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Patel EU, Grieb SM, Winiker AK, Ching J, Schluth CG, Mehta SH, Kirk GD, Genberg BL. Structural and social changes due to the COVID-19 pandemic and their impact on engagement in substance use disorder treatment services: a qualitative study among people with a recent history of injection drug use in Baltimore, Maryland. Harm Reduct J 2024; 21:91. [PMID: 38720307 PMCID: PMC11077846 DOI: 10.1186/s12954-024-01008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 04/22/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Substance use disorder treatment and recovery support services are critical for achieving and maintaining recovery. There are limited data on how structural and social changes due to the COVID-19 pandemic impacted individual-level experiences with substance use disorder treatment-related services among community-based samples of people who inject drugs. METHODS People with a recent history of injection drug use who were enrolled in the community-based AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland participated in a one-time, semi-structured interview between July 2021 and February 2022 about their experiences living through the COVID-19 pandemic (n = 28). An iterative inductive coding process was used to identify themes describing how structural and social changes due to the COVID-19 pandemic affected participants' experiences with substance use disorder treatment-related services. RESULTS The median age of participants was 54 years (range = 24-73); 10 (36%) participants were female, 16 (57%) were non-Hispanic Black, and 8 (29%) were living with HIV. We identified several structural and social changes due the pandemic that acted as barriers and facilitators to individual-level engagement in treatment with medications for opioid use disorder (MOUD) and recovery support services (e.g., support group meetings). New take-home methadone flexibility policies temporarily facilitated engagement in MOUD treatment, but other pre-existing rigid policies and practices (e.g., zero-tolerance) were counteracting barriers. Changes in the illicit drug market were both a facilitator and barrier to MOUD treatment. Decreased availability and pandemic-related adaptations to in-person services were a barrier to recovery support services. While telehealth expansion facilitated engagement in recovery support group meetings for some participants, other participants faced digital and technological barriers. These changes in service provision also led to diminished perceived quality of both virtual and in-person recovery support group meetings. However, a facilitator of recovery support was increased accessibility of individual service providers (e.g., counselors and Sponsors). CONCLUSIONS Structural and social changes across several socioecological levels created new barriers and facilitators of individual-level engagement in substance use disorder treatment-related services. Multilevel interventions are needed to improve access to and engagement in high-quality substance use disorder treatment and recovery support services among people who inject drugs.
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Affiliation(s)
- Eshan U Patel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Suzanne M Grieb
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abigail K Winiker
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jennifer Ching
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Catherine G Schluth
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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Brown KG, Chen CY, Dong D, Lake KJ, Butelman ER. Impact of the COVID-19 Pandemic on Functions of Nursing Professionals in the Care of Opioid Use Disorder: Systematic Review. J Addict Nurs 2024; 35:107-113. [PMID: 38830000 DOI: 10.1097/jan.0000000000000573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
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.
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Affiliation(s)
- Kate G Brown
- Kate G. Brown, NP, MS, Carina Y. Chen, BA, Deanna Dong, NP, MS, Kimberly J. Lake, NP, MS, and Eduardo R. Butelman, PhD, MS, Laboratory on the Biology of Addictive Diseases, The Rockefeller University, New York, New York
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Romain Dagenhardt DM, Liu X, Richards J, Mersky J. Family treatment courts and the COVID-19 pandemic: Barriers and facilitators to program implementation, client engagement, and recovery. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 159:209278. [PMID: 38135119 DOI: 10.1016/j.josat.2023.209278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/10/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
INTRODUCTION Family Treatment Courts (FTCs) serve child welfare-involved parents with substance use issues who are working toward recovery and reunification with their children. Research has linked FTCs to successful outcomes such as treatment access and completion and family reunification, but there has been less attention to factors that hinder and facilitate program implementation and client engagement. Moreover, little is known about how the shift to virtual services during the COVID-19 pandemic impacted FTC programs and the families they serve. METHODS This study examined interview data gathered from staff in six FTCs located in different regions of the country to investigate the impact of the pandemic on programs and the clients they serve. Interviews conducted with clients from one FTC in the Midwest reinforce the data. RESULTS FTC programs and professionals adjusted to the pandemic by attempting to replicate face-to-face services in an online environment. Virtual services were vital for sustaining FTCs and mitigating barriers to client engagement during the pandemic. At the same time, FTCs were compelled to navigate new barriers to online program implementation as well as acute challenges that clients faced such as greater isolation and reduced treatment access. CONCLUSIONS We discuss implications from these findings with an eye toward maximizing FTC implementation and impact through the intentional use of both in-person programming and online technology after the pandemic.
