Methadone Maintenance Treatment for Older Adults: Cost and Logistical Considerations

As the opioid epidemic in the United States worsens, the need for medication-assisted treatment (MAT) for opioid use disorder continues to grow. Over 300,000 people in the United States are now enrolled in methadone maintenance treatment (MMT) programs for opioid use disorder, roughly 10 times the number of people using buprenorphine (1). A robust literature supports MMT in effectively reducing mortality and improving quality of life (2,3). In recent years, the age demographics among MMT recipients have shifted sharply; a recent study in New York City suggests that 13% of adults receiving MMT are over 60 years of age. Additionally, adults ages 50–59 years were among the largest age demographic receiving MMT, evidence that the total number of older adults receiving MMT will continue to rise (4). A proportion of this older population began MMT soon after it became available in 1972, continued indefinitely, and are advancing in age, whereas others entered treatment much later in life. Scant literature on this population exists, however. As such, this growing and understudied population warrants a consideration of care trajectories, logistical considerations, and health policies.

Cost and Policy Issues

Medical comorbidities and neurobehavioral changes often accumulate with age. These age-related changes are often accompanied by cognitive decline, with the result that adults on MMT who are advancing into older age become increasingly vulnerable to drug-drug interactions and potential side effects of MMT. These age-related changes pose challenges to remaining in MMT programs. As adults on MMT advance in age, they must continue to adhere to MMT federal regulations. For example, MMT requires visits for methadone administration that may range from daily to every 28 days, depending on a myriad of factors, including current phase of treatment, ongoing use of cannabis or other illicit substances, and concomitant use of controlled prescription medication. Federal requirements also mandate that MMT recipients attend counseling appointments, visit regularly with methadone prescribers, and comply with toxicology screens. Additionally, MMT recipients are required to respond to random and same-day requests to present with take-home methadone bottles for counting as a screen for treatment adherence and diversion. Although these treatment requirements ensure safety and prevent diversion, such regulations may pose challenges to older adults experiencing a decline in health and functional status and restricted mobility.

Additionally, problems with accessing MMT are exacerbated considerably for older adults who become homebound or who require transfer to long-term care facilities. Nursing homes and other long-term care facilities, as well as home health agencies, generally do not administer methadone when it is used for the treatment of opioid use disorder (5). Although skilled nursing facilities are permitted to administer methadone temporarily to individuals admitted for short-term medical/surgical rehabilitation, long-term residents of skilled nursing or assisted living facilities must be enrolled in an MMT program, which may be impractical or impossible in many cases. In some cases, facilities may accommodate select patient populations—such as individuals living with HIV—but in general, patients’ need for continued methadone maintenance for opioid use disorder may not be accommodated. MMT recipients who require long-term residential care may be required to taper methadone quickly, even when it is counter to patients’ wishes. Tapering MMT can be a time-consuming process; decreasing methadone by 1 mg per week is not uncommon, especially among long-term users. Yet amid a rapid decline in health status, a preferred slow taper may not be possible. Scant literature exists on how medical frailty potentially exacerbates the physiological stress of methadone withdrawal.

Equally problematic for community-dwelling older adults is the substantial cost of MMT. As adults reach 65 years of age, when most Americans depend on Medicare for health care coverage, out-of-pocket expenses increase, because Medicare does not currently pay for methadone when it is prescribed to treat opioid use disorder (6). Although methadone is covered under Medicare Part D when it is prescribed for pain management, federal restrictions mandate that methadone be dispensed from a federally approved clinic when it is used for the treatment of opioid use disorder, therefore deeming it ineligible for pharmacy benefits. These federal mandates, which regulate methadone dispensation, are unique and do not apply to the two other forms of MAT, both which are eligible for Medicare reimbursement: buprenorphine (approved in 2002) (7) and long-acting naltrexone injection (approved in 2010) (8). As a result, older adults receiving MMT report higher out-of-pocket expenses on transition to Medicare. In our experience, processes for claims reimbursement are subject to an arduous process, during which claims must first be submitted to Medicare to await denial. Only then may eligible states provide reimbursement for opioid use disorder treatment via state block grants. For dual Medicaid and Medicare holders, a similar process exists, in which Medicare must first deny claims before submission to Medicaid. Medicaid coverage for MMT varies from state to state, so that dual Medicaid and Medicare holders may have little recourse for payment relief.

Although the Affordable Care Act (ACA) designated addiction treatment services as essential health benefits (EHBs) and required parity, methadone was not explicitly included because the EHB category for prescription drugs is based on the US Pharmacopeia Medicare Model Guidelines, which excludes methadone (9). One recent analysis of 2017 EHB benchmark plans by the National Center on Addiction and Substance Abuse found that seven states’ benchmark plans explicitly exclude methadone, three states explicitly cover methadone, and the rest do not address methadone at all (9). Projected changes to both the ACA and EHBs are anticipated, though to what extent is unclear. Although there are no epidemiological data available to quantify the number of affected Medicare recipients paying out of pocket for MMT, it is clear that as the U.S. government considers changes to funding mechanisms, providing access to MMT and addressing the unique treatment needs of older adults should be considered.

Clinical Needs of Older MMT Users

The clinical needs of adults of advancing age receiving MMT have received minimal attention. Our ongoing qualitative work with long-term MMT users in Rhode Island indicate that in many cases, adults ages 65 and older who have used MMT for decades have no immediate or long-term plans to taper methadone. For those who plan to discontinue treatment, such plans are often vague and ill-defined. Adults of advancing age report anxiety at the prospect of entering very old age and being opiate dependent yet also report anxiety at the prospect of discontinuing treatment. Cross-tapering to an alternative form of MAT, such as buprenorphine (agonist) or naltrexone (antagonist) may be a theoretical possibility, yet this possibility often provokes anxiety and distress for patients worried about potential rebound pain, opiate withdrawal, and the prospect of relapse.

Clinical guidelines are lacking that would assist in treatment decisions for determining when MMT should be tapered and discontinued. Determining when to discontinue with either a slow or a rapid taper, or when to switch to an alternative MAT option, is needed for healthy older adults who have received long-term MMT for years, as well as for those experiencing a decline in health status when the need for medication changes become more urgent. Equally important is ensuring that relevant structural supports are in place (continuing MMT within long-term care or skilled nursing facilities) when the decision to continue MMT is the optimal clinical choice.

Conclusions

The proportion of older adults receiving MMT is expected to rise (4). For long-term users of MMT, indefinite treatment into very old age is likely. Furthermore, during a nationwide epidemic, older adults are also vulnerable to late-onset opioid use disorder. MMT—a clinically and cost-effective treatment option—will remain the optimal treatment choice for many. Yet understanding when treatment may no longer be clinically indicated—and developing treatment algorithms to assist providers and patients in treatment decisions—is especially important for adults advancing in age. Research and clinical guidance are needed to develop evidence-based guidelines that consider the physical, mental, and social health of older adults receiving MMT. Given the changing health care system and the growing opioid epidemic, reconsideration of clinical treatment and related policies to ensure continuation of care for older adults with OUD is especially timely.