Methadone Matters: What the United States Can Learn from the Global Effort to Treat Opioid Addiction

Rural opioid treatment program patient perspectives on take-home methadone policy changes during COVID-19: a qualitative thematic analysis

BACKGROUND

In the United States, methadone for opioid use disorder (OUD) is highly regulated. Federal agencies announced guidelines in March 2020 allowing for relaxation of take-home methadone dispensing at opioid treatment programs (OTPs) to improve treatment access and reduce COVID-19 transmission risk during the public health emergency. We explored patient perspectives at three OTPs serving rural communities on how take-home policy changes were received and implemented and how these changes impacted their addiction treatment and recovery.

METHODS

We completed semi-structured individual qualitative interviews in 2 phases: (1) August-October 2020 and (2) November 2020-January 2021 (total n = 46), anticipating possible policy changes as the pandemic progressed. We interviewed patients with OUD enrolled at 3 rural OTPs in Oregon. Participants received varying take-home methadone allowances following the COVID-19-related policy changes. All interviews were conducted via phone, audio-recorded, and transcribed. We conducted a thematic analysis, iteratively coding transcripts, and deductively and inductively generating codes.

RESULTS

The 46 participants included 50% women and 89% had Medicaid insurance. Three main themes emerged in the analysis, with no differences between study phases: (1) Adapting to changing OTP policies throughout the pandemic; (2) Recognizing the benefits, and occasional struggles, with increased take-home methadone dosing; and (3) Continuing policies and procedures post-pandemic. Participants described fears and anxieties around ongoing methadone access and safety concerns prior to OTP policy changes, but quickly adapted as protocols soon seemed "natural." The majority of participants acknowledged significant benefits to increased take-homes independent of reducing COVID-19 infection risk including feeling "more like a normal person," improved recovery support, reduced time traveling, and having more time with family and for work. Looking to a post-pandemic future, participants thought some COVID-19-related safety protocols should continue that would reduce risk of other infections, make OTP settings less stressful, and result in more individualized care.

CONCLUSIONS

As the pandemic progressed, study participants adapted to rapidly changing OTP policies. Participants noted many unanticipated benefits to increased take-home methadone and other COVID-19 protocols including strengthened self-efficacy and recovery and reduced interpersonal conflict, with limited evidence of diversion. Patient perspectives should inform future policies to better address the ongoing overdose epidemic.

Treatment provider perceptions of take-home methadone regulation before and during COVID-19

BACKGROUND

The loosening of U.S. methadone regulations during the COVID-19 pandemic expanded calls for methadone reform. This study examines professional perceptions of methadone take-home dose regulation before and during the COVID-19 pandemic to understand responses to varied methadone distribution policies.

METHODS

Fifty-nine substance use disorder treatment professionals were interviewed between 2017 and 2020 in-person or over video call. An inductive iterative coding process was used to analyze the data. Constructivist grounded theory guided the collection and analysis of in-depth interviews.

RESULTS

Treatment professionals expressed mixed views toward methadone take-home regulations. Participants justified regulation using several arguments: 1) patient care benefitting from supervision, 2) attributing improved patient safety to take-home regulation, 3) fearing liability for methadone-related harms, and 4) relying on buprenorphine as an "escape hatch" for patients who cannot manage MMT policies. Other professionals suggested partial deregulation, while others strongly opposed pre-pandemic take-home regulation, explaining such regulations impede medication access and hinder patient-centered care. Some professionals supported the COVID-19 policy changes and saw these as a test run for broader deregulation, while others framed the changes as temporary and cautiously applied deregulation to their services, at times revoking looser rules for patients they perceived as nonadherent.

CONCLUSION

Treatment professionals working in a range of modalities, including opioid treatment programs, expressed hesitation toward expanded take-home methadone access. While some participants also supported forms of deregulation, post-pandemic efforts to extend looser methadone distribution policies will have to address apprehensive professionals if such policy changes are to be meaningfully adopted in community services.

Beyond harm-producing versus harm-reducing: A qualitative meta-synthesis of people who use drugs' perspectives of and experiences with the extramedical use and diversion of buprenorphine

INTRODUCTION

This review synthesizes the literature on the perspectives and experiences of people who use drugs to better understand motivations and behaviors related to the extramedical use and diversion of buprenorphine. Given the particular social construction of buprenorphine against methadone, and the centrality of concerns around extramedical use in delivering opioid agonist therapies, a focus on extramedical buprenorphine use can provide an important lens through which to analyze treatment for opioid use disorder. This review is framed within persistent tensions between potential harm-producing versus harm-reducing effects of extramedical use that have long been described for opioid agonist therapies.

METHODS

The research team conducted a qualitative meta-synthesis based on a systematic search of eight databases as well as hand searching. The review includes all primary qualitative and mixed-methods studies related to the perspectives and experiences of people who use drugs on extramedical buprenorphine use. The study team carried out three rounds of qualitative coding using NVivo 12, and constructivist grounded theory and the constant comparative method informed the synthesis.

