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

A Novel Use of the "3-Day Rule": Post-discharge Methadone Dosing in the Emergency Department

Introduction

Methadone is a medically necessary and lifesaving medication for many patients with opioid use disorder. To adequately address these patients' needs, methadone should be offered in the hospital, but barriers exist that limit its continuation upon discharge. The code of federal regulations allows for methadone dosing as an inpatient as well as outpatient dispensing for up to three days to facilitate linkage to treatment. As a quality initiative, we created a new workflow for discharging patients on methadone to return to the emergency department (ED) for uninterrupted dosing.

Methods

Our addiction medicine team changed hospital methadone policy to better allow hospitalization as a window of opportunity to start methadone. This necessitated the creation of a warm-handoff process to link patients to methadone clinics if that linkage could not happen immediately on discharge. Thus, our team created the "ED Bridge" process, which uses the "3-day rule" to dispense methadone from the ED post hospital discharge. We then followed every patient we directed through this workflow as an observational cohort for outcomes and trends.

Results

Of the patients for whom ED bridge dosing was planned, 40.4% completed all bridge dosing and an additional 17.3% received at least one but not all bridge doses. Established methadone patients made up 38.1% of successful linkages, and 61.9% were patients who were newly started on methadone in the hospital.

Conclusion

Improving methadone as a treatment option remains an ongoing issue for policymakers and advocates. Our ED bridge workflow allows us to expand access and continuation of methadone now using existing laws and regulations, and to better use hospitals as a point of entry into methadone treatment.

A trial of implementation facilitation to increase timely admission to methadone treatment

BACKGROUND

During the ongoing opioid epidemic, some Opioid Treatment Programs (OTPs) are unable to admit program applicants in a timely fashion. Interim methadone (IM) treatment (without routine counseling) is an effective approach to overcome this challenge when counseling capacity is inadequate to permit admissions within 14 days of request. It requires both federal and state approval and has been rarely utilized since its incorporation into the federal OTP regulations in 1993.

METHODS

We evaluated the impact of Implementation Facilitation (IF) on OTPs providing timely admission to methadone treatment (i.e., within 14 days of request), adopting IM, and changing admissions procedures. IF included data collection on admission processes and an external facilitator who engaged OTP leadership, Local Champions through site visits, remote academic detailing, and feedback. Local Champions and State Opioid Treatment Authorities (SOTAs) participated in learning collaboratives. Using a modified stepped wedge design, six OTPs in four US states on the east and west coasts were randomly assigned to one of two clusters that staggered the timing of IF receipt. Study Phases included: Pre-Implementation, IF, and Sustainability. OTPs submitted data on treatment requests and admissions for 28 months (N = 3108 requests for treatment).

RESULTS

Although none of the OTPs adopted IM, all six developed policies and procedures to enable its use. Some OTPs streamlined admissions processes prior to study launch and during the IF intervention. OTPs reduced admission delays over time, although there was substantial site heterogeneity. The IF Phase for the early cluster coincided with the onset of COVID-19, complicating the study. Rates of timely admission within 14 days of request were 56.2 % (Pre-Implementation), 55.8 % (IF), and 78.8 % (Sustainability). Compared to the Pre-Implementation Phase, the odds of timely admission were not significantly different during the IF Phase but significantly higher during the Sustainability Phase (OR = 2.35 [95 % CI = 1.34, 4.12]; p = 0.003).

CONCLUSIONS

Committing to study participation and IF activities may have prompted some OTPs to change practices that improved timely admission. Attributing changes to IF should be done with caution considering study limitations. Data collection for the study spanned the COVID-19 pandemic, which complicates interpretation.

TRIAL REGISTRATION

Clinicaltrials.gov registration # NCT04188977.

Payment-related barriers to medications for opioid use disorder: A critical review of the literature and real-world application

BACKGROUND

The national opioid crisis continues to intensify, despite the fact that opioid use disorder (OUD) is treatable and opioid overdose deaths are preventable through first-line treatment with medications for opioid use disorder (MOUD). This study identifies and categorizes payment-related barriers that impact MOUD access and retention from both the provider and patient perspectives and provides insight into how these barriers can be addressed.

METHODS

We performed a critical review of the literature (peer-reviewed studies and relevant documents from the gray literature) to identify payment-related access and retention barriers to MOUD. We used the results of this review to develop an analytic framework to understand how payment impacts MOUD access and retention for both providers and patients. In addition, we reviewed action plans developed by Massachusetts communities that participated in the Healing Communities Study (HCS) to analyze which payment-related barriers were addressed through the study.

RESULTS

We identified 18 payment-related barriers that patients or providers face when initiating or continuing MOUD with either methadone or buprenorphine in Opioid Treatment Programs (OTP) and non-OTP settings. Patient-related barriers mainly relate to health insurance coverage or the design of health plans (e.g., cost sharing, covered benefits) resulting in direct (medical and non-medical) and indirect costs that can affect both access and retention, especially as they relate to services provided in OTPs. Provider-related barriers include low reimbursement and administrative burden and are most likely to impact access to MOUD. Evidence-based strategies to expand MOUD as part of the HCS in Massachusetts targeted about half of the patient and provider payment-related barriers identified.

CONCLUSION

Patients and providers face an array of payment-related barriers that impact access to and retention on MOUD, most of which relate to inadequate health insurance coverage, features of health plans, and key federal and state policies. As new regulatory policies are enacted that expand access to MOUD, such as greater flexibility in OTPs and MOUD delivered via telehealth, it will be important to align these delivery changes with payment reform involving payers, providers, and policymakers.

[Increase of overdose and deaths related to methadone during COVID-19 epidemic in 2020]

INTRODUCTION

Due to the risk of overdoses increase especially with methadone, a reinforced monitoring has been set up by the French Addictovigilance Network following the first lockdown related to coronavirus disease 2019 (COVID-19). In this context, we managed a specific study to analyze overdoses related to methadone in 2020 compared to 2019.

MATERIAL AND METHODS

We analyzed methadone-related overdoses which occurred in 2019 and 2020 from two sources: DRAMES program (deaths with toxicological analysis) and the French pharmacovigilance database (BNPV) (overdoses that did not lead to death).

RESULTS

Data from DRAMES program in 2020 show methadone as the first drug involved in deaths as well as an increase in deaths: in number (n=230 versus n=178), in proportion (41% versus 35%) and number of deaths per 1000 exposed subjects (3.4 versus 2.8). According to BNPV, the number of overdose increased in 2020 compared to 2019 (98 versus 79; i.e., 1.2-fold increase) particularly during several target periods: first lockdown, end of lockdown/summer period and second lockdown. In 2020, a higher number of cases were observed in April (n=15) and May (n=15). Overdoses and deaths occurred in subjects enrolled in treatment programs or not (naïve subjects/occasional users who obtained methadone from street market or family/friends). Overdoses resulted from different factors: overconsumption, multiple drug use with depressants drugs or cocaine, injection, consumption for sedative, recreational purposes or voluntary drug poisoning.

DISCUSSION/CONCLUSION

All these data show an increase of morbidity and mortality related to methadone during COVID-19 epidemic. This trend has been observed in other countries.

Association between Individual versus Community-level Social Vulnerability and Neonatal Opioid Withdrawal Syndrome among Pregnant Individuals Receiving Buprenorphine for Opioid Use Disorder

OBJECTIVE

 Individual patient-level measures of adverse social determinants of health are associated with neonatal opioid withdrawal syndrome (NOWS), but the relative impact of community-level adverse social determinants of health remains to be defined. We examined the association between community-level social vulnerability and NOWS among pregnant individuals receiving buprenorphine for opioid use disorder.

STUDY DESIGN

 We conducted a secondary analysis of an established cohort of pregnant individuals and their infants participating in a multidisciplinary prenatal/addiction care program from 2013 to 2021. Addresses were geocoded using ArcGIS and linked at the census tract to the Centers for Disease Control and Prevention 2018 Social Vulnerability Index (SVI), incorporating 15 census variables. The primary exposure was the SVI as a composite measure of community-level social vulnerability, and secondarily, individual scores for four thematic domains (socioeconomic status, household composition and disability, minority status and language, and housing type and transportation). The primary outcome was a clinical diagnosis of NOWS defined as withdrawal requiring pharmacological treatment following buprenorphine exposure.

RESULTS

 Among 703 pregnant individuals receiving buprenorphine, 39.8% (280/703) of infants were diagnosed with NOWS. Among our patinets, those who were nulliparous, had post-traumatic stress disorder, a term birth (≥ 37 weeks) and had a male infant were more likely to have an infant diagnosed with NOWS. Individuals with and without an infant diagnosed with NOWS had similarly high community-level social vulnerability per composite SVI scores (mean [standard deviation]: 0.6 [0.4-0.7] vs. 0.6 [0.4-0.7], p = 0.2]. In adjusted analyses, SVI, as a composite measure as well as the four domains, was not associated with NOWS diagnosis.

CONCLUSION

 Among pregnant persons receiving buprenorphine enrolled in a multidisciplinary prenatal and addition care program, while individual risk factors that measure adverse social determinants of health were associated with an NOWS diagnosis in the infant, community-level social vulnerability as measured by the SVI was not associated with the outcome.

KEY POINTS

· Community-level SVI was not associated with neonatal opioid use disorder.. · Certain individual risk factors were identified as being associated with NOWS.. · Homogeneity of composite SVI scores may have led to lack of significant findings..

Changes in stillbirths and child and youth mortality in 2020 and 2021 during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has been extensively studied for its impact on mortality, particularly in older age groups. However, the pandemic effects on stillbirths and mortality rates in neonates, infants, children and youth remain poorly understood. This study comprehensively analyses the pandemic influence on young mortality and stillbirths across 112 countries and territories in 2020 and 104 in 2021.

