Episode Summary: How Do We Treat Opioid Addiction?

Podcast: New Books Network – New Books in Drugs, Addiction and Recovery
Host: Emily Dufton
Guest: Mark Parrino, President of the American Association for the Treatment of Opioid Dependence (AATOD)
Date: January 19, 2026

Overview

This episode diverges from New Books Network’s usual book interviews to focus on a landmark report: a comprehensive census of patients in U.S. certified opioid treatment programs (OTPs) and the medications they receive. Host Emily Dufton talks to Mark Parrino, whose five decades of frontline experience in opioid treatment bring rich historical insight and a practical lens on America’s current overdose crisis. The conversation explores the historic development of opioid agonist treatment, the enduring controversies and stigma, how regulation shaped and siloed the field, the fentanyl-driven crisis, and possible futures for expanding effective care.

Key Discussion Points & Insights

1. The Origin and Controversy of Methadone Treatment

• Medical Breakthrough (02:52–03:51)

  • Methadone maintenance began in the mid-1960s with research by Vincent Dole, Marie Niswander, and Mary Jeanne Kreek at Rockefeller University.
  • Methadone creates a “barrier” that blocks heroin’s effects—an “important pharmacologic breakthrough” (C, 03:32).

• Treatment Before Methadone (03:51–04:45)

  • Previously dominated by abstinence-only approaches or ineffective medications.
  • Cold turkey or gradual withdrawal was the norm, often unsuccessful.

• Regulatory and Cultural Pushback (04:45–07:04)

  • Methadone treatment met intense skepticism and enforcement hostility.
  • “It seems counterintuitive to use an opioid to treat opioid addiction.” (C, 05:33)
  • Persistent stigma is due in part to lack of public education on why medication works.

2. The Regulatory Isolation (“Siloing”) of OTPs

• Formation of Specialized Clinics (07:55–12:21)

  • Methadone’s rejection by mainstream medicine led to standalone clinics.
  • Intensive federal regulation began in the 1970s, requiring registration with both the FDA and DEA.
  • Community opposition (NIMBYism) and restrictive zoning were major barriers to clinic expansion.

• Stigma’s Price

  • Strong local and societal opposition hindered expansion and visibility.

3. Firsthand Perspective: Entering the Field

• Parrino’s career started in 1974 in Manhattan, when methadone clinics were still new, doubted, underdeveloped, and often met with hostility (12:51–14:46).

• Mid-1980s Backlash

  • Media attacks (like Florida’s “Methadone: The Deadly Cure” series) reinforced negative perceptions.

• Response and Advocacy: The Birth of AATOD (14:46–15:08)

  • Parrino co-founded an advocacy organization that grew to 29 state chapters, representing 1,300 programs.

4. The Broader Opioid Crisis and Practice Evolution

• Prescription Crisis (15:08–20:45)

  • Opioid epidemic’s recent phase started with widespread prescription painkillers in the late 1990s.
  • “There was tremendous pressure on doctors and hospitals to treat their patients and effectively manage pain... There was not any effective education for the patients.” (C, 16:35)

• Changing Patient Demographics (20:45–24:36)

  • Today, the crisis is driven by fentanyl, responsible for about 70% of current opioid-related U.S. deaths.
  • Newer waves include more patients who are white, middle class, and who began by injecting prescription opioids before turning to heroin or fentanyl.

• Modern Policy Measures

  • New federal regulations are encouraging mobile methadone vans, better data, and some creative outreach strategies, like expanding into the justice system with mandated medication access in prisons.

5. Insights from the 2022 Census Report

• Snapshot Findings (26:03–30:09)

  • As of January 2021, there were about 1,837 programs and ~513,000 patients (with an 85% response rate; the true number is likely higher).
  • Over 480,000 were using methadone, reflecting both regulatory restrictions and the fact that fentanyl requires “a full agonist” medication.
  • Methadone can only be dispensed from OTPs; buprenorphine, newly deregulated, can now be more widely prescribed.

  “I use [‘snapshot in time’] because I'm anticipating a significant expansion to treatment access ... particularly in underserved suburban and rural communities.” (C, 26:03)

• Buprenorphine Policy Shift (30:09–32:13)

  • The removal of the “X waiver” theoretically opens the doors for more prescribers, though real physician utilization lags.

