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Russell C, Ashley J, Ali F, Bozinoff N, Corace K, Marsh DC, Mushquash C, Wyman J, Zhang M, Lange S. Examining inequities in access to opioid agonist treatment (OAT) take-home doses (THD): A Canadian OAT guideline synthesis and systematic review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 127:104343. [PMID: 38554565 DOI: 10.1016/j.drugpo.2024.104343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 01/08/2024] [Accepted: 01/30/2024] [Indexed: 04/01/2024]
Abstract
BACKGROUND Daily supervised Opioid Agonist Treatment (OAT) medication has been identified as a barrier to treatment retention. Canadian OAT guidelines outline take-home dose (THD) criteria, yet, OAT prescribers use their clinical judgement to decide whether an individual is 'clinically stable' to receive THD. There is limited information regarding whether these decisions may result in inequitable access to THD, including in the context of updated COVID-19 guidance. The current Canadian OAT THD guideline synthesis and systematic review aimed to address this knowledge gap. METHODS This systematic review included a two-pronged approach. First, we searched available academic literature in Embase, Medline, and PsychINFO up until October 12th, 2022, to identify studies that compared characteristics of individuals on OAT who had and had not been granted access to THD to explore potential inequities in access. Next, we identified all Canadian national and provincial OAT guidelines through a semi-structured grey literature search (conducted between September-October 2022) and extracted all THD 'stability' and allowances/timeline criteria to compare against characteristics identified in the literature search. Data from both review arms were synthesized and narratively presented. RESULTS A total of n = 56 guidelines and n = 7 academic studies were included. The systematic review identified a number of patient characteristics such as age, sex, race/ethnicity, marital status, housing, employment, neighborhood income, drug use, mental health, health service utilization, as well as treatment duration that were associated with differential access to THD. The Canadian OAT THD guideline synthesis identified many of these same characteristics as 'stability' criteria, underscoring the potential for Canadian OAT guidelines to result in inequitable access to THD. CONCLUSIONS This two-pronged literature review demonstrated that current guidelines likely contribute to inequitable OAT THD access due primarily to inconsistent 'stability' criteria across guidelines. More research is needed to understand differential OAT THD access with a focus on prescriber decision-making and evaluating associated treatment and safety outcomes. The development of a client-centered, equity-focused, and evidence-informed decision making framework that incorporates more clear definitions of 'stability' criteria and indications for prescriber discretion is warranted.
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Affiliation(s)
- Cayley Russell
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1; Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1; Institute of Medical Science, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada, M5S 1A8.
| | - Jenna Ashley
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1
| | - Farihah Ali
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1; Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1
| | - Nikki Bozinoff
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College St., Toronto, Ontario, Canada, M5T 1R8; Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th floor, Toronto, Canada, M5G1V7
| | - Kim Corace
- Department of Psychiatry, Faculty of Medicine, University of Ottawa, Roger Guindon Hall, 451 Smyth Rd #2044, Ottawa, Ontario, Canada, K1H 8M5; Substance Use and Concurrent Disorders Program, The Royal Ottawa Mental Health Center, 1145 Carling Avenue, Ottawa, Ontario, Canada, K1Z 7K4; University of Ottawa Institute of Mental Health Research, The Royal Ottawa Mental Health Center, 1145 Carling Avenue, Ottawa, Ontario, Canada, K1Z 7K4
| | - David C Marsh
- NOSM University, 935 Ramsey Lake Road, Sudbury, Ontario, Canada, P3E 2C6; ICES North, 56 Walford Road, Sudbury, Ontario, Canada, P3E 2H3; Health Science North Research Institute, 56 Walford Road, Sudbury, Ontario, Canada, P3E 2H3
| | - Christopher Mushquash
- Department of Psychology, Lakehead University, 955 Oliver Road, Thunder Bay, ON P7B 5E1, Canada
| | - Jennifer Wyman
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th floor, Toronto, Canada, M5G1V7; Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada
| | - Maria Zhang
- Pharmacy Services, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada, M6J 1H4; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Canada, M5S 3M2
| | - Shannon Lange
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, Canada, M5S 2S1; Institute of Medical Science, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, Ontario, Canada, M5S 1A8; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College St., Toronto, Ontario, Canada, M5T 1R8; Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, Canada, M5T 1R8