RESULTS

The review includes twenty-one studies. Findings are organized into the following three themes: 1) the experiences of people who use drugs (PWUD) with extramedical use of buprenorphine and their motivations to engage in it (including the desire to self-medicate and achieve "stability", to manage ongoing use of other opioids, and to "get high"); 2) the relationship between extramedical use and formal medical opioid agonist therapy programs; and 3) the established drug economy of extramedical buprenorphine.

CONCLUSIONS

The review identified varied and often divergent perspectives and experiences with extramedical buprenorphine use. An examination of the reported "normalizing" effects of extramedical buprenorphine suggests this practice as extending medicalized discipline beyond the clinical environment. Taken together, these findings identify a need to move beyond the tension of harm-reducing versus harm-producing effects toward forms of health care and promotion that focus on the needs, perspectives, and priorities of people who use drugs.

COVID-19-related policy changes for methadone take-home dosing: A multistate survey of opioid treatment program leadership

Background: In the United States, methadone for treatment of opioid use disorder is dispensed via highly-regulated accredited opioid treatment programs (OTP). During the COVID-19 pandemic, federal regulations were loosened, allowing for greater use of take-home methadone doses. We sought to understand how OTP leaders responded to these policy changes. Methods: We distributed a multistate electronic survey from September to November 2020 of OTP leadership to members of the American Association for the Treatment of Opioid Dependence (AATOD) who self-identified as leaders of OTPs. We asked study participants about how their OTP(s) implemented COVID-19-related policy changes into their clinical practice focusing on provision of take-home methadone doses, factors used to determine patient stability, and potential concerns about increased take-home doses. We used Chi-square test to compare survey responses between characterizations of the OTPs. Results: Of 170 survey respondents (17% response rate), the majority represented leadership of for-profit OTPs (69%) and were in a Southern state (54%). Routine allowances and practices related to take-home methadone doses varied across OTPs during the COVID-19 pandemic: 80 (47%) reported 14 days for newly enrolled patients (within past 90 days), 89 (52%) reported 14 days for "less stable" patients, and 112 (66%) reported 28 days for "stable" patients. Conclusions: We found that not all eligible OTP leaders adopted the practice of routinely allowing newly enrolled, "less stable," and "stable" patients on methadone to have increased take-home doses up to the limit allowed by federal regulations during COVID-19. The pandemic provides an opportunity to critically re-evaluate long-established methadone and OTP regulations in preparation for future emergencies.

Economic analysis of out-of-pocket costs among people in opioid agonist treatment: A cross-sectional survey in three Australian jurisdictions

BACKGROUND

Out-of-pocket costs for opioid agonist treatment (OAT) constitute a barrier to treatment entry and retention.This study examines OAT clients' total out-of-pocket costs (including dispensing fees, travel costs and OAT-related appointment costs) in different treatment settings (public clinics, community pharmacies, and private clinics).

METHODS

Cross-sectional survey of 402 people with opioid drug use (OUD) in New South Wales (NSW), Victoria (VIC), Tasmania (TAS), Australia; 266 clients (66%) currently receiving methadone, buprenorphine or buprenorphine-naloxone treatment were asked about dispensing fees, travel costs and OAT-related appointment costs in the past 28 days. A two-part regression model was used to deal with non-normal distributions of costing data (right skew and excess zeros).

RESULTS

Among clients currently receiving OAT, 87% paid out-of-pocket costs. Among those who paid out-of-pocket costs (N=194), travel costs accounted for more than half of total costs (52%), followed by dispensing fees (44%). The mean monthly total out-of-pocket costs were AU$135 (SD: AU$121) for public clinics, AU$161 (SD: AU$110) to AU$214 (SD: AU$166) for community pharmacies and AU$355 (SD: AU$159) for private clinics. Compared to participants in NSW private clinics, those at public clinics paid one third the total out-of-pocket costs (coefficient = 0.33; 95%CI = 0.23-0.48) and those at NSW, TAS, VIC pharmacies paid approximately half the costs (coefficient = 0.58; 95%CI = 0.42-0.79; coefficient = 0.51; 95%CI = 0.36-0.72; coefficient = 0.47; 95%CI = 0.34-0.66, respectively). People in OAT for more than a year paid half the total out-of-pocket costs, compared with those in OAT less than a year (coefficient = 0.49, 95%CI = 0.31-0.77).

CONCLUSIONS

Participants in the current study spent one-eighth of their income on out-of-pocket costs associated with OAT representing a substantial financial burden. Total out-of-pocket costs disproportionately affects those who are newer in treatment and receiving fewer unsupervised doses. Considering and addressing total out-of-pocket costs, especially travel costs and dispensing fees, to clients is critical to prevent cost from being a barrier from receiving effective care.