METHODS

Using data from civil registers and vital statistics systems (CRVS) and the Health Management Information System (HMIS), we estimate expected mortality levels in a non-pandemic setting and relative mortality changes (p-scores) through generalized linear models. The analysis focuses on the distribution of country-specific mortality changes and the proportion of countries experiencing deficits, no changes and excess mortality in each age group.

RESULTS

Results show that stillbirths and under-25 mortality were as expected in most countries during 2020 and 2021. However, among countries with changes, more experienced deficits than excess mortality, except for stillbirths, neonates and those aged 10-24 in 2021, where, despite the predominance of no changes, excess mortality prevailed. Notably, a fifth of examined countries saw increases in stillbirths and a quarter in young adult mortality (20-24) in 2021. Our findings are highly consistent between females and males and similar across income levels.

CONCLUSION

Despite global disruptions to essential services, stillbirths and youth mortality were as expected in most observed countries, challenging initial hypotheses. However, the study suggests the possibility of delayed adverse effects that require more time to manifest at the population level. Understanding the lasting impacts of the COVID-19 pandemic requires ongoing, long-term monitoring of health and deaths among children and youth, particularly in low- and lower-middle-income countries.

Impact of the COVID-19 Pandemic on Functions of Nursing Professionals in the Care of Opioid Use Disorder: Systematic Review

BACKGROUND

Nursing professionals are vitally involved in the cascade of care for opioid use disorders (OUDs). The global spread of COVID-19 has had complex effects on public health aspects of major diseases, including OUDs. There are limited data on the major ways in which the COVID-19 pandemic has affected the functions of nursing professionals in the care of OUDs.

METHOD

This systematic review followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and examined published data for trends in OUD care during the first 2 years of the COVID-19 pandemic, focusing on nursing functions. The National Library of Medicine PubMed database and the EMBASE database were examined for peer-reviewed studies with primary data published between January 1, 2020, and December 31, 2021.

REVIEW FINDINGS AND CONCLUSIONS

Rapid changes were observed in numerous aspects of OUDs during the early pandemic stage, as well as its care by nursing and other health professionals. These changes include increased overdoses (primarily from synthetic opioids such as fentanyl) and emergency department visits. These trends varied considerably across U.S. jurisdictions, underscoring the importance of region-specific examinations for public health policy and intervention. Out of necessity, healthcare systems and nursing professionals adapted to the challenges of OUD care in the pandemic. These adaptations included increases in telehealth services, increases in take-home doses of methadone or buprenorphine/naloxone, and expansion of layperson training in the use of naloxone for overdose reversal. It is likely that some of these adaptations will result in long-term changes in standards of care practices for OUDs by nursing professionals.

State guidance and system changes related to COVID-19: Impact on opioid treatment programs

INTRODUCTION

In the United States, methadone treatment may only be provided through opioid treatment programs (OTPs), which operate under a complex system of federal and state regulations. During the pandemic, federal regulators relaxed several longstanding restrictions for OTPs by permitting expanded eligibility for take-home medication and allowing counseling and medication management through telehealth. The purpose of this study was to assess the guidance provided by states regarding the revised guidelines and efforts to protect staff and patients in response to the pandemic.

METHODS

Between September and October of 2020, The National Association of State Alcohol and Drug Abuse Directors (NASADAD) and Friends Research Institute, fielded a web-based qualitative survey of state opioid treatment authorities (SOTAs) across the United States, the District of Columbia, and Puerto Rico. The study conducted the survey prior to the availability of the COVID vaccines. It queried 42 SOTAs concerning state guidance provided to OTPs on treatment operations and practices for existing patients and new admissions; actions to protect staff and patients; changes in treatment need and operational capacity; and administrative practices regarding treatment. This study examines the responses of 42 SOTAs (65 %) who completed the survey.

RESULTS

Using content analysis, responses to the survey indicate that most states provided guidance to OTPs in response to the revised federal regulations and the need to protect staff and patients. All respondents reported that their states permitted increased number of take-homes doses for existing patients (100 %) and most reported doing so for new admissions (69 %; N=29). Ninety-eight percent (98 %; N=41) reported permitting remote counseling for existing patients and 90 % (N=38) permitting this for new admissions. SOTAs reported providing guidance on staff safety, operational procedures, oversight, and reforming billing practices to align with new models of service delivery.

CONCLUSIONS

SOTAs generally reported that federal guidance increased patient access, engagement, and retention. Increased take-home flexibilities were viewed as important for expanding access and continuity of treatment, with the majority of SOTAs stating that the revised treatment practices (e.g., expansion of telehealth, flexible medication dispensing practices) were beneficial. These regulatory flexibilities, many believe, promoted the continuation of treatment and successful patient outcomes during the pandemic.

Predictors of mental health among U.S. adults during COVID-19 early pandemic, mid- pandemic, and post-vaccine eras

BACKGROUND

A collective trauma like COVID-19 impacts individuals differently due to socio-contextual and individual characteristics. Younger adults, minorities, affiliates of certain political parties, and residents of some regions of the United States reported experiencing poorer mental health during the pandemic. Being diagnosed with COVID-19, or losing a friend/family to it, was related to more adverse mental health symptoms. While the negative impact of COVID-19 on health outcomes has been studied, mental health changes during this pandemic need further exploration.

METHODS

In a study of 8,612 U.S. households, using three surveys collected from a nationally representative panel between May 2020 and October 2021, using a repeated cross-sectional design, a linear mixed effect regression model was performed to investigate factors associated with the mental health status, based on the Mental Health Inventory-5, of individuals throughout different phases of the COVID-19 pandemic, and whether an improvement over time, especially after vaccines became available, was observed.

RESULTS

An overall improvement in mental health was observed after vaccines became available. Individuals with no COVID-related death in their household, those not wearing masks, those identifying as members of the Republican Party, race/ethnicities other than Asian, men, older adults, and residents of the South were less likely than others to report mental health challenges.

CONCLUSIONS

Our results highlight the need for widespread mental health interventions and health promotion to address challenges during the COVID-19 pandemic and beyond. Due to the worse mental health observed among Asians, younger adults, women, low-income families, those with a higher level of concern for COVID-19, people who lost someone to COVID-19, and/or individuals with histories of opioid use disorder and criminal legal involvement, over the period of this study, targeted attention needs to be given to the mental health of these groups.

Impact of the Communities That HEAL Intervention on Buprenorphine-Waivered Practitioners and Buprenorphine Prescribing: A Prespecified Secondary Analysis of the HCS Randomized Clinical Trial

Importance

Buprenorphine significantly reduces opioid-related overdose mortality. From 2002 to 2022, the Drug Addiction Treatment Act of 2000 (DATA 2000) required qualified practitioners to receive a waiver from the Drug Enforcement Agency to prescribe buprenorphine for treatment of opioid use disorder. During this period, waiver uptake among practitioners was modest; subsequent changes need to be examined.

Objective

To determine whether the Communities That HEAL (CTH) intervention increased the rate of practitioners with DATA 2000 waivers and buprenorphine prescribing.

Design, Setting, and Participants

This prespecified secondary analysis of the HEALing Communities Study, a multisite, 2-arm, parallel, community-level, cluster randomized, open, wait-list-controlled comparison clinical trial was designed to assess the effectiveness of the CTH intervention and was conducted between January 1, 2020, to December 31, 2023, in 67 communities in Kentucky, Massachusetts, New York, and Ohio, accounting for approximately 8.2 million adults. The participants in this trial were communities consisting of counties (n = 48) and municipalities (n = 19). Trial arm randomization was conducted using a covariate constrained randomization procedure stratified by state. Each state was balanced by community characteristics including urban/rural classification, fatal opioid overdose rate, and community population. Thirty-four communities were randomized to the intervention and 33 to wait-list control arms. Data analysis was conducted between March 20 and September 29, 2023, with a focus on the comparison period from July 1, 2021, to June 30, 2022.

Intervention

Waiver trainings and other educational trainings were offered or supported by the HEALing Communities Study research sites in each state to help build practitioner capacity.

Main Outcomes and Measures

The rate of practitioners with a DATA 2000 waiver (overall, and stratified by 30-, 100-, and 275-patient limits) per 100 000 adult residents aged 18 years or older during July 1, 2021, to June 30, 2022, were compared between the intervention and wait-list control communities. The rate of buprenorphine prescribing among those waivered practitioners was also compared between the intervention and wait-list control communities. Intention-to-treat and per-protocol analyses were performed.

Results

A total of 8 166 963 individuals aged 18 years or older were residents of the 67 communities studied. There was no evidence of an effect of the CTH intervention on the adjusted rate of practitioners with a DATA 2000 waiver (adjusted relative rate [ARR], 1.04; 95% CI, 0.94-1.14) or the adjusted rate of practitioners with a DATA 2000 waiver who actively prescribed buprenorphine (ARR, 0.97; 95% CI, 0.86-1.10).

Conclusions and Relevance

In this randomized clinical trial, the CTH intervention was not associated with increases in the rate of practitioners with a DATA 2000 waiver or buprenorphine prescribing among those waivered practitioners. Supporting practitioners to prescribe buprenorphine remains a critical yet challenging step in the continuum of care to treat opioid use disorder.

Trial Registration

ClinicalTrials.gov Identifier: NCT04111939.

Polysubstance mortality trends in White and Black Americans during the opioid epidemic, 1999-2018

BACKGROUND

Psychoactive drug combinations are increasingly contributing to overdose deaths among White and Black Americans. To understand the evolving nature of overdose crisis, inform policies, and develop tailored and equitable interventions, this study provides a comprehensive assessment of polysubstance mortality trends by race and sex during the opioid epidemic.