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López-Castro T, Jakubowski A, Masyukova M, Peterson M, Pierz A, Kodali S, Arnsten JH, Starrels JL, Nahvi S. Loss, liberation, and agency: Patient experiences of methadone treatment at opioid treatment programs during the COVID-19 pandemic. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 157:209235. [PMID: 38061636 PMCID: PMC10932891 DOI: 10.1016/j.josat.2023.209235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/14/2023] [Accepted: 11/20/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Despite its safety and effectiveness, methadone treatment for opioid use disorder (OUD) remains highly stigmatized, and stringent opioid treatment program (OTP) attendance requirements create barriers to retention for many patients. The COVID-19 pandemic prompted a shift in federal regulations governing methadone, including a blanket exemption permitting increased take-home doses of methadone. We studied the impact of these changes upon established patients' experiences of OTP care. METHOD We conducted semi-structured qualitative interviews with 18 OTP patients who met our criteria of having established OTP care (i.e., enrolled at the OTP for at least 12 weeks) and were administered methadone three to six days weekly prior to the March 2020 blanket exemption. Interviews centered on how COVID-19 had affected their experiences of receiving treatment at an OTP. RESULTS We identified three interconnected themes relevant to transformation of OTP care by the COVID-19 pandemic. Participants described mourning therapeutic OTP relationships and structure (1. loss), yet feeling more satisfaction with fewer in-person OTP visits (2. liberation), and appreciating more opportunities to self-direct their OUD care (3. agency). DISCUSSION Structural changes made to OTP care early in the COVID-19 pandemic resulted in loss of community and structure. Increasing the availability of take-home methadone also improved patient experience and sense of agency. Our findings join a diverse body of converging evidence in support of policy changes allowing for more flexible dosing and individualized OTP care.
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Affiliation(s)
- Teresa López-Castro
- Department of Psychology, Colin Powell School of Civic and Global Leadership, The City College of New York, 160 Convent Avenue, New York, NY 10031, United States.
| | - Andrea Jakubowski
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States
| | - Mariya Masyukova
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States; Project Renwal, Inc. 200 Varick Street, 9th Floor New York, NY 10014
| | - Meghan Peterson
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States; Department of Social Medicine, University of North Carolina - Chapel Hill School of Medicine, 321 S Columbia St, Chapel Hill, NC 27599, United States
| | - Amanda Pierz
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States; The City University of New York Graduate School of Public Health and Health Policy, 55 W. 125(th) Street, New York, NY 10027, United States
| | - Sruthi Kodali
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States
| | - Julia H Arnsten
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States
| | - Shadi Nahvi
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States
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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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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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Oviedo-Joekes E, Dobischok S, Carvajal J, MacDonald S, McDermid C, Klakowicz P, Harrison S, LaJeunesse J, Chow N, Brown M, Gill S, Schechter M. Clients' experiences on North America's first take-home injectable opioid agonist treatment (iOAT) program: a qualitative study. BMC Health Serv Res 2023; 23:553. [PMID: 37237256 DOI: 10.1186/s12913-023-09558-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND To support public health measures during the COVID-19 pandemic, oral opioid agonist treatment (OAT) take-home doses were expanded in Western countries with positive results. Injectable OAT (iOAT) take-home doses were previously not an eligible option, and were made available for the first time in several sites to align with public health measures. Building upon these temporary risk-mitigating guidelines, a clinic in Vancouver, BC continued to offer two of a possible three daily doses of take-home injectable medications to eligible clients. The present study explores the processes through which take-home iOAT doses impacted clients' quality of life and continuity of care in real-life settings. METHODS Three rounds of semi-structured qualitative interviews were conducted over a period of seventeen months beginning in July 2021 with eleven participants receiving iOAT take-home doses at a community clinic in Vancouver, British Columbia. Interviews followed a topic guide that evolved iteratively in response to emerging lines of inquiry. Interviews were recorded, transcribed, and then coded using NVivo 1.6 using an interpretive description approach. RESULTS Participants reported that take-home doses granted them the freedom away from the clinic to have daily routines, form plans, and enjoy unstructured time. Participants appreciated the greater privacy, accessibility, and ability to engage in paid work. Furthermore, participants enjoyed greater autonomy to manage their medication and level of engagement with the clinic. These factors contributed to greater quality of life and continuity of care. Participants shared that their dose was too essential to divert and that they felt safe transporting and administering their medication off-site. In the future, all participants would like more accessible treatment such as access longer take-home prescriptions (e.g., one week), the ability to pick-up at different and convenient locations (e.g., community pharmacies), and a medication delivery service. CONCLUSIONS Reducing the number of daily onsite injections from two or three to only one revealed the diversity of rich and nuanced needs that added flexibility and accessibility in iOAT can meet. Actions such as licencing diverse opioid medications/formulations, medication pick-up at community pharmacies, and a community of practice that supports clinical decisions are necessary to increase take-home iOAT accessibility.