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Affiliation(s)
| | - Xiyao Liu
- Department of Social Work, University of Wisconsin-, Milwaukee, United States of America
| | - Jayden Richards
- Department of Criminal Justice & Criminology, University of Wisconsin -, Milwaukee, United States of America
| | - Joshua Mersky
- Department of Social Work, University of Wisconsin-, Milwaukee, United States of America
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Elliott KS, Nabulsi EH, Sims-Rhodes N, Dubre V, Barena E, Yuen N, Morris M, Sass SM, Kennedy B, Singh KP. Modality and terminology changes for behavioral health service delivery during the COVID-19 pandemic: a systematic review. Front Psychiatry 2024; 14:1265087. [PMID: 38375514 PMCID: PMC10876001 DOI: 10.3389/fpsyt.2023.1265087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/27/2023] [Indexed: 02/21/2024] Open
Abstract
Introduction The COVID-19 pandemic prompted healthcare professionals to implement service delivery adaptations to remain in compliance with safety regulations. Though many adaptations in service delivery were reported throughout the literature, a wide variety of terminology and definitions were used. Methods To address this, we conducted a PRISMA review to identify service delivery adaptations across behavioral healthcare services in the United States from March 2020 to May 2022 and to identify variations in terminology used to describe these adaptations. We identified 445 initial articles for our review across eight databases using predetermined keywords. Using a two-round screening process, authors used a team approach to identify the most appropriate articles for this review. Results Our results suggested that a total of 14 different terms were used to describe service modality changes, with the most frequent term being telehealth (63%). Each term found in our review and the frequency of use across identified articles is described in detail. Discussion Implications of this review such as understanding modality changes during the COVID-19 pandemic and beyond are discussed. Our findings illustrate the importance of standardizing terminology to enhance communication and understanding among professionals.
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Affiliation(s)
- Kimberly S. Elliott
- Department of Healthcare Policy, Economics and Management, University of Texas at Tyler Health Science Center, Tyler, TX, United States
| | - Eman H. Nabulsi
- Department of Epidemiology and Biostatistics, University of Texas at Tyler, Tyler, TX, United States
| | - Nicholas Sims-Rhodes
- Department of Epidemiology and Biostatistics, University of Texas at Tyler, Tyler, TX, United States
| | - Vandy Dubre
- Robert R. Muntz Library, The University of Texas at Tyler, Tyler, TX, United States
| | - Emily Barena
- Department of Psychology and Counseling, The University of Texas at Tyler, Tyler, TX, United States
| | - Nelly Yuen
- Department of Psychology and Counseling, The University of Texas at Tyler, Tyler, TX, United States
| | - Michael Morris
- Department of Healthcare Policy, Economics and Management, University of Texas at Tyler Health Science Center, Tyler, TX, United States
| | - Sarah M. Sass
- Department of Psychology and Counseling, The University of Texas at Tyler, Tyler, TX, United States
| | - Bridget Kennedy
- Department of Psychology and Counseling, The University of Texas at Tyler, Tyler, TX, United States
| | - Karan P. Singh
- Department of Epidemiology and Biostatistics, University of Texas at Tyler, Tyler, TX, United States
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Mitchell SG, Jester J, Gryczynski J, Whitter M, Fuller D, Halsted C, Schwartz RP. Impact of COVID-19-related methadone regulatory flexibilities: views of state opioid treatment authorities and program staff. Addict Sci Clin Pract 2023; 18:61. [PMID: 37848970 PMCID: PMC10580566 DOI: 10.1186/s13722-023-00417-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 10/09/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND During the COVID-19 pandemic, federal regulations in the USA for methadone treatment of opioid use disorder (OUD) were temporarily revised to reduce clinic crowding and promote access to treatment. METHODS As part of a study seeking to implement interim methadone without routine counseling to hasten treatment access in Opioid Treatment Programs with admission delays, semi-structured qualitative interviews were conducted via Zoom with participating staff (N = 11) in six OTPs and their State Opioid Treatment Authorities (SOTAs; N = 5) responsible for overseeing the OTPs' federal regulatory compliance. Participants discussed their views on the response of OTPs in their states to the pandemic and the impact of the COVID-related regulatory flexibilities on staff, established patients, and new program applicants. Interviews were audio recorded, transcribed, and a content analysis was conducted using ATLAS.ti. RESULTS All SOTAs requested the blanket take-home exemption and supported the use of telehealth for counseling. Participants noted that these changes were more beneficial for established patients than program applicants. Established patients were able to obtain a greater number of take-homes and attend individual counseling remotely. Patients with limited resources had greater difficulty or were unable to access remote counseling. The convenience of intake through telehealth did not extend to new program applicants because the admission physical exam requirement was not waived. CONCLUSIONS The experienced reflections of SOTAs and OTP providers on methadone practice changes during the COVID-19 pandemic offer insights on SAMHSA's proposed revisions to its OTP regulations. Trial registration Clinicaltrials.gov # NCT04188977.