Methadone Access for Opioid Use Disorder During the COVID-19 Pandemic Within the United States and Canada

Importance

Methadone access may be uniquely vulnerable to disruption during COVID-19, and even short delays in access are associated with decreased medication initiation and increased illicit opioid use and overdose death. Relative to Canada, US methadone provision is more restricted and limited to specialized opioid treatment programs.

Objective

To compare timely access to methadone initiation in the US and Canada during COVID-19.

Design, Setting, and Participants

This cross-sectional study was conducted from May to June 2020. Participating clinics provided methadone for opioid use disorder in 14 US states and territories and 3 Canadian provinces with the highest opioid overdose death rates. Statistical analysis was performed from July 2020 to January 2021.

Exposures

Nation and type of health insurance (US Medicaid and US self-pay vs Canadian provincial).

Main Outcomes and Measures

Proportion of clinics accepting new patients and days to first appointment.

Results

Among 268 of 298 US clinics contacted as a patient with Medicaid (90%), 271 of 301 US clinics contacted as a self-pay patient (90%), and 237 of 288 Canadian clinics contacted as a patient with provincial insurance (82%), new patients were accepted for methadone at 231 clinics (86%) during US Medicaid contacts, 230 clinics (85%) during US self-pay contacts, and at 210 clinics (89%) during Canadian contacts. Among clinics not accepting new patients, at least 44% of 27 clinics reported that the COVID-19 pandemic was the reason. The mean wait for first appointment was greater among US Medicaid contacts (3.5 days [95% CI, 2.9-4.2 days]) and US self-pay contacts (4.1 days [95% CI, 3.4-4.8 days]) than Canadian contacts (1.9 days [95% CI, 1.7-2.1 days]) (P < .001). Open-access model (walk-in hours for new patients without an appointment) utilization was reported by 57 Medicaid (30%), 57 self-pay (30%), and 115 Canadian (59%) contacts offering an appointment.

Conclusions and Relevance

In this cross-sectional study of 2 nations, more than 1 in 10 methadone clinics were not accepting new patients. Canadian clinics offered more timely methadone access than US opioid treatment programs. These results suggest that the methadone access shortage was exacerbated by COVID-19 and that changes to the US opioid treatment program model are needed to improve the timeliness of access. Increased open-access model adoption may increase timely access.

Pharmacists should treat patients who have opioid use disorders, not police them

Pharmacists are caught in the throes of a relentless overdose crisis that has already claimed half a million lives and threatens to claim thousands more. The addiction treatment system is fragmented and inadequate to meet demand. Few physicians provide medications for opioid use disorder (MOUDs), the most effective form of evidence-based treatment, and insufficient treatment options leave patients vulnerable to overdose. Pharmacists routinely interact with patients who have OUD but lack ways to treat them. The primary tools that pharmacists have received to curb the crisis are prescription drug monitoring programs (PDMPs), big data surveillance technologies that they can use to track patients' medication acquisition patterns. Pharmacists like PDMPs because they help them make decisions efficiently. However, PDMPs are enforcement technologies, not health care tools; therefore, pharmacists typically use PDMPs to police patients instead of treating them. Policing patients not only fails to help combat overdose, but can also exacerbate harm. Informed by a decade's worth of interviews with pharmacists before and after PDMP implementation, I argue that pharmacists should be better equipped to help patients with OUD. Specifically, clinical and community pharmacists should mobilize to provide MOUDs through collaborative practice agreements with physicians. Studies show that collaborative practice models are effective at reducing the risk of overdose and saving money and physicians' time. And pharmacists have the clinical competencies necessary to provide MOUDs for patients. Pharmacists must overcome legal, economic, and interprofessional barriers to do so, but giving pharmacists the tools to treat patients will affirm their professional commitment to caring for patients and saving lives.

ILC-OPI: impulsive lifestyle counselling versus cognitive behavioral therapy to improve retention of patients with opioid use disorders and externalizing behavior: study protocol for a multicenter, randomized, controlled, superiority trial

BACKGROUND

Substance use disorders show a high comorbidity with externalizing behavior difficulties, creating treatment challenges, including difficulties with compliance, a high risk of conflict, and a high rate of offending post-treatment. Compared with people with other substance use disorders those with opioid use disorders have the highest risk of criminal activity, but studies on the evidence base for psychosocial treatment in opioid agonist treatment (OAT) are scarce. The Impulsive Lifestyle Counselling (ILC) program may be associated with better retention and outcomes among difficult-to-treat patients with this comorbidity.