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Affiliation(s)
- 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.
| | - Sophia Dobischok
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - José Carvajal
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Cheryl McDermid
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Piotr Klakowicz
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Julie LaJeunesse
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Nancy Chow
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Murray Brown
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Sam Gill
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Martin 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
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Adams A, Blawatt S, MacDonald S, Finnick R, Lajeunesse J, Harrison S, Byres D, Schechter MT, Oviedo-Joekes E. Provider experiences with relaxing restrictions on take-home medications for opioid use disorder during the COVID-19 pandemic: A qualitative systematic review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 117:104058. [PMID: 37182352 PMCID: PMC10165059 DOI: 10.1016/j.drugpo.2023.104058] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/03/2023] [Accepted: 04/25/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Historical restrictions on take-home medications for opioid use disorder have generated considerable debate. The COVID-19 pandemic shifted the perceived risks and benefits of daily clinic attendance and led to widespread policy reform, creating an unprecedented opportunity to explore the impact of more flexible prescribing. We conducted a qualitative systematic review to synthesize the evidence on providers' experiences with relaxing restrictions on take-home doses of medications prescribed for opioid use disorder during the COVID-19 pandemic. METHODS The protocol for this systematic review was registered in PROSPERO (CRD42022360589; https://www.crd.york.ac.uk/prospero/). From Sept.-Nov. 2022, we searched Medline, Embase, CINAHL, PsycInfo, Web of Science, the Cochrane Register of Controlled Trials, and the grey literature from 2020 onward. Studies were eligible for inclusion if they used qualitative methods to investigate providers' experiences with relaxed restrictions on take-home medications for opioid use disorder during the COVID-19 pandemic. We appraised study quality using the CASP qualitative checklist and used thematic synthesis and GRADE-CERQual to synthesize the results. RESULTS We retrieved 13 articles representing 11 studies. Six were conducted in the United States and most focused on changes to methadone treatment. Providers' experiences with increased flexibilities around take-homes were broadly positive, despite widespread initial concern over client safety and the potential for medication misuse. For a small number of providers, concerns about diversion were a specific manifestation of more general unease with loss of control over clients and the treatment process. Most providers appreciated increased flexibilities and described them as enabling more individualized, person-centered care. CONCLUSION Our findings support the continuation of flexibilities around take-homes and demonstrate that regulations and policies that reduce flexibility around take-homes conflict with person-centered approaches to care. Stronger guidance and support from professional regulatory agencies may help increase uptake of flexibilities around take-homes.
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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
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada; Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BCV6B 1G6, Canada
| | - Rhys Finnick
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, 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
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada; Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Eugenia Oviedo-Joekes
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada; Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada.
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Leventelis C, Katsouli A, Stavropoulos V, Karasavvidou A, Papadopoulos P, Barmpas PT, Tasoulis S, Veskoukis AS, Tsironi M. 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. NORDIC STUDIES ON ALCOHOL AND DRUGS 2023; 40:76-94. [PMID: 36793483 PMCID: PMC9893127 DOI: 10.1177/14550725221135574] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/12/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Christonikos Leventelis
- Christonikos Leventelis, Toxicology Scientist, Department of Nursing, University of Peloponnese, Tripoli, 22100, Greece.