METHODS

We used serial cross-sectional US mortality data for White and Black populations from 1999 through 2018 to calculate annual age-adjusted death rates (AADR) involving any opioid, opioid subtypes, benzodiazepines, cocaine, psychostimulants, or combinations of these drugs, stratified by race and sex. Trend changes in AADR were analyzed using joinpoint regression models and expressed as average annual percent change (AAPC) during each period of the three waves of the opioid epidemic: 1999-2010 (wave 1), 2010-2013 (wave 2), and 2013-2018 (wave 3). Prevalence measures assessed the percent co-involvement of an investigated drug in the overall death from another drug.

RESULTS

Polysubstance mortality has shifted from a modest rise in death rates due to benzodiazepine-opioid overdoses among White persons (wave 1) to a substantial increase in death rates due to illicit drug combinations impacting both White and Black populations (wave 3). Concurrent cocaine-opioid use had the highest polysubstance mortality rates in 2018 among Black (5.28 per 100,000) and White (3.53 per 100,000) persons. The steepest increase in death rates during wave 3 was observed across all psychoactive drugs when combined with synthetic opioids in both racial groups. Since 2013, Black persons have died faster from cocaine-opioid and psychostimulant-opioid overdoses. Between 2013 and 2018, opioids were highly prevalent in cocaine-related deaths, increasing by 33% in White persons compared to 135% in Blacks. By 2018, opioids contributed to approximately half of psychostimulant and 85% of benzodiazepine fatal overdoses in both groups. The magnitude and type of drug combinations with the highest death rates differed by race and sex, with Black men exhibiting the highest overdose burden beginning in 2013.

CONCLUSIONS

The current drug crisis should be considered in the context of polysubstance use. Effective measures and policies are needed to curb synthetic opioid-involved deaths and address disparate mortality rates in Black communities.

Risks of opioid overdose among New York State Medicaid recipients with chronic pain before and during the COVID-19 pandemic

OBJECTIVE

The COVID-19 pandemic contributed to healthcare disruptions for patients with chronic pain. Following initial disruptions, national policies were enacted to expand access to long-term opioid therapy (LTOT) for chronic pain and opioid use disorder (OUD) treatment services, which may have modified risk of opioid overdose. We examined associations between LTOT and/or OUD with fatal and non-fatal opioid overdoses, and whether the pandemic moderated overdose risk in these groups.

METHODS

We analyzed New York State Medicaid claims data (3/1/2019-12/31/20) of patients with chronic pain (N = 236,391). We used generalized estimating equations models to assess associations between LTOT and/or OUD (neither LTOT or OUD [ref], LTOT only, OUD only, and LTOT and OUD) and the pandemic (03/2020-12/2020) with opioid overdose.

RESULTS

The pandemic did not significantly (ns) affect opioid overdose among patients with LTOT and/or OUD. While patients with LTOT (vs. no LTOT) had a slight increase in opioid overdose during the pandemic (pre-pandemic: aOR:1.65, 95% CI:1.05, 2.57; pandemic: aOR:2.43, CI:1.75,3.37, ns), patients with OUD had a slightly attenuated odds of overdose during the pandemic (pre-pandemic: aOR:5.65, CI:4.73, 6.75; pandemic: aOR:5.16, CI:4.33, 6.14, ns). Patients with both LTOT and OUD also experienced a slightly reduced odds of opioid overdose during the pandemic (pre-pandemic: aOR:5.82, CI:3.58, 9.44; pandemic: aOR:3.70, CI:2.11, 6.50, ns).

CONCLUSIONS

Findings demonstrated no significant effect of the pandemic on opioid overdose among people with chronic pain and LTOT and/or OUD, suggesting pandemic policies expanding access to chronic pain and OUD treatment services may have mitigated the risk of opioid overdose.

Dynamic changes in methadone utilisation for opioid use disorder treatment: a retrospective observational study during the COVID-19 pandemic

OBJECTIVES

Opioid use disorder (OUD) is a major public health concern in the USA, resulting in high rates of overdose and other negative outcomes. Methadone, an OUD treatment, has been shown to be effective in reducing the risk of overdose and improving overall health and quality of life. This study analysed the distribution of methadone for the treatment of OUD across the USA over the past decade and through the COVID-19 pandemic.

DESIGN

Retrospective observational study using secondary data analysis of the Drug Enforcement Administration and Medicaid Databases.

SETTING

USA.

PARTICIPANTS

Patients who were dispensed methadone at US opioid treatment programmes (OTPs).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were the overall pattern in methadone distribution and the number of OTPs in the USA per year. The secondary outcome was Medicaid prescriptions for methadone.

RESULTS

Methadone distribution for OUD has expanded significantly over the past decade, with an average state increase of +96.96% from 2010 to 2020. There was a significant increase in overall distribution of methadone to OTP from 2010 to 2020 (+61.00%, p<0.001) and from 2015 to 2020 (+26.22%, p<0.001). However, the distribution to OTPs did not significantly change from 2019 to 2021 (-5.15%, p=0.491). There was considerable state-level variation in methadone prescribing to Medicaid patients with four states having no prescriptions.

CONCLUSIONS

There have been dynamic changes in methadone distribution for OUD. Furthermore, pronounced variation in methadone distribution among states was observed, with some states having no OTPs or Medicaid coverage. New policies are urgently needed to increase access to methadone treatment, address the opioid epidemic in the USA and reduce overdose deaths.

Methadone prescribing by addiction specialists likely to leave communities without available methadone treatment

Methadone treatment for opioid use disorder is not available in most suburban and rural US communities. We examined 2 options to expand methadone availability: (1) addiction specialty physician or (2) all clinician prescribing. Using 2022 Health Resources and Services Administration data, we used mental health professional shortage areas to indicate the potential of addiction specialty physician prescribing and the location of federally qualified health centers (ie, federally certified primary care clinics) to indicate the potential of all clinician prescribing. We examined how many census tracts without an available opioid treatment program (ie, methadone clinic) are (1) located within a mental health professional shortage area and (2) are also without an available federally qualified health center. Methadone was available in 49% of tracts under current regulations, 63% of tracts in the case of specialist physician prescribing, and 86% of tracts in the case of all clinician prescribing. Specialist physician prescribing would expand availability to an additional 12% of urban, 18% of suburban, and 16% of rural tracts, while clinician prescribing would expand to an additional 30% of urban, 53% of suburban, and 58% of rural tracts relative to current availability. Results support enabling broader methadone prescribing privileges to ensure equitable treatment access, particularly for rural communities.

Developing a Theoretically Informed Implementation Model for Telemedicine-Delivered Medication for Opioid Use Disorder: Qualitative Study With Key Informants

BACKGROUND

Telemedicine-delivered medication for opioid use disorder (TMOUD) has become more prevalent during the COVID-19 pandemic, particularly in North America. This is considered a positive development as TMOUD has the potential to increase access to evidence-based treatment for a population heavily affected by the opioid crisis and consequent rising mortality and morbidity rates in relation to opioid use disorder. Despite the increase in the use of TMOUD, there are no established service- and process-focused models to guide the implementation of this intervention.

OBJECTIVE

This study aims to develop a process- and service-focused implementation model in collaboration with key stakeholders and bring together peer-reviewed literature, practice-based knowledge, and expert opinions.

METHODS

The simple rules for evidence translation in complex systems framework was applied to guide the development of a 6-step qualitative study. The steps were definition of the scope and objectives of the model, identification of evidence, stakeholder engagement, draft model development, key informant consultation, and final model specification.

RESULTS

The final specification for the TMOUD implementation model incorporated key strategic priorities, service delivery prerequisites, service design elements, stakeholder identification and engagement, key process domains, and iterative cycles of evaluation and improvement.

CONCLUSIONS

Through stakeholder engagement and key informant consultation, we produced a process- and service-focused TMOUD implementation model. The model is modifiable to different contexts and settings while also in keeping with the current evidence base and national and international standards of high-quality opioid use disorder care.

Typology of laws restricting access to methadone treatment in the United States: A latent class analysis

BACKGROUND

In the United States, methadone treatment for opioid use disorder is only available at opioid treatment programs (OTPs). In addition to federal regulations, states can enact laws which shape access to OTPs. We aimed to define classes of states according to restrictiveness of state OTP laws and examine population characteristics associated with class membership.

METHODS

A set of laws was extracted from a database of statutes and regulations governing OTPs in 49 states and the District of Columbia as of June 2021. Latent class analysis of laws was used to estimate the probability of class membership for each state. Class-weighted multinomial logistic regression analysis assessed state-level correlates of class membership and adjusted Relative Risk Ratio (aRRR) and 95% confidence intervals (95%CI) were generated.

RESULTS

States (n = 50) were assigned to three classes; Class 1) High restrictiveness on patient experience, low restrictiveness on access to service (n = 13); Class 2) Medium restrictiveness on patient experience, high restrictiveness on access to service (n = 14); Class 3) Low restrictiveness on patient experience, low restrictiveness on access to service (n = 23). States with a higher probability of membership in Classes with higher restrictiveness had higher rates of unemployment (Class 1 vs Class 3, aRRR:1.24; 95%CI:1.06-1.45), and Black residents (Class 2 vs Class 3, aRRR:1.10; 95%CI:1.04-1.15), and lower likelihood of Medicaid coverage of methadone (Class 1 vs Class 3, aRRR:0.25; 95%CI:0.07-0.88). States with a higher probability of membership in Classes with higher restrictiveness also had higher rates of potential indicators for opioid use disorder treatment need, including rates of opioid dispensing (Class 1 vs Class 3, aRRR:1.06; 95%CI:1.02-1.10, Class 2 vs Class 3, aRRR:1.07; 95%CI:1.03-1.11) and HIV diagnoses attributed to injection (Class 1 vs Class 3, aRRR:3.92; 95%CI:1.25-12.22).

CONCLUSIONS

States with indicators of greater potential need for opioid use disorder treatment have the most restrictions, raising concerns about unmet treatment need.