  “Throughout the 20 year history of buprenorphine use in private settings, you never have more than 50% of active prescribers treating patients.” (C, 31:42)

  • A new “MATE Act” may require more training for all opioid prescribers, correcting past mistakes of poor practitioner education.

6. Growing the Treatment System

• Program Expansion (34:31–38:46)

  • OTP patient enrollments jumped from 347,000 (2020) to over 512,000 (2021), likely due to rising fentanyl addiction and expanded insurance coverage.
  • Opening a new OTP requires federal, state, and DEA approval, and staffing is regulated to ensure quality (e.g. counselor-patient ratios).

• Professionalization

  • Marked improvement over the early system; increasing optimism about clinical standards and “greater professionalism... not the case in the 1970s.” (C, 38:46)

7. Optimism, Ongoing Barriers, and Future Directions

• Recent Progress (40:25–44:09)

  • New regulations and training requirements, expanded access to care (including for inmates), and government support are all positive shifts.
  • Long-term: practice is slowly being integrated more into holistic, collaborative care.

• Methadone’s Value Despite Skepticism

  • Used-car analogy: “This is a used car that will keep going with great mileage, will not need much in the terms of repair, and will get you from one place to the other with regularity.” (C, 45:04)

• Correctional System Shifts

  • Treating inmates reduces both post-release mortality (>50% decrease) and recidivism (55% decrease).

  “You have, for lack of a better way of putting it, a captive audience... [treatment in jail] reduces recidivism. Now we've learned that works.” (C, 46:16)

Notable Quotes & Memorable Moments

• On Medication Stigma:
  “It seems counterintuitive to use an opioid to treat opioid addiction ... there’s never been a public education campaign ... that explains how the medications are useful and where they are effective. So people are left to their own consideration ... and that's part of why this is still a stigmatized treatment.”
  —Mark Parrino, 05:33

• On System Isolation:
  “If you wanted to see a community organize, even businesses and neighbors that wouldn’t talk to one another, all you had to do was say, ‘We’re going to open up a methadone treatment program.’ That’s when the NIMBY...is seen, because it’s a direct threat.”
  —Mark Parrino, 10:51

• On Patient Demographics Changing:
  “Of that 45% [prescription opioid admissions], 30% were injecting ... at that time ... about 70% of their population are middle class white patients.”
  —Mark Parrino, 19:11

• On Methadone’s Double-Edged Sword:
  “Methadone is an extremely effective medication when used properly, but it’s an unforgiving medication when it’s used improperly.”
  —Mark Parrino, 33:51

• On Inmate Treatment Impact:
  “As the inmate is inducted with medications during their period of confinement, and then referred upon release ... there has been a decrease of more than 50% in post-release mortality, and ... in recidivism, by 55%.”
  —Mark Parrino, 47:47

• Looking Forward:
  “It's not like an electric switch...but it is heading in a proper direction in my judgment...longevity in the system will help you. After 40 years ... you get an idea of what works and what doesn't work.”
  —Mark Parrino, 40:54

Timestamps for Key Segments

• History of Methadone Treatment: 02:52–09:24
• Siloing and Regulation of OTPs: 09:24–12:21
• AATOD and the Dark Ages of Methadone: 14:46–20:45
• Rise of Prescription Epidemic & Fentanyl: 20:45–24:36
• 2022 Census Snapshot and Policy Change: 26:03–34:31
• Opening an OTP, Regulatory Demands: 36:25–38:46
• Professional Expansion & Optimism: 38:46–41:33
• Correctional System & Treatment Impact: 43:22–48:30
• Parrino's Core Recommendations: 49:03–53:22

Recommendations and Closing Thoughts

• Holistic Treatment:
  Emphasize opioid use disorder's complexity—comorbidity with mental health, trauma, and infectious disease.
• Public Education:
  Educate the public to fight stigma and dispel misconceptions.
• Thoughtful Policy:
  Avoid “quick fixes”; consider history and context to prevent repeating failed approaches.
• Focus on Equity:
  Expand treatment access beyond urban centers, and especially in correctional facilities.
• Stay Up to Date:
  Read the full census report at aatod.org.

This conversation provides a deep, nuanced look at opioid treatment’s past, present, and future—grounded in data, historical experience, and pragmatic optimism. Highly informative for anyone seeking to understand the realities and policy challenges of treating opioid addiction in 21st-century America.