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Affiliation(s)
| | | | - Jan Gryczynski
- Friends Research Institute, Inc., 1040 Park Avenue, Baltimore, MD, 21201, USA
| | - Melanie Whitter
- National Association of State Alcohol and Drug Abuse Directors, Inc., Washington, D.C., USA
| | - Douglas Fuller
- National Association of State Alcohol and Drug Abuse Directors, Inc., Washington, D.C., USA
| | - Caroline Halsted
- National Association of State Alcohol and Drug Abuse Directors, Inc., Washington, D.C., USA
| | - Robert P Schwartz
- Friends Research Institute, Inc., 1040 Park Avenue, Baltimore, MD, 21201, USA
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Adams A, Blawatt S, Magel T, MacDonald S, Lajeunesse J, Harrison S, Byres D, Schechter MT, Oviedo-Joekes E. The impact of relaxing restrictions on take-home doses during the COVID-19 pandemic on program effectiveness and client experiences in opioid agonist treatment: a mixed methods systematic review. Subst Abuse Treat Prev Policy 2023; 18:56. [PMID: 37777766 PMCID: PMC10543348 DOI: 10.1186/s13011-023-00564-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/13/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic led to an unprecedented relaxation of restrictions on take-home doses in opioid agonist treatment (OAT). We conducted a mixed methods systematic review to explore the impact of these changes on program effectiveness and client experiences in OAT. METHODS The protocol for this review was registered in PROSPERO (CRD42022352310). From Aug.-Nov. 2022, we searched Medline, Embase, CINAHL, PsycInfo, Web of Science, Cochrane Register of Controlled Trials, and the grey literature. We included studies reporting quantitative measures of retention in treatment, illicit substance use, overdose, client health, quality of life, or treatment satisfaction or using qualitative methods to examine client experiences with take-home doses during the pandemic. We critically appraised studies using the Mixed Methods Appraisal Tool. We synthesized quantitative data using vote-counting by direction of effect and presented the results in harvest plots. Qualitative data were analyzed using thematic synthesis. We used a convergent segregated approach to integrate quantitative and qualitative findings. RESULTS Forty studies were included. Most were from North America (23/40) or the United Kingdom (9/40). The quantitative synthesis was limited by potential for confounding, but suggested an association between take-home doses and increased retention in treatment. There was no evidence of an association between take-home doses and illicit substance use or overdose. Qualitative findings indicated that take-home doses reduced clients' exposure to unregulated substances and stigma and minimized work/treatment conflicts. Though some clients reported challenges with managing their medication, the dominant narrative was one of appreciation, reduced anxiety, and a renewed sense of agency and identity. The integrated analysis suggested reduced treatment burden as an explanation for improved retention and revealed variation in individual relationships between take-home doses and illicit substance use. We identified a critical gap in quantitative measures of patient-important outcomes. CONCLUSION The relaxation of restrictions on take-home doses was associated with improved client experience and retention in OAT. We found no evidence of an association with illicit substance use or overdose, despite the expansion of take-home doses to previously ineligible groups. Including patient-important outcome measures in policy, program development, and treatment planning is essential to ensuring that decisions around take-home doses accurately reflect their value to clients.
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Affiliation(s)
- Alison Adams
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Sarin Blawatt
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Tianna Magel
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BCV6B 1G6, Canada
| | - Julie Lajeunesse
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BCV6B 1G6, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BCV6B 1G6, Canada
| | - David Byres
- Provincial Health Services Authority, 200-1333 W Broadway, Vancouver, BC, V6H 4C1, Canada
| | - Martin T Schechter
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Eugenia Oviedo-Joekes
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada.