METHODS

The study is a multicenter, randomized, controlled, superiority clinical trial. Participants will be a total of 137 hard-to-treat individuals enrolled in opioid agonist treatment (OAT). Participants will be randomized to either a standard treatment (14 sessions of individual manual-based cognitive behavioral therapy and motivational interviewing (MOVE-I)) or six sessions of ILC followed by nine sessions of MOVE-I. All participants will receive personalized text reminders prior to each session and vouchers for attendance, as well as medication as needed. The primary outcome is retention in treatment. Secondary measures include severity of drug use and days of criminal offending for profit three and nine months post-randomization. A secondary aim is, through a case-control study, to investigate whether participants in the trial differ from patients receiving treatment as usual in municipalities where ILC and MOVE-I have not been implemented in OAT. This will be done by comparing number of offences leading to conviction 12 months post-randomization recorded in the national criminal justice register and number of emergency room contacts 12 months post-randomization recorded in the national hospital register.

DISCUSSION

This is the first randomized, controlled clinical trial in OAT to test the effectiveness of ILC against a standardized comparison with structural elements to increase the likelihood of exposure to the elements of treatment. Results obtained from this study may have important clinical, social, and economic implications for publicly funded treatment of opioid use disorder.

TRIAL REGISTRATION

ISRCTN, ISRCTN19554367 , registered on 04/09/2020.

Mobile methadone dispensing in Delhi, India: implementation research

Objective

To assess the implementation of a mobile dispensing service to improve opioid users’ access to methadone maintenance therapy.

Methods

In March 2019, we started mobile methadone dispensing in an urban underprivileged locality in Delhi, India. The doctor was available only at the main community drug treatment clinic for clinical services, while the nurse dispensed methadone from a converted ambulance. We involved patients in identifying community leaders for sensitization and in deciding the location and timings for dispensing. We conducted a retrospective chart review of the programme data collected during delivery of clinical services. We compared the numbers of patients registered for methadone therapy and their retention and adherence to therapy in the 12-month periods before and after implementation of the mobile service.

Findings

The number of patients registered for therapy at the clinic increased from 167 in the year before implementation to 671 in the year after. A significantly higher proportion of patients were retained in therapy at 3, 6 and 9 months after enrolment; 9-month retention rates were 19% (32/167 patients) and 45% (44/97 patients) in the year before and after implementation, respectively. There was no significant difference in patients’ adherence to therapy between the two periods. Challenges included providing suitable dispensing hours for patients in employment and concerns of local community near to the dispensing sites.

Conclusion

It is feasible to dispense methadone by a mobile team in an urban setting, with better retention rates in therapy compared with dispensing through a stationary clinic.

Expanding access to methadone treatment in Ohio through federally qualified health centers and a chain pharmacy: A geospatial modeling analysis

BACKGROUND

In the United States, methadone provision for opioid use disorder (OUD) occurs at opioid treatment programs (OTPs). Ohio recently enacted a policy to expand methadone administration to Federally Qualified Health Centers (FQHC). We compared how the provision of methadone at current OTPs or the proposed expansion to FQHCs and pharmacies meets the urban and rural need for OUD treatment.

METHODS

Cross-sectional geospatial analysis of zip codes within Ohio with at least one 2017 opioid overdose death stratified by Rural-Urban Commuting Area codes. Our primary outcome was the proportion of need by zip code (using opioid overdose deaths as a proxy for need) within a 15- or 30- minute drive time of an OTP.

RESULTS

Among 581 zip codes, sixty four percent of treatment need was within a 15-minute drive time and 81 %, within a 30-minute drive time. The proportion of need within a 15-minute drive decreased with increasing rural classification (urban 78 %, suburban 20 %, large rural 9%, and small rural 1%;p<.001). The portion of need within a 15-minute drive time increased with the addition of FQHCs (96 %) and the addition of chain pharmacies (99 %) relative to OTPs alone among all zip codes and for all urban-rural strata (p<.001).

CONCLUSION

Over one-third of OUD treatment need was not covered by existing OTPs and coverage decreased with rural classification of zip codes. Most of the gap between supply and need could be mitigated with FQHC methadone provision, which would expand both urban and rural access.

Use of an electronic pillbox to increase number of methadone take-home doses during the COVID-19 pandemic

This study describes use of the commercially available Medminder electronic pillbox at a community substance use disorder treatment program to safely increase the number of methadone take-home doses administered during the COVID-19 pandemic. The pillbox contains 28 cells that lock independently and can be opened only during preprogrammed time windows. This study provided patients (n = 42) deemed vulnerable to take-home mismanagement or more severe symptoms from COVID-19 infection the pillbox and observed them for 11 weeks. A telephone support line was staffed daily to manage technical issues. Overall, patients received about 14 more take-home doses per month after receiving the pillbox. Most medication was dispensed within scheduled windows. The study observed few incidents of suspected tampering, though five patients had their pillbox rescinded to allow more intensive on-site clinical monitoring. The study supports use of an electronic pillbox with a telephone support line to help vulnerable patients to better observe stay-at-home guidelines during the COVID-19 pandemic. The pillbox may offer public health and clinical benefits that extend beyond the pandemic by increasing program treatment capacity and patient satisfaction.

