A chance to do it better: Methadone maintenance treatment in the age of Covid-19

The relationship of pain intensity and opioid craving with delayed methadone dose: A preliminary study of individuals with opioid use disorder

AIMS

Despite a strong theoretical link between opioid craving and pain, little is known about the temporal relationship between pain and craving and the acute experience of pain in the context of methadone treatment. Using a cross-over design, the current study evaluated the time course of pain and craving and objective experience of pain as a function of the last methadone dose.

METHODS

Participants (n = 20) presented for the study in the morning and either received methadone dose as scheduled or delayed dose until the afternoon. During the 4-h study visit, participants completed a series of tasks, including repeated assessment of pain and craving at 0, +40, +70, +130, +160 and +240 min and a cold pressor test (CPT) at +15 and +220 min.

RESULTS

Separate mixed model results demonstrated no effect of dosing condition on craving; however, there was a significant dosing condition by time interaction (F(5,209) = 3.38, P = .006) such that pain increased over time in the delayed methadone condition but decreased in time in the scheduled methadone condition. A mixed model predicting self-reported pain revealed a three-way interaction between dosing condition, craving and time (F(5,197) = 2.39, P = .039) explained by a positive association between craving and pain at each time point (except 240 min) in delayed condition (P-range = .004-.0001). A separate mixed model on CPT data indicated a significant condition by time interaction such that pain threshold decreased in the delayed, but not scheduled, condition (F(1,57) = 4.01, P = .050).

CONCLUSIONS

These preliminary findings highlight the potential for increased risks after even a short delay in receiving a methadone dose.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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.

Opioid use and COVID-19: a secondary analysis of the impact of relaxation of methadone take-home dosing guidelines on use of illicit opioids

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.

Substance Use Disorders: Basic Overview for the Anesthesiologist

Substance use disorders (SUDs) represent a current major public health concern in the United States and around the world. Social and economic stressors secondary to the coronavirus disease 2019 (COVID-19) pandemic have likely led to an increase in SUDs around the world. This chronic, debilitating disease is a prevalent health problem, and yet many clinicians do not have adequate training or clinical experience diagnosing and treating SUDs. Anesthesiologists and other perioperative medical staff frequently encounter patients with co-occurring SUDs. By such, through increased awareness and education, physicians and other health care providers have a unique opportunity to positively impact the lives and improve the perioperative outcomes of patients with SUDs. Understanding commonly used terms, potentially effective perioperative screening tools, diagnostic criteria, basics of treatment, and the perioperative implications of SUDs is essential to providing adequate care to patients experiencing this illness.

Changes in Opioid Agonist Treatment Practice in Germany during the COVID-19 Pandemic: What Have Physicians Done, and What Would They Like to Keep Doing?

INTRODUCTION

Opioid agonist treatment (OAT) is the most common and most effective treatment option for persons with opioid use disorders (OUD). In Germany, the prescription of OAT medications is regulated by the Narcotic Drugs Prescription Ordinance. With the introduction of restrictions to contain the SARS-CoV-2 virus, the German OAT regulations have been amended to ensure a legal continuation of OAT for people with OUD. In this study, we aimed to examine the use of the OAT regulations in practice, the experience made by physicians prescribing OAT medications, and their perspective on OAT regulations.

METHODS

Between September and December 2021, a questionnaire on the current situation and potential changes in the provision of OAT during the COVID-19 pandemic was sent out to 2,416 German physicians prescribing OAT medications. Differences between physicians with and without addiction medicine certification were analyzed.

RESULTS

The response rate of physicians was 22.8%. Their average age was 57.4 (±10.1) years, and 62.3% were male. During the COVID-19 pandemic, take-home periods for stable patients have been extended by 48.2% of physicians, and 52.6% would like to maintain this prescribing practice in the future. Most physicians (71.6%) indicated that patients handled the extended take-home prescriptions predominantly responsibly. A total of 71.8% of the physicians generally did not use video consultation. A corona pandemic-related switch of the OST medication to depot buprenorphine injection did rather not occur, as 71.2% reported no patients treated with depot buprenorphine, and only 2.6% switched first-time or more patients to depot buprenorphine due to the COVID-19 pandemic.

CONCLUSION

The corona situation opened up opportunities for physicians and patients and enabled change processes in OAT. Physicians had positive experiences implementing expanded take-home prescriptions for stable patients. Video contacts rarely took place, suggesting resistance to digital consultation. The number of depot buprenorphine prescriptions has not increased substantially since the pandemic's beginning and has remained at low levels. Further research is needed to assess to what extent the changes in OAT will be maintained over time and whether they will also lead to long-term benefits for OAT patients.

Provider experiences with relaxing restrictions on take-home medications for opioid use disorder during the COVID-19 pandemic: A qualitative systematic review

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.

