated to cost between $200,000-$300,000. There are also many variable costs like labor to operate the unit and handle new administrative and billing issues, medication supplies, repairs, and gas for the vehicle. Most mobile units have to operate using funding from philanthropy and other sources as existing reimbursement for services typically does not offset costs of operation (especially since many patients mobile units encounter are uninsured).

States and local governments are receiving money from the opioid litigation. How should they think through whether they should invest in mobile methadone? 

The new opioid litigation funds create an important opportunity for states to expand mobile methadone services. As mentioned, external funding is essential to ensuring that opioid treatment programs can afford to operate a mobile unit. States should create special mobile methadone grants that provide upfront payments to brick-and-mortar units to purchase a vehicle and additional funding for basic operating expenses. This funding could make the difference between a few operators entering the market and all opioid treatment programs in the state offering mobile methadone. The state may even realize economic benefits from providing this funding; opioid overdoses can be extremely expensive for state Medicaid programs and law enforcement. Moreover, methadone is a gold standard treatment option for opioid use disorder, especially for patients with greater severity of illness. Existing methadone treatment options in many states are insufficient to meet service demand, so mobile methadone may be able to fill these gaps.

Tell us about your research into mobile methadone. What questions are you exploring, and when can we expect to see something? 

Operating a mobile unit is challenging. One of the most complex parts is figuring out where to use the vehicle to ensure it has the greatest possible impact given operational and legal constraints. In collaboration with other colleagues from Johns Hopkins, I have been working to develop a simulation model that estimates the potential treatment impact that could result from sending mobile units to different locations. This model leverages the relationship between observed treatment rates and patient proximity to treatment locations to estimate hypothetical treatment rates in a fictional world where prospective mobile units closed the gap between patients and viable treatment options. The paper summarizing the model and some preliminary results of employing it to study a sample of Louisiana Medicaid patients will be sent out for peer-review later this summer. In addition, we have recently submitted an Agency for Health Research and Quality R21 research grant to further develop and apply the simulation model in New York. For this work, we will partner with New York’s Office of Addiction Services and Supports to help optimize mobile unit location choices in the state, study their impacts on methadone treatment rates, and interview operators and community members about facilitators and barriers to implementation. This work will likely pick up in Fall 2022.

Where can people go for more information? 

Interested readers can visit the federal register to learn specific details about the regulations related to the new DEA rule.  To learn more about facilitators and barriers to mobile methadone  implementation, I would recommend reading two recent articles that were published in Health Affairs and JAMA Psychiatry.  A brief history of mobile methadone was also recently published in the Journal of Substance Abuse Treatment.  Finally, a press release regarding the first mobile unit to be approved under the new rule can be found here.

Jason’s research is at the intersection of industrial organization, applied econometrics, machine learning, pharmacoepidemiology, and mental health and substance use disorder policy. He has previously held research positions with the United States Department of Veteran Affairs, the Michigan Department of Health and Human Services, and the Massachusetts Health Policy Commission, and the Institute for Health Policy and Innovation at the University of Michigan. He received his PhD in Health Services Organization and Policy (Economics Cognate) from the University of Michigan and his BA in economics from the University of Chicago.