The impact of the implementation of medication for opioid use disorder and COVID-19 in a statewide correctional system on treatment engagement, postrelease continuation of care, and overdose

BACKGROUND

People with opioid use disorder (OUD) are overrepresented in US correctional facilities and experience disproportionately high risk for overdose after release. Medications for OUD (MOUD) are highly efficacious but not available to most incarcerated individuals. In 2018, Vermont began providing MOUD for all incarcerated individuals with OUD statewide. In 2020, the COVID-19 state of emergency began. We assessed the impact of both events on MOUD utilization and treatment outcomes.

METHODOLOGY

Analyses linked Vermont Department of Corrections administrative data and Medicaid claims data between 07/01/2017 and 03/31/2021. The study used logistic regression to analyze treatment engagement among all incarcerated individuals in Vermont. Multilevel modeling assessed change in clinical outcomes among release episodes that occurred among individuals with an OUD diagnosis Medicaid claim.

RESULTS

Prescriptions for MOUD while incarcerated increased from 0.8% to 33.9% of the incarcerated population after MOUD implementation (OR = 67.4) and subsequently decreased with the onset of COVID-19 to 26.6% (OR = 0.7). After MOUD implementation, most prescriptions (63.1%) were to individuals who had not been receiving MOUD prior to incarceration, but this figure decreased to 53.9% with the onset of COVID-19 (OR = 0.7). Prescriptions for MOUD within 30 days after release increased from 33.9% of those with OUD before to 41.0% after MOUD implementation (OR = 1.4) but decreased to 35.6% with the onset of COVID-19 (OR = 0.8). Simultaneously, opioid-related nonfatal overdoses within 30 days after release decreased from 1.2% before to 0.8% after statewide MOUD implementation (OR = 0.3) but increased to 1.9% during COVID-19 (OR = 3.4). Fatal overdoses within 1 year after release decreased from 27 deaths before to ≤10 after statewide MOUD implementation and remained ≤10 during COVID-19.

CONCLUSIONS

This longitudinal evaluation demonstrated increased treatment engagement and a decrease in opioid-related overdose following implementation of MOUD in a statewide correctional system. In contrast, these improvements were somewhat attenuated with the onset of COVID-19, which was associated with decreased treatment engagement and an increase in nonfatal overdoses. Considered together, these findings demonstrate the benefits of statewide MOUD for incarcerated individuals as well as the need to identify and address barriers to continuation of care following release from incarceration in the context of COVID-19.

Changes to methadone maintenance therapy in the United States, Canada, and Australia during the COVID-19 pandemic: A narrative review

INTRODUCTION

In response to the COVID-19 pandemic, countries across the world made adaptations to policies regulating the provision of methadone maintenance therapy (MMT) to facilitate social distancing for health care providers and people in treatment. Many countries issued guidance about increasing take-home methadone doses after the onset of the pandemic.

METHODS

In this review, we compare the regulation of MMT prior to the pandemic in the United States, Canada, and Australia, analyze changes to treatment policy in the context of COVID-19, and review emerging data on treatment outcomes.

RESULTS

The United States only permits the prescription and disbursement of methadone for MMT treatment at federally designated opioid treatment programs (OTPs). Conversely, Australia and Canada operate on a community pharmacy-based distribution model, where patients can access methadone doses either in participating pharmacies or in some methadone clinics.

CONCLUSION

Given reports of similar treatment outcomes and increased patient satisfaction since the pandemic-related policy changes, some changes including increased receipt of take-home doses should be considered for incorporation into post-pandemic treatment policies and regulations.

Methadone Treatment Gap in Tennessee and How Medication Units Could Bridge the Gap: A Review

The opioid epidemic has been an ongoing public health concern in the United States (US) for the last few decades. The number of overdose deaths involving opioids, hereafter referred to as overdose deaths, has increased yearly since the mid-1990s. One treatment modality for opioid use disorder (OUD) is medication-assisted treatment (MAT). As of 2022, only three pharmacotherapy options have been approved by the Food and Drug Administration (FDA) for treating OUD: buprenorphine, methadone, and naltrexone. Unlike buprenorphine and naltrexone, methadone dispensing and administrating are restricted to opioid treatment programs (OTPs). To date, Tennessee has no medication units, and administration and dispensing of methadone is limited to licensed OTPs. This review details the research process used to develop a policy draft for medication units in Tennessee. This review is comprised of three parts: (1) a rapid review aimed at identifying obstacles and facilitators to OTP access in the US, (2) a descriptive analysis of Tennessee's geographic availability of OTPs, pharmacies, and federally qualified health centers (FQHCs), and (3) policy mapping of 21 US states' OTP regulations. In the rapid review, a total of 486 articles were imported into EndNote from PubMed and Embase. After removing 152 duplicates, 357 articles were screened based on their title and abstract. Thus, 34 articles underwent a full-text review to identify articles that addressed the accessibility of methadone treatment for OUD. A total of 18 articles were identified and analyzed. A descriptive analysis of Tennessee's availability of OTP showed that the state has 22 OTPs. All 22 OTPs were matched to a county and a region based on their address resulting in 15 counties (16%) and all three regions having at least one OTP. A total of 260 FQHCs and 2294 pharmacies are in Tennessee. Each facility was matched to a county based on its address resulting in 70 counties (74%) having at least one FQHC and 94 counties (99%) having at least one pharmacy. As of 31 December 2022, 17 states mentioned medication units in their state-level OTP regulations. Utilizing the regulations for the eleven states with medication units and federal guidelines, a policy draft was created for Tennessee's medication units.

Recent modifications to the US methadone treatment system are a Band-Aid-not a solution-to the nation's broken opioid use disorder treatment system

For 5 decades, US federal regulations have segregated methadone treatment for opioid use disorder from the rest of the health care system, confining its availability to specialty treatment programs that are highly regulated. These regulations have led to severe shortages in the availability of methadone and grave underutilization of this lifesaving medication despite a worsening overdose crisis. In this commentary, we discuss current barriers to methadone in the US opioid treatment system and how recent changes to federal regulations fall short of the reforms needed to significantly expand access to this treatment. Instead, we propose the urgent need to expand methadone to mainstream health care settings by allowing for office-based prescribing and pharmacy dispensing of methadone, the norm in many other developed countries.

Opioid use in the era of COVID-19: a multifaceted study of the opioid epidemic in Canada

Introduction: The COVID-19 pandemic has had wide economic, social, and health impacts, and has disproportionately affected individuals who were already vulnerable. Individuals who use opioids have dealt with evolving public health measures and disruptions while also dealing with the ongoing opioid epidemic. Opioid-related mortalities in Canada increased throughout the COVID-19 pandemic, but it is unclear to what extent public health measures and the progression of the pandemic contributed to opioid-related harms. Methods: To address this gap, we used emergency room (ER) visits recorded in the National Ambulatory Care Reporting System (NACRS) between 1 April 2017, and 31 December 2021, to investigate trends of opioid-related harms throughout the pandemic. This study also included semi-structured interviews with service providers in the field of opioid use treatment, to help contextualize the trends seen in ER visits and offer perspectives on how opioid use and services have changed throughout the COVID-19 pandemic. Results: Overall, the number of hospitalizations related to an opioid use disorder (OUD) decreased with progressing waves of the pandemic and with increasing severity of public health measures in Ontario. The rate of hospitalizations related to opioid poisonings (e.g., central nervous system and respiratory system depression caused by opioids) significantly increased with the progressing waves of the pandemic, as well as with increasing severity of public health measures in Ontario. Discussion: The increase in opioid-related poisonings is reflected in the existing literature whereas the decrease in OUDs is not. Moreover, the increase in opioid-related poisonings aligns with the observations of service providers, whereas the decrease in OUD contradicts the trends that service providers described. This discrepancy could be explained by factors identified by service providers, including the pressures on ERs during the pandemic, hesitancy to seek treatment, and drug toxicity.

Public transport access to drug treatment before and during COVID-19: Implications for the opioid epidemic

Public transport disruptions caused by the COVID-19 pandemic had wide-ranging impacts on the ability of individuals to access health care. Individuals with opioid use disorder represent an especially vulnerable population due to the necessity of frequent, supervised doses of opioid agonists. Focused on Toronto, a major Canadian city suffering from the opioid epidemic, this analysis uses novel realistic routing methodologies to quantify how travel times to individuals\220 nearest clinics changed due to public transport disruptions from 2019 to 2020. Individuals seeking opioid agonist treatment face very constrained windows of access due to the need to manage work and other essential activities. We find that thousands of households in the most materially and socially deprived neighbourhoods crossed 30 and 20-minute travel time thresholds to their nearest clinic. As even small changes to travel times can lead to missed appointments and heighten the chances of overdose and death, understanding the distribution of those most impacted can help inform future policy measures to ensure adequate access to care.

"As long as that place stays open, I'll stay alive": Accessing injectable opioid agonist treatment during dual public health crises

BACKGROUND

Since the onset of the COVID-19 pandemic, overdose rates in North America have continued to rise, with more than 100,000 drug poisoning deaths in the past year. Amidst an increasingly toxic drug supply, the pandemic disrupted essential substance use treatment and harm reduction services that reduce overdose risk for people who use drugs. In British Columbia, one such treatment is injectable opioid agonist treatment (iOAT), the supervised dispensation of injectable hydromorphone or diacetylmorphine for people with opioid use disorder. While evidence has shown iOAT to be safe and effective, it is intensive and highly regimented, characterized by daily clinic visits and provider-client interaction-treatment components made difficult by the pandemic.

METHODS

Between April 2020 and February 2021, we conducted 51 interviews with 18 iOAT clients and two clinic nurses to understand how the pandemic shaped iOAT access and treatment experiences. To analyze interview data, we employed a multi-step, flexible coding strategy, an iterative and abductive approach to analysis, using NVivo software.