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
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McDonald R, Bech AB, Clausen T. Flexible delivery of opioid agonist treatment during COVID-19 in Norway: qualitative and quantitative findings from an online survey of provider experiences. BMC Health Serv Res 2023; 23:965. [PMID: 37679751 PMCID: PMC10485985 DOI: 10.1186/s12913-023-09959-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 08/22/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND For patients receiving daily opioid agonist treatment (OAT) for opioid dependence, several countries relaxed treatment guidelines at the beginning of the COVID-19 pandemic. This involved longer take-home intervals for methadone and buprenorphine doses as well as a reduction in supervised dosing and drug screening. To date, little is known about the medium or long-term experience of OAT deregulation. Therefore, we conducted a survey to explore how OAT providers perceived greater flexibility in OAT service delivery at the end of the second year of the pandemic. METHODS Nationwide cross-sectional study of twenty-three OAT units in 19 publicly funded hospital trusts in Norway. OAT units were sent a 29-item online questionnaire comprising closed-format and open-ended questions on treatment provider experiences and changes in OAT service delivery during the past 12 months (January to December 2021). RESULTS Twenty-three (of whom female: 14; 60.8%) managers or lead physicians of OAT units completed the questionnaire reporting that, in 2021, most OAT units (91.3%, n = 21) still practiced some adjusted approaches as established in the beginning of the pandemic. The most common adaptions were special protocols for COVID-19 cases (95.7%, n = 22), increased use of telephone- (91.3%, n = 21) and video consultations (87.0%, n = 20), and longer take-home intervals for OAT medications (52.2%, n = 12). The use of depot buprenorphine also increased substantially during the pandemic. According to the OAT providers, most patients handled flexible treatment provision well. In individual cases, patients' substance use was identified as key factor necessitating a reintroduction of supervised dosing and drug screening. Collaboration with general practitioners and municipal health and social services was generally perceived as crucial for successful treatment delivery. CONCLUSIONS Overall, the Norwegian OAT system proved resilient in the second year of the COVID-19 pandemic, as its healthcare workforce embraced innovation in technology (telemedicine) and drug development (depot buprenorphine). According to our nationally representative sample of OAT providers, most patients were compliant with longer take-home doses of methadone and buprenorphine. Our findings suggest that telemedicine can be useful as adjunct to face-to-face treatment and provide greater flexibility for patients.
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Affiliation(s)
- Rebecca McDonald
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, Oslo University, P.O. Box 1171, Blindern, Oslo, 0318, Norway.
| | - Anne Berit Bech
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, Oslo University, P.O. Box 1171, Blindern, Oslo, 0318, Norway
- Faculty of Social and Health Sciences, Inland University of Applied Sciences, P.O. Box 400 Vestad, Elverum, 2418, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, Oslo University, P.O. Box 1171, Blindern, Oslo, 0318, Norway
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Tay Wee Teck J, Butner JL, Baldacchino A. Understanding the use of telemedicine across different opioid use disorder treatment models: A scoping review. J Telemed Telecare 2023:1357633X231195607. [PMID: 37661829 DOI: 10.1177/1357633x231195607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
INTRODUCTION The COVID-19 pandemic has instigated the development of telemedicine-mediated provision of medications for opioid use disorder such as buprenorphine and methadone, referred to as TMOUD in this study. As services start to return to pre-pandemic norms, there is a debate around the role of TMOUD as addition to or replacement of the conventional cascade of care for people with opioid use disorder (PWOUD). This scoping review is designed to characterize existing TMOUD services and provide insights to enable a more nuanced discussion on the role of telemedicine in the care of PWOUD. METHODS The literature search was conducted in OVID Medline, CINAHL, and PsycINFO, from inception up to and including April 2023, using the Joanna Briggs Institute methodology for scoping reviews. The review considered any study design that detailed sufficient descriptive information on a given TMOUD service. A data extraction form was developed to collect and categorize a range of descriptive characteristics of each discrete TMOUD model identified from the obtained articles. RESULTS A total of 45 articles met the inclusion criteria, and from this, 40 discrete TMOUD services were identified. In total, 33 services were US-based, three from Canada, and one each from India, Ireland, the UK, and Norway. Through a detailed analysis of TMOUD service characteristics, four models of care were identified. These were TMOUD to facilitate inclusion health, to facilitate transitions in care, to meet complex healthcare needs, and to maintain opioid use disorder (OUD) service resilience. CONCLUSIONS Characterizing TMOUD according to its functional benefits to PWOUD and OUD services will help support evidence-based policy and practice. Additionally, particular attention is given to how digital exclusion of PWOUD can be mitigated against.
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Affiliation(s)
- Joseph Tay Wee Teck
- DigitAS Project, Population and Behavioural Science, School of Medicine, University of St Andrews, St Andrews, UK
- Forward Leeds and Humankind Charity, Durham, UK
| | - Jenna L Butner
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Alex Baldacchino
- DigitAS Project, Population and Behavioural Science, School of Medicine, University of St Andrews, St Andrews, UK
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Panwala V, Thorn E, Amiri S, Socias ME, Lutz R, Amram O. Opioid use and COVID-19: a secondary analysis of the impact of relaxation of methadone take-home dosing guidelines on use of illicit opioids. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2023; 49:597-605. [PMID: 37433122 DOI: 10.1080/00952990.2023.2222336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 05/29/2023] [Accepted: 06/02/2023] [Indexed: 07/13/2023]
Abstract
Background: An exemption to existing U.S. regulation of methadone maintenance therapy after the onset of the COVID-19 pandemic permitted increased take-home doses beginning March 2020.Objectives: We assessed the impact of this exemption on opioid use.Methods: A pre/post study of 187 clients recruited from an OTP who completed a survey and consented to share their urine drug testing (UDT) data. Use of fentanyl, morphine, hydromorphone, codeine, and heroin was assessed via UDT. Receipt of take-home methadone doses was assessed from clinic records for 142 working days pre- and post-COVID exemption. Analysis was conducted using a linear regression model to assess the association between increased take-home doses and use of illicit opioids.Results: In the pre- vs. post-COVID-19 SAMHSA exemption periods, 26.2% vs. 36.3% of UDTs were positive for 6-acetylmorphine respectively, 32.6% vs. 40.6% positive for codeine, 34.2% vs 44.2% positive for hydromorphone, 39.5% vs. 48.1% positive for morphine, 8.0% vs. 14.4% positive for fentanyl (p-value < .001). However, in the unadjusted descriptive data, when grouped by change in substance use, those clients who experienced a decrease in the use of morphine, codeine, and heroin post-COVID-19 were given significantly more take-home doses than the groups that had no change or an increase in the use of these substances. In the adjusted model, there was no significant relationship between change in opioid use and increased receipt of take-home methadone doses.Conclusions: Although take-home doses post-COVID-19 nearly doubled, this increase was not associated with a significant change in use of illicit opioids.