"How will I get my next week's script?" Reactions of Reddit opioid forum users to changes in treatment access in the early months of the coronavirus pandemic

BACKGROUND

The COVID-19 pandemic poses significant challenges to people with opioid use disorder (OUD). As localities enforce lockdowns and pass emergency OUD treatment regulations, questions arise about how these changes will affect access and retention in care. In this study, we explore the influence of COVID-19 on access to, experiences with, and motivations for OUD treatment through a qualitative analysis of public discussion forums on Reddit.

METHODS

We collected data from Reddit, a free and international online platform dedicated to public discussions and user-generated content. We extracted 1000 of the most recent posts uploaded between March 5th and May 13th, 2020 from each of the two most popular opioid subreddits "r/Opiates" and "r/OpiatesRecovery" (total 2000). We reviewed posts for relevance to COVID-19 and opioid use and coded content using a hybrid inductive-deductive approach. Thematic analysis identified common themes related to study questions of interest.

RESULTS

Of 2000 posts reviewed, 300 (15%) discussed topics related to the intersection of opioid use and COVID-19. Five major themes related to OUD treatment were identified: Concern about closure of OUD treatment services; transition to telehealth and virtual care; methadone treatment requirements and increased exposure to COVID-19; reactions to changing regulations on medications for OUD; and influences of the pandemic on treatment motivation and progress.

CONCLUSION

In the face of unprecedented challenges due to COVID-19, reactions of Reddit opioid forum users ranged from increased distress in accessing and sustaining treatment, to encouragement surrounding new modes of treatment and opportunities to engage in care. New and less restrictive avenues for treatment were welcomed by many, but questions remain about how new norms and policy changes will be sustained beyond this pandemic and impact OUD treatment access and outcomes long-term.

Clinician perspectives on methadone service delivery and the use of telemedicine during the COVID-19 pandemic: A qualitative study

Objectives

During the COVID-19 pandemic, opioid treatment programs (OTPs) in the U.S. were granted new flexibility in methadone dispensing and the use of telemedicine. To explore the impact of the pandemic and accompanying policy changes on service delivery, we asked OTP clinicians about changes in care patterns and perceptions of impacts on access and quality.

Methods

In May–June 2020, we completed semistructured telephone interviews with 20 OTP clinicians (physicians, physician assistants, and nurse practitioners) from 13 U.S. states. The study recruited participants through Medscape, an online platform where clinicians access clinical content. We used rapid thematic analysis, a qualitative approach, to summarize participants' expressed views related to the research objectives.

Results

Clinicians identified a range of changes to methadone and ancillary service delivery as a result of COVID-19. Most clinicians reported that OTPs were prescribing more take-home doses of methadone and providing psychosocial services and medication management via telemedicine. Many also reported reducing the frequency of urine toxicology screening and accepting fewer new patients. While some clinicians expressed support for the increased flexibility around dosing and use of telemedicine, others expressed concern about increased risk of medication diversion and overdose. Clinicians reported several advantages and disadvantages of the changes due to the pandemic and that continued reimbursement would be required to maintain telemedicine services.

Conclusions

The COVID-19 pandemic dramatically altered the delivery of methadone treatment in the U.S. This study's findings suggest that OTPs may have reduced their methadone treatment during the early months of the pandemic and that the flexibilities that policy changes offered may not have resulted in changes in care delivery for all patients. Careful consideration and additional analysis should inform which changes OTPs should maintain long-term.

Research priorities for expanding access to methadone treatment for opioid use disorder in the United States: A National Institute on Drug Abuse Center for Clinical Trials Network Task Force report

In the US, methadone treatment can only be provided to patients with opioid use disorder (OUD) through federal and state-regulated opioid treatment programs (OTPs). There is a shortage of OTPs, and racial and geographic inequities exist in access to methadone treatment. The National Institute on Drug Abuse Center for Clinical Trials Network convened the Methadone Access Research Task Force to develop a research agenda to expand and create more equitable access to methadone treatment for OUD. This research agenda included mechanisms that are available within and outside the current regulations. The task force identified 6 areas where research is needed: (1) access to methadone in general medical and other outpatient settings; (2) the impact of methadone treatment setting on patient outcomes; (3) impact of treatment structure on outcomes in patients receiving methadone; (4) comparative effectiveness of different medications to treat OUD; (5) optimal educational and support structure for provision of methadone by medical providers; and (6) benefits and harms of expanded methadone access. In addition to outlining these research priorities, the task force identified important cross-cutting issues, including the impact of patient characteristics, treatment, and treatment system characteristics such as methadone formulation and dose, concurrent behavioral treatment, frequency of dispensing, urine or oral fluid testing, and methods of measuring clinical outcomes. Together, the research priorities and cross-cutting issues represent a compelling research agenda to expand access to methadone in the US.