RESULTS

Qualitative analysis revealed the ways in which the pandemic shaped clients' lives and the provision of iOAT care. First, client narratives illuminated how the pandemic reinforced existing inequities. For example, socioeconomically marginalized clients expressed concerns around their financial stability and economic impacts on their communities. Second, clients with health comorbidities recognized how the pandemic amplified health risks, through potential COVID-19 exposure or by limiting social connection and mental health supports. Third, clients described how the pandemic changed their engagement with the iOAT clinic and medication. For instance, clients noted that physical distancing guidelines and occupancy limits reduced opportunities for social connection with staff and other iOAT clients. However, pandemic policies also created opportunities to adapt treatment in ways that increased patient trust and autonomy, for example through more flexible medication regimens and take-home oral doses.

CONCLUSION

Participant narratives underscored the unequal distribution of pandemic impacts for people who use drugs but also highlighted opportunities for more flexible, patient-centered treatment approaches. Across treatment settings, pandemic-era changes that increase client autonomy and ensure equitable access to care are to be continued and expanded, beyond the duration of the pandemic.

Ingestion of Illicit Substances by Young Children Before and During the COVID-19 Pandemic

Importance

Information about the trend in illicit substance ingestions among young children during the pandemic is limited.

Objectives

To assess immediate and sustained changes in overall illicit substance ingestion rates among children younger than 6 years before and during the COVID-19 pandemic and to examine changes by substance type (amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids) while controlling for differing statewide medicinal and recreational cannabis legalization policies.

Design, Setting, and Participants

Retrospective cross-sectional study using an interrupted time series at 46 tertiary care children's hospitals within the Pediatric Health Information System (PHIS). Participants were children younger than 6 years who presented to a PHIS hospital for an illicit substance(s) ingestion between January 1, 2017, and December 31, 2021. Data were analyzed in February 2023.

Exposure

Absence or presence of the COVID-19 pandemic.

Main Outcome(s) and Measure(s)

The primary outcome was the monthly rate of encounters for illicit substance ingestions among children younger than 6 years defined by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code(s) for poisoning by amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids. The secondary outcomes were the monthly rate of encounters for individual substances.

Results

Among 7659 children presenting with ingestions, the mean (SD) age was 2.2 (1.3) years and 5825 (76.0%) were Medicaid insured/self-pay. There was a 25.6% (95% CI, 13.2%-39.4%) immediate increase in overall ingestions at the onset of the pandemic compared with the prepandemic period, which was attributed to cannabis, opioid, and ethanol ingestions. There was a 1.8% (95% CI, 1.1%-2.4%) sustained monthly relative increase compared with prepandemic trends in overall ingestions which was due to opioids. There was no association between medicinal or recreational cannabis legalization and the rate of cannabis ingestion encounters.

Conclusions and Relevance

In this study of illicit substance ingestions in young children before and during the COVID-19 pandemic, there was an immediate and sustained increase in illicit substance ingestions during the pandemic. Additional studies are needed to contextualize these findings in the setting of pandemic-related stress and to identify interventions to prevent ingestions in face of such stress, such as improved parental mental health and substance treatment services, accessible childcare, and increased substance storage education.

Availability of timely methadone treatment in the United States and Canada during COVID-19: A census tract-level analysis

OBJECTIVES

We sought to compare timely access to methadone treatment in the United States (US) and Canada during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional study of census tracts and aggregated dissemination areas (used for rural Canada) within 14 US and 3 Canadian jurisdictions in 2020. We excluded census tracts or areas with a population density of less than one person per square km. Data from a 2020 audit of timely medication access was used to determine clinics accepting new patients within 48 h. Unadjusted and adjusted linear regressions were performed to examine the relationship between area population density and sociodemographic covariates and three outcome variables: 1) driving distance to the nearest methadone clinic accepting new patients, 2) driving distance to the nearest methadone clinic accepting new patients for medication initiation within 48 h, and 3) the difference in the driving distance between the first and second outcome.

RESULTS

We included 17,611 census tracts and areas with a population density greater than one person per square kilometer. After adjusting for area covariates, US jurisdictions were a median of 11.6 miles (p value <0.001) further from a methadone clinic accepting new patients and 25.1 miles (p value <0.001) further from a clinic accepting new patients within 48 h than Canadian jurisdictions.

CONCLUSIONS

These results suggest that the more flexible Canadian regulatory approach to methadone treatment is associated with a greater availability of timely methadone treatment and reduced urban-rural disparity in availability, compared to the US.

The development and validation of the pandemic medication-assisted treatment questionnaire for the assessment of pandemic crises impact on medication management and administration for patients with opioid use disorders

Pandemic and the globally applied restriction measures mainly affect vulnerable population groups, such as patients with opioid use disorders. Towards inhibiting SARS-Cov-2 spread, the medication-assisted treatment (MAT) programs follow strategies targeting the reduction of in-person psychosocial interventions and an increase of take-home doses. However, there is no available instrument to examine the impact of such modifications on diverse health aspects of patients under MAT. The aim of this study was to develop and validate the PANdemic Medication-Assisted Treatment Questionnaire (PANMAT/Q) to address the pandemic effect on the management and administration of MAT. In total, 463 patients under ΜΑΤ participated. Our findings indicate that PANMAT/Q has been successfully validated exerting reliability and validity. It can be completed within approximately 5 min, and its implementation in research settings is advocated. PANMAT/Q could serve as a useful tool to identify the needs of patients under MAT being at high risk of relapse and overdose.

Structures of drug-specific monoclonal antibodies bound to opioids and nicotine reveal a common mode of binding

Opioid-related fatal overdoses have reached epidemic proportions. Because existing treatments for opioid use disorders offer limited long-term protection, accelerating the development of newer approaches is critical. Monoclonal antibodies (mAbs) are an emerging treatment strategy that targets and sequesters selected opioids in the bloodstream, reducing drug distribution across the blood-brain barrier, thus preventing or reversing opioid toxicity. We previously identified a series of murine mAbs with high affinity and selectivity for oxycodone, morphine, fentanyl, and nicotine. To determine their binding mechanism, we used X-ray crystallography to solve the structures of mAbs bound to their respective targets, to 2.2 Å resolution or higher. Structural analysis showed a critical convergent hydrogen bonding mode that is dependent on a glutamic acid residue in the mAbs' heavy chain and a tertiary amine of the ligand. Characterizing drug-mAb complexes represents a significant step toward rational antibody engineering and future manufacturing activities to support clinical evaluation.

Machine Learning Techniques to Explore Clinical Presentations of COVID-19 Severity and to Test the Association With Unhealthy Opioid Use: Retrospective Cross-sectional Cohort Study

BACKGROUND

The COVID-19 pandemic has exacerbated health inequities in the United States. People with unhealthy opioid use (UOU) may face disproportionate challenges with COVID-19 precautions, and the pandemic has disrupted access to opioids and UOU treatments. UOU impairs the immunological, cardiovascular, pulmonary, renal, and neurological systems and may increase severity of outcomes for COVID-19.

OBJECTIVE

We applied machine learning techniques to explore clinical presentations of hospitalized patients with UOU and COVID-19 and to test the association between UOU and COVID-19 disease severity.

METHODS

This retrospective, cross-sectional cohort study was conducted based on data from 4110 electronic health record patient encounters at an academic health center in Chicago between January 1, 2020, and December 31, 2020. The inclusion criterion was an unplanned admission of a patient aged ≥18 years; encounters were counted as COVID-19-positive if there was a positive test for COVID-19 or 2 COVID-19 International Classification of Disease, Tenth Revision codes. Using a predefined cutoff with optimal sensitivity and specificity to identify UOU, we ran a machine learning UOU classifier on the data for patients with COVID-19 to estimate the subcohort of patients with UOU. Topic modeling was used to explore and compare the clinical presentations documented for 2 subgroups: encounters with UOU and COVID-19 and those with no UOU and COVID-19. Mixed effects logistic regression accounted for multiple encounters for some patients and tested the association between UOU and COVID-19 outcome severity. Severity was measured with 3 utilization metrics: low-severity unplanned admission, medium-severity unplanned admission and receiving mechanical ventilation, and high-severity unplanned admission with in-hospital death. All models controlled for age, sex, race/ethnicity, insurance status, and BMI.

RESULTS

Topic modeling yielded 10 topics per subgroup and highlighted unique comorbidities associated with UOU and COVID-19 (eg, HIV) and no UOU and COVID-19 (eg, diabetes). In the regression analysis, each incremental increase in the classifier's predicted probability of UOU was associated with 1.16 higher odds of COVID-19 outcome severity (odds ratio 1.16, 95% CI 1.04-1.29; P=.009).

CONCLUSIONS

Among patients hospitalized with COVID-19, UOU is an independent risk factor associated with greater outcome severity, including in-hospital death. Social determinants of health and opioid-related overdose are unique comorbidities in the clinical presentation of the UOU patient subgroup. Additional research is needed on the role of COVID-19 therapeutics and inpatient management of acute COVID-19 pneumonia for patients with UOU. Further research is needed to test associations between expanded evidence-based harm reduction strategies for UOU and vaccination rates, hospitalizations, and risks for overdose and death among people with UOU and COVID-19. Machine learning techniques may offer more exhaustive means for cohort discovery and a novel mixed methods approach to population health.

Methadone and buprenorphine-related deaths among people prescribed and not prescribed Opioid Agonist Therapy during the COVID-19 pandemic in England

BACKGROUND

The coronavirus pandemic resulted in many changes which had the potential to impact mortality related to opioid agonist therapy (OAT; methadone, buprenorphine), including changes in the prescribing and dispensing of OAT and patterns of drug availability and use. We aimed to assess the impact of the first lockdown (initiated March 23rd 2020) on methadone- and buprenorphine-related deaths in England in people both prescribed and not prescribed OAT using data from the National Programme on Substance Abuse Deaths.