;
| | | | | | | | | | - Petros T. Barmpas
- Department of Computer science and Biomedical Informatics, University of Thessaly, Lamia, Greece
| | - Sotiris Tasoulis
- Department of Computer science and Biomedical Informatics, University of Thessaly, Lamia, Greece
| | | | - Maria Tsironi
- Nursing Department, University of Peloponnese, Panarcadian Hospital Erythrou, Tripoli, Greece
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9
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Müllerschön B, Stöver H. Nutzen und zukünftige Relevanz der Corona-bedingt befristeten
Änderungen in der Substitution in Deutschland. SUCHTTHERAPIE 2022. [DOI: 10.1055/a-1968-5655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Zusammenfassung
Ziel der Studie Die COVID-19-Pandmie hat die Substitutionsbehandlung vor
große Herausforderungen gestellt. An der oft als restriktiv angesehenen
Rechtsgrundlage (BtM-VV) wurden befristete Änderungen vorgenommen, um
Behandler:innen mehr Spielraum bei der Gestaltung der Therapien zu
gewährleisten. Weitreichende Flexibilisierungen wurden in den Bereichen
Take-Home-Verschreibungen, konsiliarische Behandlung und Delegation vorgenommen.
Zusätzlich wurden neue Vergütungsmöglichkeiten im
Einheitlichen Bewertungsmaßstab (EBM) geschaffen. Durch
leitfadengestützte Interviews mit substituierenden Ärzt:innen
wurde eine Evaluation der befristeten BtM-VV- und EBM- Änderungen
vorgenommen.
Methodik Im Jahr 2021 wurden 16 qualitative Interviews mit
substituierenden Ärzt:innen aus zehn verschiedenen Bundesländern
in Deutschland geführt. Die Interviewten wurden zu ihren Erfahrungen mit
den Corona-bedingt befristeten BtM-VV- und EBM-Änderungen befragt. Im
Fokus stand dabei, ob die temporären Flexibilitäten dauerhaft in
die post-pandemische Praxis übernommen werden sollten. Der
Interviewleitfaden enthielt zusätzlich Fragen zu strukturellen
Barrieren, Nachwuchsmangel und Stigmatisierung.
Ergebnisse Zur Kontaktreduzierung verlängerte die Mehrheit der
Ärzt:innen Take-Home-Rezepte. In Folge machte nur eine befragte Person
ausschließlich negative Erfahrungen. Insgesamt berichteten die
Ärzt:innen über keine und/oder positive
Veränderungen im Therapieverlauf. Behandler:innen nutzten die meisten
der befristeten Rechts- und Vergütungsänderungen in der
Behandlungsgestaltung. Sie sprachen sich überwiegend für eine
Übernahme der befristeten Regelungen in den post-pandemisch Regelbetrieb
aus. Kontrovers wurden die Änderungen bezüglich der Aufhebung
der Kapazitätsgrenze bei der Konsiliarregelung und der erweiterten
Delegation diskutiert.
Schlussfolgerung Die Ergebnisse sprechen für die Übernahme
der befristeten BtM-VV- und EBM-Änderungen in den post-pandemischen
Regelbetrieb. Die Flexibilisierungen erleichtern die Anpassung der Therapie an
individuelle Umstände der Behandler:innen und Patient:innen. Dies
könnte dazu beitragen, die derzeitigen Versorgungsengpässe zu
entschärfen und mehr Menschen mit Opioid-Abhängigkeit eine
qualitativ hochwertige Substitutionstherapie anbieten zu können. Eine
Untersuchung und Beseitigung struktureller Barrieren darf bei der Ein- bzw.
Fortführung erweiterter Handlungsspielräume nicht vergessen
werden. Da gesetzliche Flexibilisierungen zwangsläufig mehr
Verantwortung auf die einzelnen Ärzt:innen übertragen, sollte
eine verstärkte Unterstützung durch Schulungen und Vernetzung
angeboten werden.