Global opioid agonist treatment: a review of clinical practices by country

AIMS

We assessed how opioid agonist treatment (OAT) for opioid use disorder (OUD), specifically methadone and buprenorphine, including buprenorphine-naloxone, is delivered in routine clinical practice, with a focus on factors that affect access to and delivery of these services. The aims of this review were to summarize eligibility criteria for entry to OAT, doses in routine clinical practice, access to and eligibility for unsupervised dosing and urine drug screening practices in OAT programs globally.

METHODS

We completed searches of PubMed, Embase, and grey literature databases for cross-sectional or observational cohort studies of OAT using either methadone or buprenorphine. Dose data extracted from eligible studies were compared with guidelines provided by WHO.

RESULTS

We found 140 reports from 41 countries that contained data for at least one of the relevant indicators. A diagnosis of opioid dependence or opioid use disorder was the most common eligibility requirement for OAT (13 or 17 countries). Reported mean or median doses for methadone ranged from 16-131 mg whereas range for buprenorphine was 2.5-19 mg. Access to unsupervised dosing under some conditions was reported in 18 of 27 countries. Frequency of regular urine drug screenings (UDS) ranged from several times a week to eight times per year (methadone) or as clinically indicated.

CONCLUSIONS

Opioid agonist treatment practices, including doses prescribed, vary greatly both within and across countries. Of particular concern is the persistence of lower dose prescribing practices, in which patients may be prescribed doses below those proven to yield significant clinical benefits.

The next wave? Mental health comorbidities and patients with substance use disorders in under-resourced and rural areas

The rapid spread of the coronavirus disease (COVID-19) has impacted the lives of millions around the globe. The COVID-19 pandemic has caused increasing concern among treatment professionals about mental health and risky substance use, especially among those who are struggling with a substance use disorder (SUD). The pandemic's impact on those with an SUD may be heightened in vulnerable communities, such as those living in under-resourced and rural areas. Despite policies loosening restrictions on treatment requirements, unintended mental health consequences may arise among this population. We discuss challenges that under-resourced areas face and propose strategies that may improve outcomes for those seeking treatment for SUDs in these areas.

Comparison of Driving Times to Opioid Treatment Programs and Pharmacies in the US

IMPORTANCE

Methadone maintenance is an effective treatment of opioid use disorder, but federal regulations in the US restrict methadone dispensing to opioid treatment programs (OTPs). In Australia, Canada, and the UK, patients can obtain methadone maintenance from community pharmacies.

OBJECTIVE

To compare driving access to methadone maintenance treatment between OTP and pharmacy dispensing models.

DESIGN, SETTING, AND PARTICIPANTS

This descriptive cross-sectional study assessed driving times from census tract mean centers of population to OTPs and pharmacies. Census tracts from the 50 US states and the District of Columbia (based on the 2010 US Census) were included if their population was greater than 0, if their mean center of population (MCP) was within 3 miles of the road network, and if the 1-way driving times from the census tract MCP to both an OTP and a pharmacy were 12 hours or less. Data analyses were performed from November 15, 2019, to April 18, 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome was the population-weighted mean driving time from census tract MCPs to OTPs and pharmacies in the US. Census tract MCPs are population-weighted geographic centroids of residents living in each census tract. Driving times were estimated using historical average driving speeds.

RESULTS

All 1682 unique locations of OTPs were included, and 69 475 unique pharmacy locations were included after geocoding. A total of 72 443 census tracts were included in the analysis. The mean population-weighted driving time from census tract MCPs was 20.4 minutes (95% CI, 20.3-20.6 minutes) to OTPs and 4.5 minutes (95% CI, 4.4-4.5 minutes) to pharmacies (P < .001). Differences in driving time, distance, and cost between 1-way trips ending at OTPs and pharmacies were largest in micropolitan and noncore counties.

CONCLUSIONS AND RELEVANCE

In this study, population-weighted mean driving times from US census tract MCPs were longer to OTPs than to pharmacies.

Medication treatment for opioid use disorder and community pharmacy: Expanding care during a national epidemic and global pandemic

Medications for opioid use disorder (MOUD), such as methadone and buprenorphine, are effective strategies for treatment of opioid use disorder (OUD) and reducing overdose risk. MOUD treatment rates continue to be low across the US, and currently, some evidence suggests access to evidence-based treatment is becoming increasingly difficult for those with OUD as a result of the 2019 novel corona virus (COVID-19). A major underutilized source to address these serious challenges in the US is community pharmacy given the specialized training of pharmacists, high levels of consumer trust, and general availability for accessing these service settings. Canadian, Australian, and European pharmacists have made important contributions to the treatment and care of those with OUD over the past decades. Unfortunately, US pharmacists are not permitted to prescribe MOUD and are only currently allowed to dispense methadone for the treatment of pain, not OUD. US policymakers, regulators, and practitioners must work to facilitate this advancement of community pharmacy-based through research, education, practice, and industry. Advancing community pharmacy-based MOUD for leading clinical management of OUD and dispensation of treatment medications will afford the US a critical innovation for addressing the opioid epidemic, fallout from COVID-19, and getting individuals the care they need.