METHODS

This was a retrospective post-mortem toxicology study of OAT-related deaths which occurred in the 3-month period March 23rd to June 22nd in the years 2016-2020. Provisional data regarding numbers accessing treatment for opioid use disorder was provided by the National Drug Treatment Monitoring System.

RESULTS

We found a 64% increase in methadone-related deaths in March to June 2020 compared to March to June 2019 (2019 n = 96; 2020 projected n = 157). There were increases in the mortality rate of both in-treatment decedents (22% increase; 2019 n = 45; an exponential smoothing model of the 2016-19 trend [α=0.5] predicted 44 deaths in 2020, 55 were reported) and decedents not prescribed methadone (74% increase; 2019 n = 46; 2016-19 trend predicted 43 deaths in 2020, 80 were reported). There was no increase in buprenorphine-related deaths (2019 n = 9/529; 2020 n = 11/566). There were no changes in the numbers of deaths where other opioids or multiple substances were detected, or in methadone levels detected. Numbers of people accessing treatment for opioid use disorder in 2020 did not decrease relative to previous years (p >0.05).

CONCLUSIONS

Methadone-related deaths in non-prescribed individuals, but not prescribed individuals, increased considerably above the annual trend forecast for 2020 during the first COVID-19 lockdown in England. Further studies are thus needed to understand this difference.

The impact of COVID-19 and rapid policy exemptions expanding on access to medication for opioid use disorder (MOUD): A nationwide Veterans Health Administration cohort study

BACKGROUND

In March 2020, Veterans Health Administration (VHA) enacted policies to expand treatment for Veterans with opioid use disorder (OUD) during COVID-19. In this study, we evaluate whether COVID-19 and subsequent OUD treatment policies impacted receipt of therapy/counseling and medication for OUD (MOUD).

METHODS

Using VHA's nationwide electronic health record data, we compared outcomes between a comparison cohort derived using data from prior to COVID-19 (October 2017-December 2019) and a pandemic-exposed cohort (January 2019-March 2021). Primary outcomes included receipt of therapy/counseling or any MOUD (any/none); secondary outcomes included the number of therapy/counseling sessions attended, and the average percentage of days covered (PDC) by, and months prescribed, each MOUD in a year.

RESULTS

Veterans were less likely to receive therapy/counseling over time, especially post-pandemic onset, and despite substantial increases in teletherapy. The likelihood of receiving buprenorphine, methadone, and naltrexone was reduced post-pandemic onset. PDC on MOUD generally decreased over time, especially methadone PDC post-pandemic onset, whereas buprenorphine PDC was less impacted during COVID-19. The number of months prescribed methadone and buprenorphine represented relative improvements compared to prior years. We observed important disparities across Veteran demographics.

CONCLUSION

Receipt of treatment was negatively impacted during the pandemic. However, there was some evidence that coverage on methadone and buprenorphine may have improved among some veterans who received them. These medication effects are consistent with expected COVID-19 treatment disruptions, while improvements regarding access to therapy/counseling via telehealth, as well as coverage on MOUD during the pandemic, are consistent with the aims of MOUD policy exemptions.

The impact of benzodiazepine exposure on treatment retention in an open-access methadone program: A retrospective cohort study

BACKGROUND

Open-access opioid treatment programs (OTP) offer same-day access to methadone without an appointment and aim to minimize treatment barriers that often reduce admission and/or retention. We explored whether patients with benzodiazepine exposure at treatment entry would have similar 12-month retention compared to those without benzodiazepine exposure.

METHODS

We conducted a retrospective cohort study of 2968 patients consecutively initiated on methadone between January 2015 and February 2017 at an open-access OTP. The sample was stratified into benzodiazepine-exposed and nonexposed groups based on intake urine toxicology. Group comparison of 12-month retention was conducted. Kaplan Meier analysis compared time to methadone treatment discontinuation between groups with a log-rank test. Multivariable Cox regression was performed to compare retention by baseline benzodiazepine exposure with adjustment for confounders.

RESULTS

Overall, 31% of patients with benzodiazepine exposure (n = 171) and 31% without exposure (n = 2423) were retained at 12 months (p = 0.95). Median treatment duration was 182 days (95% CI, 152-239) and 175 days (95% CI, 156-196) for patients with and without benzodiazepine exposure, respectively. Kaplan-Meier analysis showed no significant difference in treatment duration between groups (log-rank test p = 0.73). Cox regression found no difference in treatment retention between groups (adjusted Hazard Ratio= 1.03, 95% CI, 0.91-1.16).

CONCLUSIONS

In this cohort of patients receiving methadone at an open-access OTP, benzodiazepine exposure at intake was not observed to impact 12-month treatment retention or duration. These findings support U.S. Food and Drug Administration (FDA) recommendations to not withhold medications for opioid use disorder from patients taking benzodiazepines.

Factors associated with self-reported avoidance of harm reduction services during the COVID-19 pandemic by people who use drugs in five cities in the United States and Canada

BACKGROUND

This study examines individual-level factors associated with avoiding two important health services for people who use drugs-medications for treatment of opioid use disorder and syringe service programs-during the first year of the COVID-19 pandemic.

METHODS

Data come from two subsamples of people who use drugs who were active participants in one of nine cohort studies in Vancouver, British Columbia; Baltimore, Maryland; Los Angeles, California; Chicago, Illinois; and Miami, Florida. Participants were interviewed remotely about COVID-19-associated disruptions to healthcare. We estimated the association of demographic, social, and health factors with each outcome using logistic regression among 702 participants (medication analysis) and 304 participants (syringe service analysis.) Analyses were repeated, stratified by city of residence, to examine geographic variation in risk.

RESULTS

There were large differences between cities in the prevalence of avoiding picking up medications for opioid use disorder, with almost no avoidance in Vancouver (3%) and nearly universal avoidance in Los Angeles, Chicago, and Miami (>90%). After accounting for between-city differences, no individual factors were associated with avoiding picking up medications. The only factor significantly associated with avoiding syringe service programs was higher levels of self-reported worry about COVID-19.

CONCLUSION

During the first year of the COVID-19 pandemic, geographic differences in service and policy contexts likely influenced avoidance of health and harm reduction services by people who use drugs in the United States and Canada more than individual differences between people.

Opioid agonist treatment take-home doses ('carries'): Are current guidelines resulting in low treatment coverage among high-risk populations in Canada and the USA?

Opioid agonist treatment (OAT) is the primary intervention for opioid use disorder (OUD) in Canada and the USA. Yet, a number of barriers contribute to sub-optimal treatment uptake and retention, including daily-supervised medication administration. Thus, clients are eventually granted access to take-home OAT doses (i.e., ‘carries’) to reduce this burden. However, this decision is based on physician discretion and whether patients can demonstrate stability in various life domains, many of which are inextricably linked to the social determinants of health (SDOH). Current Canadian and USA OAT carry guidance documents are not standardized and do not take the SDOH into consideration, resulting in the potential for inequitable access to OAT carries, which may be the case particularly among marginalized populations such as individuals with OUD who have been released from custody. This perspective article posits that current OAT guidelines contribute to inequities in access to OAT carries, and that these inequities likely result in disproportionately low coverage for OUD treatment among some high-risk groups, including individuals on release from incarceration in particular. Relevant impacts of COVID-19 and related policy changes are considered, and suggestions and recommendations to amend current OAT guidance documents are provided.

Improving geographic access to methadone clinics

INTRODUCTION

Opioid misuse is a nationwide public health crisis. Methadone treatment is proven to be highly successful in preventing opioid use disorder, reducing the use of illicit drugs, and preventing overdoses. Clients acquire methadone daily from clinics, making geographic access crucial for the initiation of and adherence to treatment.

METHODS

This work estimates unsatisfied methadone demand due to lack of geographic access at a census tract level and models the problem of identifying optimal locations to open new methadone clinics. The objective function of the model is a weighted combination of providing access to individuals with unmet methadone demand and improving the travel time of individuals currently attending a clinic. Data on existing methadone clinics and statewide methadone demand is acquired from Substance Abuse and Mental Health Services Administration (SAMHSA) surveys from 2019. Unsatisfied demand is estimated through a linear regression model after aggregating the population, heroin use, and satisfied methadone demand at the state level.

RESULTS

Nationwide, we find 18.2 % of the United States population does not have geographic access to a methadone clinic and estimate 77,973 individuals in these areas would attend a clinic if geographic access barriers were removed (95 % CI: 67,413-88,532). In a case study of six Midwestern states, we find that geography significantly contributes to the value of opening additional clinics and we see large differences in expected gains between states sharing similar characteristics such as population and satisfied methadone demand. The number of additional clients served by opening one new clinic ranges from 180 to 804 across these six states, representing between 8.4 % and 16.2 % of state unmet demand. Between 1.2 % and 14.1 % of existing clients were reassigned with a single newly opened clinic, with a one-way average travel distance improvement between 6.3 and 11.9 miles / person / day for these clients.

CONCLUSIONS

The results demonstrate the large unserved methadone demand in the United States, the significant improvement in methadone access for new and existing clients that can be achieved by opening new clinics, and the important role state-specific geography plays in these decisions.

Changes in Buprenorphine and Methadone Supplies in the US During the COVID-19 Pandemic

Importance

The opioid crisis has been exacerbated by the COVID-19 pandemic in the US, with concerns over major disruptions to medication treatment of opioid use disorder.

Objective

To investigate whether the COVID-19 pandemic was associated with disruption of buprenorphine and methadone supplies in the US.

Design, Setting, and Participants

This repeated cross-sectional study used ARCOS (Automated Reports and Consolidated Ordering System) data, which monitor the flow of controlled substances in the US, from January 1, 2012, through June 30, 2021. Manufacturers and point of sale or distribution at the dispensing or retail level, including hospitals, retail pharmacies, clinicians, midlevel clinicians, and teaching institutions, were included in the analysis.