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Affiliation(s)
- Victoria Panwala
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Emily Thorn
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Solmaz Amiri
- Institute for Research and Education to Advance Community Health (IREACH), Elson S. Floyd College of Medicine, Washington State University, Seattle, WA, USA
| | - M Eugenia Socias
- British Columbia Centre on Substance Use, University of British Columbia, Vancouver, BC, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Robert Lutz
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Ofer Amram
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
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Panwala V, Joudrey P, Kowalski M, Bach P, Amram O. Changes to methadone maintenance therapy in the United States, Canada, and Australia during the COVID-19 pandemic: A narrative review. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 152:209086. [PMID: 37270103 PMCID: PMC10232933 DOI: 10.1016/j.josat.2023.209086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/08/2023] [Accepted: 05/23/2023] [Indexed: 06/05/2023]
Abstract
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.
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Affiliation(s)
- Victoria Panwala
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA.
| | - Paul Joudrey
- Center for Research on Health Care, University of Pittsburgh, PA, USA
| | - Melanie Kowalski
- Mental Health and Wellbeing Division, Department of Health, Victoria, Australia
| | - Paxton Bach
- British Columbia Centre on Substance Use, University of British Columbia, Vancouver, BC, Canada
| | - Ofer Amram
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA; Paul G. Allen School for Global Animal Health, Washington State University, Pullman, WA, USA
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Choi S, O’Grady MA, Cleland CM, Knopf E, Hong S, D’Aunno T, Bao Y, Ramsey KS, Neighbors CJ. Clinics Optimizing MEthadone Take-homes for opioid use disorder (COMET): Protocol for a stepped-wedge randomized trial to facilitate clinic level changes. PLoS One 2023; 18:e0286859. [PMID: 37294821 PMCID: PMC10256218 DOI: 10.1371/journal.pone.0286859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/04/2023] [Indexed: 06/11/2023] Open
Abstract
INTRODUCTION Regulatory changes made during the COVID-19 public health emergency (PHE) that relaxed criteria for take-home dosing (THD) of methadone offer an opportunity to improve quality of care with a lifesaving treatment. There is a pressing need for research to study the long-term effects of the new PHE THD rules and to test data-driven interventions to promote more effective adoption by opioid treatment programs (OTPs). We propose a two-phase project to develop and test a multidimensional intervention for OTPs that leverages information from large State administrative data. METHODS AND ANALYSIS We propose a two-phased project to develop then test a multidimensional OTP intervention to address clinical decision making, regulatory confusion, legal liability concerns, capacity for clinical practice change, and financial barriers to THD. The intervention will include OTP THD specific dashboards drawn from multiple State databases. The approach will be informed by the Health Equity Implementation Framework (HEIF). In phase 1, we will employ an explanatory sequential mixed methods design to combine analysis of large state administrative databases-Medicaid, treatment registry, THD reporting-with qualitative interviews to develop and refine the intervention. In phase 2, we will conduct a stepped-wedge trial over three years with 36 OTPs randomized to 6 cohorts of a six-month clinic-level intervention. The trial will test intervention effects on OTP-level implementation outcomes and patient outcomes (1) THD use; 2) retention in care; and 3) adverse healthcare events). We will specifically examine intervention effects for Black and Latinx clients. A concurrent triangulation mixed methods design will be used: quantitative and qualitative data collection will occur concurrently and results will be integrated after analysis of each. We will employ generalized linear mixed models (GLMMs) in the analysis of stepped-wedge trials. The primary outcome will be weekly or greater THD. The semi-structured interviews will be transcribed and analyzed with Dedoose to identify key facilitators, barriers, and experiences according to HEIF constructs using directed content analysis. DISCUSSION This multi-phase, embedded mixed methods project addresses a critical need to support long-term practice changes in methadone treatment for opioid use disorder following systemic changes emerging from the PHE-particularly for Black and Latinx individuals with opioid use disorder. By combining findings from analyses of large administrative data with lessons gleaned from qualitative interviews of OTPs that were flexible with THD and those that were not, we will build and test the intervention to coach clinics to increase flexibility with THD. The findings will inform policy at the local and national level.