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Affiliation(s)
- Babette Müllerschön
- Institut für Geschichte der Medizin der
Justus-Liebig-Universität Gießen
- Institut für Suchtforschung der Frankfurt University of Applied
Sciences
| | - Heino Stöver
- Institut für Suchtforschung der Frankfurt University of Applied
Sciences
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10
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Russell C, Lange S, Kouyoumdjian F, Butler A, Ali F. Opioid agonist treatment take-home doses ('carries'): Are current guidelines resulting in low treatment coverage among high-risk populations in Canada and the USA? Harm Reduct J 2022; 19:89. [PMID: 35948961 PMCID: PMC9363267 DOI: 10.1186/s12954-022-00671-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/02/2022] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Cayley Russell
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St, Toronto, ON, M5S 2S1, Canada. .,Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), 33 Ursula Franklin St, ON, M5S 2S1, Toronto, Canada.
| | - Shannon Lange
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St, Toronto, ON, M5S 2S1, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), ON, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Fiona Kouyoumdjian
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Amanda Butler
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Farihah Ali
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St, Toronto, ON, M5S 2S1, Canada.,Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), 33 Ursula Franklin St, ON, M5S 2S1, Toronto, Canada
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11
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Durand L, Keenan E, Boland F, Harnedy N, Delargy Í, Scully M, Mayock P, Ebbitt W, Vázquez MO, Corrigan N, Killeen N, Pate M, Byrne P, Cousins G. Consensus recommendations for opioid agonist treatment following the introduction of emergency clinical guidelines in Ireland during the COVID-19 pandemic: A national Delphi study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 106:103768. [PMID: 35738029 PMCID: PMC9212711 DOI: 10.1016/j.drugpo.2022.103768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 10/30/2022]
Abstract
BACKGROUND Emergency contingency guidelines for opioid agonist treatment (OAT) were introduced in Ireland in March 2020, to ensure rapid and uninterrupted access to treatment while mitigating COVID-19 risk. The contingency guidelines deviated, across multiple clinical domains, from pre-pandemic clinical guidelines published in 2016. The objectives of this study are to (1) identify changes introduced to OAT clinical guidelines in Ireland during the pandemic; and (2) develop consensus on whether the new recommendations should be retained beyond the pandemic, using a national Delphi consensus methodology. METHODS Clinical guidance recommendations ('statements') were generated by comparing the newly established contingency guidelines with the national 2016 Clinical Guidelines for OAT. Over two rounds of on-line Delphi testing, a panel of experts (people currently accessing OAT, psychiatrists, general practitioners, community pharmacists, a nurse, a psychologist and support/key workers) independently rated their agreement with each statement and provided comments. Statements with a median score of 4 or 5 and a lower quartile of ≥4 were classified as having reached consensus. RESULTS Forty-eight panel members were recruited, with a high participation level at Round 2 (90%, n=43). Consensus was achieved for 12 of the 19 statements at Round 1. The 7 remaining statements were revised, with 2 new statements, resulting in 9 statements at Round 2. Four statements reached consensus at Round 2. The final list includes 16 clinical guidance statements; 9 relating to assessment, 3 to OAT drug choice and dosing, 1 to take-away doses, 2 to overdose prevention and 1 to the continuation of e-prescriptions. CONCLUSIONS A wide range of stakeholders involved in the delivery and receipt of OAT agreed on 16 clinical guidance statements for inclusion in OAT clinical guidelines as we move beyond the pandemic, rather than reverting to pre-pandemic guidelines. The agreed statements relate to facilitating safe access to OAT with minimal waiting time, supporting patient-centred care to promote health and well-being, and preventing drug overdose. Notably, consensus was not achieved for OAT drug dosage and frequency of urine testing during the stabilisation and maintenance phase of care.