Exposures

COVID-19 pandemic.

Main Outcomes and Measures

Quarterly supplies of buprenorphine and methadone per capita in milligrams.

Results

The per capita supply of methadone dropped from 13.2 mg in the first quarter of 2020 to 10.5 mg in the second quarter of 2020, whereas the per capita supply of buprenorphine increased from 3.6 mg to 3.7 mg in the same period. The per capita supply of methadone declined 20% (-2.7 mg) in the second quarter of 2020 compared with the first quarter of 2020, and the supply had not returned to 2019 levels as of June 2021, whereas the supply of buprenorphine per person increased consistently during the same period. There were considerable state disparities in the reduction of the methadone supply during the pandemic, with many states experiencing pronounced per capita supply decreases, including reductions as great as 50% in New Hampshire and Florida. These decreases in per capita methadone supply were not compensated by proportional increases in the per capita buprenorphine supply (linear fit, 0.17 [95% CI, -0.43 to 0.76]; P = .47).

Conclusions and Relevance

This cross-sectional study of buprenorphine and methadone supplies during the COVID-19 pandemic found a pronounced decline in the methadone supply but no disruption to the buprenorphine supply. Future research is needed to explain the pronounced state disparities in the methadone supply.

Geographic disparities in access to Medication for Opioid Use Disorder across US census tracts based on treatment utilization behavior

Drug overdose is the leading cause of accidental death in the U.S. with deaths from opioid overdose occurring at a higher rate in rural areas. The gaps in the provision of healthcare services have been exacerbated by the opioid crisis leaving vulnerable populations without access to preventative care and education, harm reduction, both chronic and acute treatment of the symptoms of opioid use disorder (OUD), and long-term psychological support for those with OUD and their families. There has been a call in the literature -and a federal mandate-for increased access to opioid treatment facilities, but to date this access has not been operationalized using best practices in geography. Medication for Opioid Use Disorder (MOUD) with FDA-approved methadone or buprenorphine has been shown to increase treatment retention, reduce opioid use and associated health and societal harms, and reduce opioid related overdose, and as such is considered the most effective treatment for OUD. The objective of this study is to examine U.S. adults' spatial access to MOUD - specifically locations of certified Opioid Treatment Programs (OTPs) and DATA-waived Buprenorphine providers. A gravity-based variant of the enhanced two-step floating catchment area model is employed, where friction of distance is based on previously published willingness to travel distances for patients visiting OTPs, to assess how opioid agonist treatment accessibility varies across the nation. Findings suggest that there are extensive 'treatment deserts' where there is little to no physical access to MOUD, especially in rural areas. The significance of this work lies in the incorporation of treatment utilization behavior in the access metric, and the continued confirmation of gaps in access to OUD services despite federal efforts to improve accessibility.

Assessment of Community-Level Vulnerability and Access to Medications for Opioid Use Disorder

IMPORTANCE

Given that COVID-19 and recent natural disasters exacerbated the shortage of medication for opioid use disorder (MOUD) services and were associated with increased opioid overdose mortality, it is important to examine how a community's ability to respond to natural disasters and infectious disease outbreaks is associated with MOUD access.

OBJECTIVE

To examine the association of community vulnerability to disasters and pandemics with geographic access to each of the 3 MOUDs and whether this association differs by urban, suburban, or rural classification.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of zip code tabulation areas (ZCTAs) in the continental United States excluding Washington, DC, conducted a geospatial analysis of 2020 treatment location data.

EXPOSURES

Social vulnerability index (US Centers for Disease Control and Prevention measure of vulnerability to disasters or pandemics).

MAIN OUTCOMES AND MEASURES

Drive time in minutes from the population-weighted center of the ZCTA to the ZCTA of the nearest treatment location for each treatment type (buprenorphine, methadone, and extended-release naltrexone).

RESULTS

Among 32 604 ZCTAs within the continental US, 170 within Washington, DC, and 20 without an urban-rural classification were excluded, resulting in a final sample of 32 434 ZCTAs. Greater social vulnerability was correlated with longer drive times for methadone (correlation, 0.10; 95% CI, 0.09 to 0.11), but it was not correlated with access to other MOUDs. Among rural ZCTAs, increasing social vulnerability was correlated with shorter drive times to buprenorphine (correlation, -0.10; 95% CI, -0.12 to -0.08) but vulnerability was not correlated with other measures of access. Among suburban ZCTAs, greater vulnerability was correlated with both longer drive times to methadone (correlation, 0.22; 95% CI, 0.20 to 0.24) and extended-release naltrexone (correlation, 0.15; 95% CI, 0.13 to 0.17).

CONCLUSIONS AND RELEVANCE

In this study, communities with greater vulnerability did not have greater geographic access to MOUD, and the mismatch between vulnerability and medication access was greatest in suburban communities. Rural communities had poor geographic access regardless of vulnerability status. Future disaster preparedness planning should match the location of services to communities with greater vulnerability to prevent inequities in overdose deaths.

Trends in Engagement With Opioid Use Disorder Treatment Among Medicaid Beneficiaries During the COVID-19 Pandemic

Question

During the COVID-19 public health emergency, did patients with opioid use disorder experience decreased access to opioid use disorder treatment?

Findings

In this cohort study of 6453 Medicaid beneficiaries with opioid use disorder in Wisconsin, buprenorphine possession remained stable at the onset and for the first 6 months of the public health emergency. In contrast, completion of urine drug tests and receipt of opioid treatment program services declined with the onset of the public health emergency and recovered partially 6 months into the public health emergency.

Meaning

The findings of this study suggest that the COVID-19 public health emergency did not disrupt access to buprenorphine but did disrupt urine drug testing and access to opioid treatment program services.

Importance

Disruptions in care during the COVID-19 pandemic may have decreased access to care for patients with opioid use disorder.

Objective

To examine trends in opioid use disorder treatment including buprenorphine possession, urine drug testing, and opioid treatment program services during the COVID-19 public health emergency.

Design, Setting, and Participants

This cohort study included 6453 parent and childless adult Medicaid beneficiaries, aged 18 to 64 years, with opioid use disorder and continuous enrollment from December 1, 2018, to September 30, 2020, in Wisconsin. Logistic regression compared differences in study outcomes before, early, and later in the COVID-19 public health emergency. Analyses were conducted from January 2021 to October 2021.

Exposures

Early (March 16, 2020, to May 15, 2020) and later (May 16, 2020, to September 30, 2020) in the public health emergency.

Main Outcomes and Measures

Person-week outcomes included possession of buprenorphine, completion of outpatient urine drug testing, and receipt of opioid treatment program services.

Results

The final cohort of 6453 participants included 3986 (61.8%) childless adults; 5741 (89%) were younger than 50 years, 3435 (53.2%) were women, 5036 (78.0%) White, and 22.0% were racial and ethnic minority groups (American Indian, 269 [4.2%]; Asian, 26 [0.4%]; Black, 458 [7.1%]; Hispanic, 292 [4.5%]; Pacific Islander, 1 [.02%]; Multiracial, 238 [3.7%]). Overall, 2858 (44.3%), 5074 (78.6%), and 2928 (45.4%) received buprenorphine, urine drug testing, or opioid treatment program services during the study period, respectively. Probability of buprenorphine possession did not change in the early or later part of the public health emergency. Probability of urine drug testing initially decreased (marginal effect [ME], –0.04; 95% CI, –0.04 to –0.03; P < .001) and then partially recovered in the later public health emergency (ME, –0.02; 95% CI, –0.03 to –0.02; P < .001). Probability of opioid treatment program services followed a similar pattern, with an early decrease (ME, –0.05; 95% CI, –0.05 to –0.04; P < .001) followed by partial recovery (ME, –0.02; 95% CI, –0.03 to –0.02; P < .001).

Conclusions and Relevance

In a sample of continuously enrolled adult Medicaid beneficiaries, the COVID-19 public health emergency was not associated with decreased probability of buprenorphine possession, but was associated with decreased probability of urine drug testing and opioid treatment program services. These findings suggest patients in office-based settings retained access to buprenorphine despite decreased on-site services like urine drug tests, whereas patients at opioid treatment programs experienced greater disruption in care. Given the importance of medications for opioid use disorder in preventing overdose, policy makers should consider permanent policy changes based on lessons learned from the public health emergency to enable ongoing enhanced access to these medications.

Opioids in COVID-19: Two Sides of a Coin

Introduction: The treatment of most severe COVID-19 patients included the large-scale use of sedatives and analgesics-possibly in higher doses than usual-which was reported in the literature. The use of drugs that decrease mortality is necessary and opioids are important agents in procedures such as orotracheal intubation. However, these drugs seem to have been overestimated in the COVID-19 pandemic. We performed a review of the PubMed-Medline database to evaluate the use of opioids during this period. The following descriptors were used to enhance the search for papers: "Opioids", "COVID-19," "COVID-19 pandemic," "SARS-CoV-2," "Opioid use disorder," "Opioid dependence" and the names of the drugs used. We also evaluated the distribution of COVID-19 patients in Brazil and the applicability of opioids in our country during the COVID-19 pandemic. Results: Several positive points were found in the use of opioids in the COVID-19 pandemic, for instance, they can be used for analgesia in orotracheal intubation, for chronic pain management, and as coadjutant in the management of acute intensification of pain. However, high doses of opioids might exacerbate the respiratory depression found in COVID-19 patients, their chronic use can trigger opioid tolerance and the higher doses used during the pandemic might result in greater adverse effects. Unfortunately, the pandemic also affected individuals with opioid use disorder, not only those individuals are at higher risk of mortality, hospitalization and need for ventilatory support, but measures taken to decrease the SARS-CoV-2 spread such as social isolation, might negatively affect the treatment for opioid use disorder. In Brazil, only morphine, remifentanil and fentanyl are available in the basic health care system for the treatment of COVID-19 patients. Out of the 5,273,598 opioid units used in this period all over the country, morphine, fentanyl, and remifentanil, accounted for, respectively, 559,270 (10.6%), 4,624,328 (87.6%), and 90,000 (1.8%) units. Many Brazilian regions with high number of confirmed cases of COVID-19 had few units of opioids available, as the Southeast region, with a 0.23 units of opioids per confirmed COVID-19 case, and the South region, with 0.05 units. In the COVID-19 pandemic scenario, positive points related to opioids were mainly the occurrence of analgesia, to facilitate intubation and their use as coadjutants in the management of acute intensification of pain, whereas the negative points were indiscriminate use, the presence of human immunosuppressor response and increased adverse effects due to higher doses of the drug. Conclusion: The importance of rational and individualized use of analgesic hypnotics and sedative anesthetics should be considered at all times, especially in situations of high demand such as the COVID-19 pandemic.