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Affiliation(s)
- Sugy Choi
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Megan A. O’Grady
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, United States of America
| | - Charles M. Cleland
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Elizabeth Knopf
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
| | - Sueun Hong
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
- New York University Wagner School of Public Policy, New York, NY, United States of America
| | - Thomas D’Aunno
- New York University Wagner School of Public Policy, New York, NY, United States of America
| | - Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States of America
| | - Kelly S. Ramsey
- New York State Office of Addiction Services and Supports (OASAS), New York, NY, United States of America
| | - Charles J. Neighbors
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, United States of America
- New York University Wagner School of Public Policy, New York, NY, United States of America
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12
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Brothers S, Palayew A, Simon C, Coulter A, Strichartz K, Voyles N, Vincent L. Patient experiences of methadone treatment changes during the first wave of COVID-19: a national community-driven survey. Harm Reduct J 2023; 20:31. [PMID: 36894968 PMCID: PMC9996563 DOI: 10.1186/s12954-023-00756-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/13/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND During COVID-19, the Substance Abuse and Mental Health Services Administration (SAMHSA) allowed Methadone Maintenance Treatment (MMT) programs to relax in-person MMT requirements to reduce COVID-19 exposure. This study examines patient-reported changes to in-person methadone clinic attendance requirements during COVID-19. METHODS From June 7, 2020, to July 15, 2020, a convenience sample of methadone patients (N = 392) were recruited in collaboration with National Survivors Union (NSU) in 43 states and Washington D.C. through social media (Facebook, Reddit, Twitter, and Web site pop-ups). The community-driven research (CDR) online survey collected information on how patient take-home methadone dosing and in-person drug testing, counseling, and clinic visit frequency changed prior to COVID-19 (before March 2020) to during COVID-19 (June and July 2020). RESULTS During the study time period, the percentage of respondents receiving at least 14 days of take-home doses increased from 22 to 53%, while the percentage receiving one or no take-home doses decreased from 22.4% before COVID-19 to 10.2% during COVID-19. In-person counseling attendance decreased from 82.9% to 19.4%. While only 3.3% of respondents accessed counseling through telehealth before COVID-19, this percentage increased to 61.7% during COVID-19. Many respondents (41.3%) reported visiting their clinics in person once a week or more during COVID-19. CONCLUSIONS During the first wave of COVID-19, methadone patients report decreased in-person clinic attendance and increased take-home doses and use of telehealth for counseling services. However, respondents reported considerable variations, and many were still required to make frequent in-person clinic visits, which put patients at risk of COVID-19 exposure. Relaxations of MMT in-person requirements during COVID-19 should be consistently implemented and made permanent, and patient experiences of these changes should be explored further.
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Affiliation(s)
- Sarah Brothers
- Department of Sociology, Pennsylvania State University, University Park, USA.
| | - Adam Palayew
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Caty Simon
- Methadone Advocacy Working Group, National Survivors Union, Greensboro, NC, USA.,NC Survivors Union, Greensboro, NC, USA.,Whose Corner Is It Anyway, Holyoke, MA, USA
| | - Abby Coulter
- Methadone Advocacy Working Group, National Survivors Union, Greensboro, NC, USA
| | - Knina Strichartz
- Methadone Advocacy Working Group, National Survivors Union, Greensboro, NC, USA
| | - Nick Voyles
- Methadone Advocacy Working Group, National Survivors Union, Greensboro, NC, USA
| | - Louise Vincent
- Methadone Advocacy Working Group, National Survivors Union, Greensboro, NC, USA.,NC Survivors Union, Greensboro, NC, USA
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13
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Krawczyk N, Rivera BD, Levin E, Dooling BCE. Synthesising evidence of the effects of COVID-19 regulatory changes on methadone treatment for opioid use disorder: implications for policy. Lancet Public Health 2023; 8:e238-e246. [PMID: 36841564 PMCID: PMC9949855 DOI: 10.1016/s2468-2667(23)00023-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 02/25/2023]
Abstract
As the USA faces a worsening overdose crisis, improving access to evidence-based treatment for opioid use disorder (OUD) remains a policy priority. Federal regulatory changes in response to the COVID-19 pandemic substantially expanded flexibilities on take-home doses for methadone treatment for OUD. These changes have fuelled questions about the effect of new regulations on OUD outcomes and the potential effect on health of permanently integrating these flexibilities into treatment policy going forward. To aide US policy makers as they consider implementing permanent methadone regulatory changes, we conducted a review synthesising peer-reviewed research on the effect of the flexibilities of methadone take-home policies introduced during COVID-19 on methadone programme operations, OUD patient and provider experiences, and patient health outcomes. We interpret the findings in the context of the federal rule-making process and discuss avenues by which these findings can be incorporated and implemented into US policies on substance use treatment going forward.