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Affiliation(s)
- Louise Durand
- School of Pharmacy and Biomolecular Science, Royal College of Surgeons in Ireland, First Floor, Ardilaun House (Block B), 111 St Stephen's Green, Dublin 2, D02 VN51, Ireland
| | - Eamon Keenan
- Health Service Executive, National Social Inclusion Office, Mill Lane, Palmerstown, Dublin 20, D20 KH63, Ireland
| | - Fiona Boland
- RCSI Data Science Centre and Department of General practice, Royal College of Surgeons in Ireland, Beaux Lane House, Mercer Street Lower, Dublin 2, D02 DH60, Ireland
| | - Norma Harnedy
- HSE Addiction Services, PO Box 486, Corporate House, Mungret Street, Limerick, V94 PV34, Ireland
| | - Íde Delargy
- Irish College of General Practitioners, Lincoln Place, Dublin 2, D02 XR68, Ireland
| | - Mike Scully
- National Drug Treatment Centre, 30/31 Pearse street, Dublin 2, D02 NY26, Ireland
| | - Paula Mayock
- School of Social Work and Social Policy, 3/4 Foster place, Trinity College Dublin Dublin 2, Ireland
| | - William Ebbitt
- National Drug Treatment Centre, 30/31 Pearse street, Dublin 2, D02 NY26, Ireland
| | - María Otero Vázquez
- UISCE, National Advocacy Service for People who use Drugs in Ireland, 8 Cabra road, Dublin 7, D07 T1W2, Ireland
| | - Nicola Corrigan
- Health Service Executive, National Social Inclusion Office, Mill Lane, Palmerstown, Dublin 20, D20 KH63, Ireland
| | - Nicki Killeen
- Health Service Executive, National Social Inclusion Office, Mill Lane, Palmerstown, Dublin 20, D20 KH63, Ireland
| | - Muriel Pate
- Health Service Executive, National Quality and Patient Safety Directorate, Dr. Steeven's Hospital, Dublin 8, D08 W2A8, Ireland
| | - Paula Byrne
- Merchants Quay Ireland Head Office, Merchants Court, 24 Merchants Quay, Dublin 8, D08 × 7YK, Ireland
| | - Gráinne Cousins
- School of Pharmacy and Biomolecular Science, Royal College of Surgeons in Ireland, First Floor, Ardilaun House (Block B), 111 St Stephen's Green, Dublin 2, D02 VN51, Ireland.
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12
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Lintzeris N, Jansen L, Hayes V. Response to Steele and Acheson. Drug Alcohol Rev 2022; 41:1023-1024. [PMID: 35538671 DOI: 10.1111/dar.13478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/14/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Nicholas Lintzeris
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia.,Addiction Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia
| | - Louisa Jansen
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia.,NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia
| | - Victoria Hayes
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia.,NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia
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13
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Evaluating interventions to facilitate opioid agonist treatment access among people who inject drugs in Toronto, Ontario during COVID-19 pandemic restrictions. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 104:103680. [PMID: 35447476 PMCID: PMC9005368 DOI: 10.1016/j.drugpo.2022.103680] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/22/2022] [Accepted: 03/30/2022] [Indexed: 12/01/2022]
Abstract
Background In March 2020, following a provincial COVID-19 emergency declaration, modifications to opioid agonist treatment (OAT) were introduced in Ontario, Canada to promote treatment access amid the pandemic and ongoing opioid overdose crisis. Modifications included federal exemptions to facilitate OAT prescription re-fills, extensions, and deliveries and interim treatment guidance emphasizing take-home (non-observed) doses and reduced urine drug screening for OAT patients. Methods We conducted an interrupted time series study using health administrative data from September 17th, 2019–September 21st, 2020, on 359 people who inject drugs with suspected opioid use disorder in Toronto, Ontario. We used segmented regression analyses to evaluate the joint effects of the provincial COVID-19 emergency declaration, federal OAT exemptions, and interim treatment guidance—all implemented between March 17th–23rd, 2020—on the weekly proportion of participants enrolled in OAT (i.e., ≥1 day(s) covered with methadone or buprenorphine/naloxone), with an opioid-related overdose (based on emergency department visits and hospitalizations), and who died (all-cause), and the weekly proportion of OAT-enrolled participants receiving take-home doses (i.e., ≥1 day(s) covered) and undergoing urine drug screening. Results Post-implementation, the interventions were associated with immediate absolute changes in OAT enrollment (+1.95%; 95% CI=0.04%–3.85%), receipt of take-home doses (+18.3%; 95% CI=13.2%–23.4%), and urine drug screening (-22.4%; 95% CI=[-26.9%]–[-17.9%]) and a gradual absolute increase of 0.56% in urine drug screening week-to-week (95% CI=0.27%–0.86%) beyond the pre-implementation trend. At 26 weeks post-implementation, OAT enrollment and urine drug screening approached pre-implementation levels whereas the increase in take-home doses was largely sustained (+15.0%; 95% CI=4.33%–25.6%). No post-implementation increases in opioid-related overdoses were observed. Death was not modelled (low event frequency). Conclusion Changes to OAT provision following provincial COVID-19 restrictions were associated with an immediate and sustained increase in take-home dose coverage among OAT-enrolled participants, without corresponding increases in opioid-related overdoses among all participants.
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