Treatment of Hepatitis C virus among people who inject drugs at a syringe service program during the COVID-19 response: The potential role of telehealth, medications for opioid use disorder and minimal demands on patients

BACKGROUND

Healthcare delivery was disrupted during the COVID-19 pandemic, requiring minimized in-person contact between patients and clinicians. During the pandemic, people with opioid use disorder (OUD) were not only at elevated risk for COVID-19, but had markedly reduced access to treatment for OUD, Hepatitis C virus (HCV) and HIV due to recommended decreased in-person visits.

METHODS

From March 15-June 15, 2020 at the syringe services program (SSP) in New Haven, Connecticut, USA, a differentiated care model evolved with reduced clinical demands on people who inject drugs (PWID) to ensure screening and treatment for HCV, HIV and OUD, with a focus on HCV treatment. This model involved a single, bundled screening, evaluation, testing (SET) and monitoring strategy for all three conditions, minimal in-person visits, followed by tele-health communication between patients, outreach workers and clinicians. In-person visits occurred only during induction onto methadone and phlebotomy at baseline and phlebotomy 12 weeks post-treatment for HCV to measure sustained virological response (SVR). Patients received supportive texts/calls from outreach workers and clinicians.

RESULTS

Overall, 66 actively injecting PWID, all with OUD, underwent bundled laboratory screening; 35 had chronic HCV infection. Participants were 40 years (mean), mostly white (N = 18) men (N = 28) and 12 were unstably housed. Two were lost to-follow-up and 2 were incarcerated, leaving 31 who started pan-genotypic direct-acting antivirals (DAAs). The mean time from referral to initial phlebotomy and initiation of DAAs was 6.9 and 9.9 days, respectively. Fourteen additional patients were newly started on buprenorphine and 6 started on methadone; three and four, respectively, were on treatment at baseline. Overall, 29 (93.5%) PWID who initiated DAAs achieved SVR; among unstably housed persons the SVR was 83.3%.

CONCLUSIONS

In response to COVID-19, an innovative differentiated care model for PWID at an SSP evolved that included successful co-treatment for HCV, HIV and OUD using a client-centered approach that reduces treatment demands on patients yet supports ongoing access to evidence-based treatments.

The COVID-19 pandemic and the health of people who use illicit opioids in New York City, the first 12 months

Background

Concurrent opioid-related overdose and COVID-19 crises in the U.S. have imposed unprecedented challenges on people who use illicit opioids.

Methods

Using the experiences of 324 people who use illicit opioids between April 2020 and March 2021, we examined four domains of health and well-being potentially impacted by COVID-19: drug risks and responses, healthcare and related services, material hardship, and mental health. Data were drawn from participants’ completed monthly survey assessments which were grouped into four periods of interest for the unfolding pandemic: April-June 2020, July-October 2020, November-January 2021, and February-March 2021.

Results

A majority of measures in our four domains showed early COVID-19 related impacts, which quickly diminished as people and agencies responded to the pandemic. Difficulty obtaining food was the most frequently reported material hardship and appeared worst in April-June 2020. Over half of the population reported depression in April-June 2020, but this declined over the study period. Some participants reported changes to the heroin supply, including higher prices, lower quality, difficulty finding the drug, and fentanyl contamination. There was no discernable temporal shift in the frequency of use of each substance or the frequency of withdrawal symptoms. Over the study period, the mean number of overdoses per month decreased while the percent of opioid use events at which both a witness and naloxone were present (i.e., protected events) increased. Most participants receiving MOUD experienced an increase in take-home doses.

Conclusions

Findings speak to the resilience of people who use drugs as a population with disproportionate experience of trauma and crisis and also to the rapid response of NYC health agencies and service providers working with this population. Despite evident signs of adaptability and resilience, the COVID-19 pandemic has highlighted some of the unique vulnerabilities of people who use illicit opioids and the need for greater rates of “protected” opioid use and greater availability of wrap-around services to efficiently address the safety, food security, mental health, and treatment needs of the population.

Design and implementation of a cohort study of persons living with HIV infection who are initiating medication treatment for opioid use disorder to evaluate HIV-1 persistence

Background

Opioid use disorder (OUD) negatively impacts the HIV continuum of care for persons living with HIV (PLH). Medication treatment for OUD (MOUD) may have differential biological effects in individuals with HIV and OUD. To understand the role of MOUD – opioid agonist methadone, partial agonist buprenorphine and antagonist naltrexone – in HIV-1 persistence and reactivation, we will use molecular virology approaches to carry out the first prospective, longitudinal studies of adults living with HIV with OUD initiating MOUD. One of the major challenges to studying the impact of MOUD on HIV persistence is the low retention rate of study participants and the requirement of large-volume blood sampling to study the HIV proviral landscape and expression profiles.

Methods

A prospective cohort study is underway to study the HIV-1 expression, proviral landscape, and clonal expansion dynamics using limited blood sampling from persons with DSM-5 diagnosed OUD who are living with HIV infection and initiating treatment with methadone, buprenorphine, or extended-release naltrexone.

Results

We describe the recruitment, laboratory, and statistical methods of this study as well as the protocol details of this on-going study. Out of the 510 screened for enrollment into the study, 35 (7%) were eligible and 27 were enrolled thus far. Retention through month 3 has been high at 95%.

Conclusions

This on-going study is evaluating the impact of MOUD on HIV persistence at the molecular virology level using limited blood sampling via a prospective, longitudinal study of people living with HIV DSM-5 OUD initiating treatment with MOUD.

Telehealth for opioid use disorder treatment in low-barrier clinic settings: an exploration of clinician and staff perspectives

BACKGROUND

The majority of individuals with opioid use disorder (OUD) face access barriers to evidence-based treatment, and the COVID-19 pandemic has exacerbated the United States (US) opioid overdose crisis. However, the pandemic has also ushered in rapid transitions to telehealth in the USA, including for substance use disorder treatment with buprenorphine. These changes have the potential to mitigate barriers to care or to exacerbate pre-existing treatment inequities. The objective of this study was to qualitatively explore Philadelphia-based low-barrier, harm-reduction oriented, opioid use disorder (OUD) treatment provider perspectives about and experiences with telehealth during the COVID-19 pandemic, and to assess their desire to offer telehealth to patients at their programs in the future.

METHODS

We interviewed 22 OUD treatment prescribers and staff working outpatient programs offering OUD treatment with buprenorphine in Philadelphia during July and August 2020. All participants worked at low-barrier treatment programs that provide buprenorphine using a harm reduction-oriented approach and without mandating counseling or other requirements as a condition of treatment. We analyzed the data using thematic content analysis.

RESULTS

Our analysis yielded three themes: 1/ Easier access for some: telehealth facilitates care for many patients who have difficulty attending in-person appointments due to logistical and psychological barriers; 2/ A layered digital divide: engagement with telehealth can be seriously limited by patients' access to and comfort with technology; and 3/ Clinician control: despite some clinic staff beliefs that patients should have the freedom to choose their treatment modality, patients' access to treatment via telehealth may hinge on clinician perceptions of patient "stability" rather than patient preferences.

CONCLUSIONS

Telehealth may address many access issues, however, barriers to implementation remain, including patient ability and desire to attend healthcare appointments virtually. In addition, the potential for telehealth models to extend OUD care to patients currently underserved by in-person models may partially depend on clinician comfort treating patients deemed "unstable" via this modality. The ability of telehealth to expand access to OUD care for individuals who have previously struggled to engage with in-person care will likely be limited if these patients are not given the opportunity to receive treatment via telehealth.

Kratom Use Within the Context of the Evolving Opioid Crisis and the COVID-19 Pandemic in the United States

Kratom (Mitragyna speciosa, Korth.) is an evergreen tree that is indigenous to Southeast Asia. When ingested, kratom leaves or decoctions from the leaves have been reported to produce complex stimulant and opioid-like effects. For generations, native populations in Southeast Asia have used kratom products to stave off fatigue, improve mood, alleviate pain and manage symptoms of opioid withdrawal. Despite the long history of kratom use in Asia, it is only within the past 10-20 years that kratom has emerged as an important herbal agent in the United States, where it is being used for the self-treatment of pain, opioid withdrawal symptoms, and mood disorders. The increase in the use of kratom in the United States has coincided with the serious epidemic of opioid abuse and dependence. Since 2015, efforts to restrict access to prescription opioids have resulted in a marked increase in the use of "street" opioids such as heroin and illicit fentanyl. At the same time, many patients with chronic pain conditions or opioid use disorder have been denied access to appropriate medical help. The lack of access to care for patients with chronic pain and opioid use disorder has been magnified by the emergence of the COVID-19 pandemic. In this report, we highlight how these converging factors have led to a surge in interest in kratom as a potential harm reduction agent in the treatment of pain and opioid use disorder.

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.