Climate disasters create life-threatening disruptions for people on methadone

Climate disasters are now part of America’s day-to-day landscape — including our health care system. In recent weeks, we have watched devastating flooding move through Texas while slow-moving storms crawled up the East Coast, drenching already saturated landscapes, resulting in more flooding. Last year, Hurricane Helene washed out much of central North Carolina’s roads and infrastructure, while the Palisades and Eaton wildfires in Southern California devastated entire communities.

More and more, we are seeing news articles pop up about how to access needed medications if caught in a climate disaster, or how to prepare for climate disasters if you have a disability. Some governmental steps are being taken to help. For instance, in May, the Missouri governor signed an executive order to assist individuals affected by recent storms in receiving prescribed medications, even if their prescriptions were lost or destroyed, their records are unavailable, or their original prescribing physician is unavailable.

However, that won’t help people on methadone. Due to onerous restrictions on their medication, those on methadone face life-threatening disruptions to their care while navigating direct endangerment from climate disasters. As climate disasters become increasingly frequent, they highlight a stark reality: Our country’s reliance on opioid treatment programs (OTPs) as the exclusive dispensers of methadone is untenable in our evolving world of frequent climate disasters. 

In the United States, people with opioid use disorder can get methadone only from strictly regulated OTPs, colloquially called methadone clinics. Methadone is a lifesaving medication, reducing the risk of death by more than half. Unlike almost all other prescribed medications, methadone cannot be dispensed by community pharmacies in the United States. Patients must travel to methadone clinics — often daily — to receive their doses. OTPs are also few and far between, with fewer than 20% of U.S. counties having an OTP.  

Even under normal circumstances, OTPs can be a logistical hassle. They often have limited opening hours, requiring patients to navigate unreliable public transportation systems or drive long distances on a daily basis — regardless of weather, other illnesses, work schedules, or child care demands. Many people who thrive on methadone are forced to discontinue treatment because of these barriers.

In a crisis or natural disaster, such as what happened in Texas, the problem is compounded. Many OTPs close for safety reasons during natural disasters, but even if they are open, patients often can’t make it due to damaged infrastructure, road closures, public transportation systems shutdowns, or evacuation orders. Further, people, including those who work at the OTP, may be unable to reach clinics for the same reasons. One recent study found that communities most susceptible to natural disasters have the least access to methadone treatment and are most likely to suffer disruptions to treatment. 

Disruptions to care can lead people who rely on methadone for long-term recovery to return to fentanyl use, leading to an increased risk of overdose and death. In a crisis, they have an impossible choice: risk their lives to go without their medication or risk their lives trying to access medication in unsafe weather conditions.

The U.S. has already witnessed the impact of climate disasters on people taking methadone. During Hurricane Sandy in 2012, many patients in New York and New Jersey were cut off from their medication as clinics closed or became inaccessible. Similar disruptions occurred in Puerto Rico after Hurricanes Irma and Maria in 2017, when damaged infrastructure and clinic closures left patients unable to access treatment.

The fallout was tragic: People experiencing excruciating withdrawal without their methadone returned to illicit opioid use, resulting in overdoses and deaths. With a nation averaging more than 70,000 opioid overdose deaths a year, changing methadone access to a more human-centered approach can help prevent needless overdoses. And while the U.S. recently saw a decrease in overdose deaths, these numbers are now ticking upward again.

Other countries provide evidence that this grim reality is not inevitable. In Canada, the United Kingdom, and Australia, methadone is readily available through community pharmacies. People affected by natural disasters can pick up their medication from another pharmacy, just as they would any other prescription, reducing the dependency on centralized clinics and making the system more resilient to disruptions. Decentralized access through pharmacies also helps integrate methadone into the broader health care system, ensuring better continuity of care.

The United States, however, remains tied to its siloed OTP system. Methadone records remain separate from other medical records, and health systems are barred from communicating effectively with one another when it comes to methadone treatment. As a result, people on methadone are uniquely vulnerable when disasters strike, unable to access care in settings where other medications are routinely dispensed. 

The U.S.’s reliance on OTPs as the exclusive providers of methadone is not just an inconvenience — it is anathema to a world grappling with escalating climate disasters. The system designed to serve people with opioid use disorder should not exacerbate their risks during times of crisis.

Increased flexibility around take-home doses of methadone, especially during emergencies, would help solve the problem. In 2020, the Substance Abuse and Mental Health Services Administration issued guidance allowing OTPs to expand the number of take-home doses of methadone during the Covid-19 pandemic.

However, these measures were time-limited relaxations rather than formal policy changes, allowing states and clinics to implement them through less formal procedures without permanently altering existing state regulations. While this was a step in the right direction, its implementation was uneven at best, in part due to largely unfounded fears of medication diversion. Studies have shown that most OTPs did not fully adopt these guidelines, leaving many patients to continue daily visits despite the risks posed by the global pandemic. Of those clinics that did implement the guidance, researchers have found no evidence that methadone diversion increased. 

In 2024, updated regulations formally codified many of these flexibilities. But the lack of clear implementation process remains, and states have the option to implement or not. That means many OTPs still have more conservative policies.

Efforts to modernize our methadone treatment systems are desperately needed, as the tightly controlled distribution system through OTPs fails to meet the demands of an increasingly unpredictable world. The intensifying climate crisis demands a reimagining of how we deliver health care, particularly for those with chronic conditions like opioid use disorder. Methadone is a proven, lifesaving treatment, but our current system of distribution is failing to protect the very people it is meant to serve. 

Leslie W. Suen, M.D., is a primary care and addiction medicine doctor, and an assistant professor at the University of California, San Francisco. Kate E. Roberts, Ph.D. M.A., L.C.S.W., is a deputy director of behavioral health policy and substance use treatment researcher at Aurrera Health Group. Rachel Luba, Ph.D., is a clinical psychologist and researcher interested in improving treatment options for opioid use disorder.