Design and Characterization of Spray-Dried Chitosan-Naltrexone Microspheres for Microneedle-Assisted Transdermal Delivery

Naltrexone (NTX) hydrochloride is a potent opioid antagonist with significant first-pass metabolism and notable untoward effects when administered orally or intramuscularly. Microneedle (MN)-assisted transdermal delivery is an attractive alternative that can improve therapeutic delivery to deeper skin layers. In this study, chitosan-NTX microspheres were developed via spray-drying, and their potential for transdermal NTX delivery in association with MN skin treatment was assessed. A quality-by-design approach was used to evaluate the impact of key input variables (chitosan molecular weight, concentration, chitosan-NTX ratio, and feed flow rate) on microsphere physical characteristics, encapsulation efficiency, and drug-loading capacity. Formulated microspheres had high encapsulation efficiencies (70%-87%), with drug-loading capacities ranging from 10%-43%. NTX flux through MN-treated skin was 11.6 ± 2.2 µg/cm²·h from chitosan-NTX microspheres, which was significantly higher than flux across intact skin. Combining MN-assisted delivery with the chitosan microsphere formulation enabled NTX delivery across the skin barrier, while controlling the dose released to the skin.

Opioid use disorder and the COVID 19 pandemic: A call to sustain regulatory easements and further expand access to treatment

We highlight the critical roles that pharmacists have related to sustaining and advancing the changes being made in the face of the current COVID-19 pandemic to ensure that patients have more seamless and less complex access to treatment. Discussed herein is how the current COVID-19 pandemic is impacting persons with substance use disorders, barriers that persist, and the opportunities that arise as regulations around treatments for this population are eased.

Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States

Importance

Treatment with methadone or buprenorphine is the current standard of care for opioid use disorder. Given the paucity of research identifying which patients will respond best to which medication, both medications should be accessible to all patients so that patients can determine which works best for them. However, given differences in the historical contexts of their initial implementation, access to each of these medications may vary along racial/ethnic lines.

Objective

To examine the extent to which capacity to provide methadone and buprenorphine vary with measures of racial/ethnic segregation.

Design, Setting, and Participants

This cross-sectional study included all counties and county-equivalent divisions in the US in 2016. Data on racial/ethnic population distribution were derived from the American Community Survey, and data on locations of facilities providing methadone and buprenorphine were obtained from Substance Abuse and Mental Health Services Administration databases. Data were analyzed from August 22, 2018, to September 11, 2019.

Exposures

Two county-level measures of racial/ethnic segregation, including dissimilarity (representing the proportion of African American or Hispanic/Latino residents who would need to move census tracts to achieve a uniform spatial distribution of the population by race/ethnicity) and interaction (representing the probability that an African American or Hispanic/Latino resident will interact with a white resident and vice versa, assuming random mixing across census tracts).

Main Outcomes and Measures

County-level capacity to provide methadone or buprenorphine, defined as the number of facilities providing a medication per 100 000 population.

Results

Among 3142 US counties, there were 1698 facilities providing methadone (0.6 facilities per 100 000 population) and 18 868 facilities providing buprenorphine (5.9 facilities per 100 000 population). Each 1% decrease in probability of interaction of an African American resident with a white resident was associated with 0.6 more facilities providing methadone per 100 000 population. Similarly, each 1% decrease in probability of interaction of a Hispanic/Latino resident with a white resident was associated with 0.3 more facilities providing methadone per 100 000 population. Each 1% decrease in the probability of interaction of a white resident with an African American resident was associated with 8.17 more facilities providing buprenorphine per 100 000 population. Similarly, each 1% decrease in the probability of interaction of a white resident with a Hispanic/Latino resident was associated with 1.61 more facilities providing buprenorphine per 100 000 population.

Conclusions and Relevance

These findings suggest that the racial/ethnic composition of a community was associated with which medications residents would likely be able to access when seeking treatment for opioid use disorder. Reforms to existing regulations governing the provisions of these medications are needed to ensure that both medications are equally accessible to all.

Pharmacy-based methadone dispensing and drive time to methadone treatment in five states within the United States: A cross-sectional study

BACKGROUND

Within the United States, there is a shortage of opioid treatment programs (OTPs), facilities which dispense methadone for opioid use disorder. It is unknown how pharmacy-based methadone dispensing, as available internationally, could affect methadone access. We aimed to compare drive times to the nearest OTP with drive times to the nearest chain pharmacy in urban and rural census tracts.