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Affiliation(s)
- Noa Krawczyk
- Department of Population Health, Center for Opioid Epidemiology and Policy (COEP), NYU Grossman School of Medicine, New York, NY, USA.
| | - Bianca D Rivera
- Department of Population Health, Center for Opioid Epidemiology and Policy (COEP), NYU Grossman School of Medicine, New York, NY, USA
| | - Emily Levin
- Regulatory Studies Center, The George Washington University, Washington, DC, USA
| | - Bridget C E Dooling
- Regulatory Studies Center, The George Washington University, Washington, DC, USA
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14
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McCuistian C, Fokuo JK, Dumoit Smith J, Sorensen JL, Arnold EA. Ethical Dilemmas Facing Substance Use Counselors During the COVID-19 Pandemic. Subst Abuse 2023; 17:11782218231158338. [PMID: 36923068 PMCID: PMC10008725 DOI: 10.1177/11782218231158338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/01/2023] [Indexed: 03/13/2023]
Abstract
Introduction During the COVID-19 pandemic, substance use disorder (SUD) treatment settings experienced several abrupt changes, including decreased admissions, reduction in services, and modified requirements for medication for substance use disorder. While these changes were implemented to facilitate the maintenance of important treatment options, the ethical consequences of such changes remained unknown. The current study aimed to explore ethical issues related to COVID-19-related changes reported by counselors in SUD treatment facilities. Method From May to August 2020, we conducted 60 to 90 minutes in-depth interviews with 18 front-line staff in 1 residential and 1 outpatient treatment program, exploring issues drawn from the ethical principles of the national organization representing SUD counselors. Counselors volunteered to participate via phone or email, and participation was confidential. Interviews were conducted via videoconferencing. Topics included day-to-day experiences of ethical dilemmas in the workplace, particularly during the COVID-19 era. Interviews were recorded, transcribed, and checked for accuracy and a trained team of analysts then coded transcripts using thematic analysis. Results As a result of the COVID-19 pandemic, SUD treatment programs quickly modified procedures to adhere to public health mandates while also continuing to offer care to clients. SUD counselors reported several ways their programs adapted new and creative procedures to reduce the risk of COVID-19 transmission. SUD counselors also identified several novel ethical dilemmas that occurred during the COVID-19 pandemic, often resulting from the counselor balancing the needs for responding to public health mandates with providing services to clients. There were several ways that COVID-19 related changes resulted in therapeutic challenges for some clients, and the SUD counselors highlighted ways that changes resulted in more flexible services for other clients. Conclusions This study highlights the quick response to COVID-19 that occurred within SUD treatment. While these changes resulted in novel ethical dilemmas, they also offered more flexible and client-centered approaches to treatment.
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Affiliation(s)
- Caravella McCuistian
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA
| | - J Konadu Fokuo
- Mood and Anxiety Disorders Program, University of Illinois at Chicago, Chicago, IL, USA
| | - Jaime Dumoit Smith
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA
| | - James L Sorensen
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Emily A Arnold
- Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
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15
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May T, Dawes J, Fancourt D, Burton A. A qualitative study exploring the impact of the COVID-19 pandemic on People Who Inject Drugs (PWID) and drug service provision in the UK: PWID and service provider perspectives. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 106:103752. [PMID: 35653821 PMCID: PMC9135844 DOI: 10.1016/j.drugpo.2022.103752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND People Who Inject Drugs (PWID) are subject to distinct socio-structural inequalities that can expose them to high risks of COVID-19 transmission and related health and social complications. In response to COVID-19 mitigation strategies, these vulnerabilities are being experienced in the context of adapted drug treatment service provision, including reduced in-person support and increased regulatory flexibility in opioid substitution therapy (OST) guidelines. This study aimed to explore the longer-term impact of the pandemic on the health and wellbeing of PWID in the UK, including provider and client experiences of treatment changes. METHODS Interviews were conducted with 19 PWID and 17 drug treatment providers between May and September 2021, recruited from drug and homelessness charities providing treatment services and healthcare in the UK. Data were analysed using reflexive thematic analysis. RESULTS Most participants expressed ongoing fears of COVID-19 transmission, although socio-structural inequalities limited the contexts in which physical distancing could be practised. In addition, virus mitigation strategies altered the risk environment for PWID, resulting in ongoing physical (e.g. changing drug use patterns, including transitions to crack cocaine, benzodiazepine and pregabalin use) and socio-economic harms (e.g. limited opportunities for sex work engagement and income generation). Finally, whilst clients reported some favourable experiences from service adaptations prompted by COVID-19, including increased regulatory flexibility in OST guidelines, there was continued scepticism and caution among providers toward sustaining any treatment changes beyond the pandemic period. CONCLUSIONS Whilst our findings emphasize the importance of accessible harm reduction measures attending to changing indices of drug-related harm during this period, there is a need for additional structural supports to ensure pre-existing disparities and harms impacting PWID are not exacerbated further by the conditions of the pandemic. In addition, any sustained policy and service delivery adaptations prompted by COVID-19 will require further attention if they are to be acceptable to both service users and providers.
