Methadone: Public Transit is a Barrier for Accessing Treatment

In a new study published in JAMA Network Open, Yale researchers examined the burdens for people who use public transit to access methadone treatment for opioid use disorder (OUD) at Opioid Treatment Programs (OTPs) in Connecticut.

While previous work has demonstrated long drive times for people using personal vehicles, these analyses did not include travel by public transit, a method of transportation used by many people who need methadone treatment.

“Not accounting for public transit access ignores transportation barriers for many people trying to access the lifesaving medication,” says Benjamin Howell, MD, MPH, assistant professor of medicine (general medicine) at Yale School of Medicine (YSM) and first author of the study.

Researchers from YSM, Yale School of Public Health (YSPH), Western University, and Virginia Tech employed a geospatial analysis to compare travel time by both personal vehicle and public transit. They used a novel, replicable methodology to evaluate these data alongside relevant patient characteristics and geographically coded overdose death incidence.

The team found that travel via public transit took, on average, five times longer than using a personal vehicle. In urban areas, the average travel time to the nearest OTP via mass transit was nearly 38 minutes.

The researchers also discovered that over half of the census block groups included in the study had limited or no public transit options to OTPs at all. Howell notes this finding makes treatment programs effectively inaccessible without a personal vehicle in some parts of the state.

Evidence-based medications for OUD, including methadone, buprenorphine, and naltrexone, are proven to significantly reduce overdose and death. However, only one in five people who could benefit from these medications receive them in a given year.

Methadone has been a gold-standard OUD treatment for several decades. While the drug is demonstrated to reduce nonprescribed opioid use, improve engagement and retention in treatment, and decrease overdose risk, a majority of patients receiving methadone treatment must visit an OTP to obtain the medication on a regular basis–in some cases, every day. Individuals without reliable access to an OTP due to transportation difficulties and geographic distance may face challenges accessing the treatment, which leads to less treatment initiation, higher rates of discontinuation, and higher risk of overdose death.

Gregg Gonsalves, PhD, associate professor of epidemiology (microbial diseases) at YSPH and senior author of the study, says federal policy surrounding this drug needs to change.

“Many other countries make this vital medicine much easier to access through primary care providers and even pharmacies,” he says. “The U.S. is way behind the curve and needs to reform its policies. Unfortunately, patients pay the price for our sluggishness and resistance to change on this drug.”

These analyses can help identify gaps in the methadone treatment infrastructure that policy and practice interventions might address, adds Junghwan Kim, PhD, MUP, assistant professor of geography at Virginia Tech, and co-author of this study.

The team envisions this research informing interventions that can address the current gap in access where it is greatest, thereby more efficiently targeting public health dollars and material resources towards improving OUD treatment outcomes and reducing opioid overdose in the state.

Other authors include: Thomas A. Thornhill, MPH; Jinhyung Lee, PhD; Emma T. Biegacki, MPH; Lauretta E. Grau, PhD; David A. Fiellin, MD; and Robert Heimer, PhD.

The Yale Program in Addiction Medicine works to expand access to and improve effectiveness of diagnosis, prevention, treatment, and harm reduction services for substance use. Our efforts span clinical practice, research, education, and policy. We provide evidence-based clinical care, conduct rigorous and innovative research, train the next generation of addiction specialists, and engage in policy and advocacy initiatives at the local, state, and national levels. Learn more about how you can support this and other practice-changing work.