METHODS

Cross-sectional geospatial analysis of 2018 OTP location data and 2017 pharmacy location data. We included census tracts with non-zero population in Indiana, Kentucky, Ohio, Virginia, and West Virginia, states with highest rates of opioid overdose deaths. Our outcome was minimum drive time in minutes from census tract mean center of population to the nearest dispensing facility.

RESULTS

Among 7918 census tracts, median (IQR) drive time to OTPs increased from urban to increasingly rural census tract classification [16.1 min (10.2-25.9) to 48.4 min (34.0-63.3);p < .001]. Median (IQR) drive time to OTPs was greater than drive time to chain pharmacies among all census tracts: 19.6 min (11.6-35.1) versus 4.4 min (2.9-7.7) respectively; p < .001. The median (IQR) difference in drive time was greater for increasingly rural census tracts [11.5 min (6.1-19.2) to 35.2 min (19.6-49.7); p <.001] with pharmacy-based methadone dispensing.

CONCLUSION

Rural census tracts have disproportionately long drive times to OTPs. Drawing from policies to increase methadone access in countries like Canada and Australia, this geographic methadone disparity could be mitigated through implementation of pharmacy-based methadone dispensing.

A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States

BACKGROUND

Opioid-related deaths have risen dramatically in rural communities. Prior studies highlight few medication treatment providers for opioid use disorder in rural communities, though literature has yet to examine rural-specific treatment barriers.

OBJECTIVES

We conducted a systematic review to highlight the state of knowledge around rural medication treatment for opioid use disorder, identify consumer- and provider-focused treatment barriers, and discuss rural-specific implications.

METHODS

We systematically reviewed the literature using PsycINFO, Web of Science, and PubMed databases (January 2018). Articles meeting inclusion criteria involved rural samples or urban/rural comparisons targeting outpatient medication treatment for opioid use disorder, and were conducted in the U.S. to minimize healthcare differences. Our analysis categorized consumer- and/or provider-focused barriers, and coded barriers as related to treatment availability, accessibility, and/or acceptability.

RESULTS

Eighteen articles met inclusion, 15 which addressed consumer-focused barriers, while seven articles reported provider-focused barriers. Availability barriers were most commonly reported across consumer (n = 10) and provider (n = 5) studies, and included the lack of clinics/providers, backup, and resources. Acceptability barriers, described in three consumer and five provider studies, identified negative provider attitudes about addiction treatment, and providers' perceptions of treatment as unsatisfactory for rural patients. Finally, accessibility barriers related to travel and cost were detailed in four consumer-focused studies whereas two provider-focused studies identified time constraints.

CONCLUSIONS

Our findings consistently identified a lack of medication providers and rural-specific implementation challenges. This review highlights a lack of rural-focused studies involving consumer participants, treatment outcomes, or barriers impacting underserved populations. There is a need for innovative treatment delivery for opioid use disorder in rural communities and interventions targeting provider attitudes.

Legal and policy changes urgently needed to increase access to opioid agonist therapy in the United States

The United States continues to face a public health crisis of opioid-related harm, the effects of which could be dramatically reduced through increased access to opioid agonist therapy with the medications methadone and buprenorphine. Despite overwhelming evidence of their efficacy, unduly restrictive federal, state, and local regulation significantly impedes access to these life-saving medications. We outline immediate, concrete steps that federal, state, and local governments can take to change law from barrier to facilitator of evidence-based treatment for opioid use disorder. These include removing onerous restrictions on the prescription and dispensing of buprenorphine and methadone for opioid agonist therapy, requiring insurance coverage of these medications, and mandating that they be provided in correctional settings and promoted by drug courts. Finally, we argue that jurisdictions should proactively offer opioid agonist therapy to individuals at high risk of overdose, remove barriers to establishing methadone treatment facilities, and address underlying social determinants and barriers to treatment. These changes have the ability to save thousands of lives annually.

Buprenorphine Treatment for Opioid Use Disorder: An Overview

Opioid use disorder affects over 26 million individuals worldwide. There are currently three World Health Organization-recommended and US Food and Drug Administration-approved medication treatments for opioid use disorder: the full opioid agonist methadone, the opioid partial agonist buprenorphine, and the opioid receptor antagonist naltrexone. We provide a review of the use of buprenorphine for the treatment of opioid use disorder and discuss the barriers, challenges, risks, and efficacy of buprenorphine treatment vs. other treatments. Although evidence from numerous studies has shown buprenorphine to be effective for the treatment of opioid use disorder, a majority of patients with opioid use disorder do not receive buprenorphine, or any other medical treatment. We review the different formulations of buprenorphine, including newer long-acting injectable formulations that may decrease the risk of diversion and improve adherence.