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Affiliation(s)
- Tom May
- Research Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, United Kingdom
| | - Jo Dawes
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, United Kingdom
| | - Daisy Fancourt
- Research Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, United Kingdom
| | - Alexandra Burton
- Research Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, United Kingdom.
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16
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Meadowcroft D, Davis W. Understanding the Effect of the COVID-19 Pandemic on Substance Use Disorder Treatment Facility Operations and Patient Success: Evidence From Mississippi. Subst Abuse 2022; 16:11782218221095872. [PMID: 35592585 PMCID: PMC9112314 DOI: 10.1177/11782218221095872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/01/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The COVID-19 pandemic has led to disruptions in the provision of care at substance use disorder (SUD) treatment facilities. Stresses associated with the pandemic could also negatively impact treatment outcomes for clients. The aim of this study is to evaluate how SUD treatment facilities in Mississippi changed their operations following the start of the pandemic. The change in client success rates at the facilities is also assessed. METHODS An online survey was completed by 12 SUD treatment facilities in Mississippi between February and May 2021. RESULTS Generally, the facilities' capacity to provide treatment to clientele was moderately affected by the pandemic. Facilities in the sample also adapted a variety of policies to limit the spread of COVID-19. Changes in the services provided by facilities was observed in the survey responses. For client success rates reported by the facilities, there was a decrease in the number of facilities stating that more than 80% of their clients completed treatment across the pre- and post-pandemic periods. However, the number of facilities with more than 80% of their clients successfully finishing treatment has increased in recent months. CONCLUSIONS To continue serving their clientele during the pandemic, facilities enacted COVID-19-related policies and began offering new services such as telehealth. Although client success rates decreased at the beginning of the pandemic, they have returned to pre-pandemic levels in recent months. Our results indicate that SUD treatment facilities and clients have improved in terms of giving and receiving care as the pandemic has progressed.
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Affiliation(s)
- Devon Meadowcroft
- Delta Research and Extension Center,
Mississippi State University, Stoneville, Mississippi, MS, USA
| | - Will Davis
- Department of Agricultural Economics,
Mississippi State University, Starkville, Mississippi, MS, USA
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17
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Wyatt JP, Suen LW, Coe WH, Adams ZM, Gandhi M, Batchelor HM, Castellanos S, Joshi N, Satterwhite S, Pérez-Rodríguez R, Rodríguez-Guerra E, Albizu-Garcia CE, Knight KR, Jordan A. Federal and State Regulatory Changes to Methadone Take-Home Doses: Impact of Sociostructural Factors. Am J Public Health 2022; 112:S143-S146. [PMID: 35349318 PMCID: PMC8965186 DOI: 10.2105/ajph.2022.306806] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Janan P Wyatt
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - Leslie W Suen
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - William H Coe
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - Zoe M Adams
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - Mona Gandhi
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - Hannah M Batchelor
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - Stacy Castellanos
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - Neena Joshi
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - Shannon Satterwhite
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - Rafael Pérez-Rodríguez
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - Esther Rodríguez-Guerra
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - Carmen E Albizu-Garcia
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - Kelly R Knight
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
| | - Ayana Jordan
- Janan P. Wyatt, William H. Coe, Zoe M. Adams, and Hannah M. Batchelor are with the Yale University School of Medicine, New Haven, CT. Leslie W. Suen is with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Mona Gandhi is with Clifford Beers, New Haven, CT. Stacy Castellanos is with the UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA. Neena Joshi and Kelly R. Knight are with the Department of Humanities and Social Sciences, University of California, San Francisco. Shannon Satterwhite is with the Department of Family and Community Medicine, University of California, Davis. Rafael Pérez-Rodríguez and Esther Rodríguez-Guerra are with Physician Correctional-DCR, San Juan, Puerto Rico. Carmen E. Albizu-Garcia is with the Center for Evaluation and Sociomedical Research, Graduate School of Public Health, University of Puerto Rico, San Juan. Ayana Jordan is with the departments of Psychiatry and Population Health, Grossman School of Medicine, New York University New York
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