The Future of the United States Overdose Crisis: Challenges and Opportunities

Policy Points People are dying at record numbers from overdose in the United States. Concerted action has led to a number of successes, including reduced inappropriate opioid prescribing and increased availability of opioid use disorder treatment and harm-reduction efforts, yet ongoing challenges include criminalization of drug use and regulatory and stigma barriers to expansion of treatment and harm-reduction services. Priorities for action include investing in evidence-based and compassionate policies and programs that address sources of opioid demand, decriminalizing drug use and drug paraphernalia, enacting policies to make medication for opioid use disorder more accessible, and promoting drug checking and safe drug supply.

"Sign Me Up": a qualitative study of video observed therapy (VOT) for patients receiving expedited methadone take-homes during the COVID-19 pandemic

BACKGROUND

Federal and state regulations require frequent direct observation of methadone ingestion at an Opioid Treatment Program (OTP)-a requirement that creates barriers to patient access. Video observed therapy (VOT) may help to address public health and safety concerns of providing take-home medications while simultaneously reducing barriers to treatment access and long-term retention. Evaluating user experiences with VOT is important for understanding the acceptability of this strategy.

METHODS

We conducted a qualitative evaluation of a clinical pilot program of VOT via smartphone that was rapidly implemented between April and August 2020 during the COVID-19 pandemic within three opioid treatment programs. In the program, selected patients submitted video recordings of themselves ingesting methadone take-home doses, which were asynchronously reviewed by their counselor. We recruited participating patients and counselors for semi-structured, individual interviews to explore their VOT experiences after program completion. Interviews were audio recorded and transcribed. Transcripts were analyzed using thematic analysis to identify key factors influencing acceptability and the effect of VOT on the treatment experience.

RESULTS

We interviewed 12 of the 60 patients who participated in the clinical pilot and 3 of the 5 counselors. Overall, patients were enthusiastic about VOT, noting multiple benefits over traditional treatment experiences, including avoiding frequent travel to the clinic. Some noted how this allowed them to better meet recovery goals by avoiding a potentially triggering environment. Most appreciated having increased time to devote to other life priorities, including maintaining consistent employment. Participants described how VOT increased their autonomy, allowed them to keep treatment private, and normalized treatment to align with other medications that do not require in-person dosing. Participants did not describe major usability issues or privacy concerns with submitting videos. Some participants reported feeling disconnected from counselors while others felt more connected. Counselors felt some discomfort in their new role confirming medication ingestion but saw VOT as a useful tool for select patients.

CONCLUSIONS

VOT may be an acceptable tool to achieve equipoise between lowering barriers to treatment with methadone and protecting the health and safety of patients and their communities.

Between Care and Control: Examining Surveillance Practices in Harm Reduction

As harm reduction programs and services proliferate, people who use drugs (PWUD) are increasingly subjected to surveillance through the collection of their personal information, systematic observation, and other means. The data generated from these practices are frequently repurposed across various institutional sites for clinical, evaluative, epidemiological, and administrative uses. Rationales provided for increased surveillance include the more effective provision of care, service optimization, risk stratification, and efficiency in resource allocation. With this in mind, our reflective essay draws on empirical analysis of work within harm reduction services and movements to reflect critically on the impacts and implications of surveillance expansion. While we argue that many surveillance practices are not inherently problematic or harmful, the unchecked expansion of surveillance under a banner of health and harm reduction may contribute to decreased uptake of services, rationing and conditionalities tied to service access, the potential deepening of health disparities amongst some PWUD, and an overlay of health and criminal-legal systems. In this context, surveillance relies on the enlistment of a range of therapeutic actors and reflects the permeable boundary between care and control. We thus call for a broader critical dialogue within harm reduction on the problems and potential impacts posed by surveillance in service settings, the end to data sharing of health information with law enforcement and other criminal legal actors, and deference to the stated need among PWUD for meaningful anonymity when accessing harm reduction and health services.

Has the treatment gap for opioid use disorder narrowed in the U.S.?: A yearly assessment from 2010 to 2019"

BACKGROUND

The United States overdose crisis continues unabated. Despite efforts to increase capacity for treating opioid use disorder (OUD) in the U.S., how actual treatment receipt compares to need remains unclear. In this cross-sectional study, we estimate progress in addressing the gap between OUD prevalence and OUD treatment receipt at the national and state levels from 2010 to 2019.

METHODS

We estimated past-year OUD prevalence rates based on the U.S. National Survey on Drug Use and Health (NSDUH), using adjustment methods that attempt to account for OUD underestimation in national household surveys. We used data from specialty substance use treatment records and outpatient pharmacy claims to estimate the gap between OUD prevalence and number of persons receiving medications for opioid use disorder (MOUD) during the past decade.

RESULTS

Adjusted estimates suggest past-year OUD affected 7,631,804 individuals in the U.S. in (2,773 per 100,000 adults 12+), relative to only 1,023,959 individuals who received MOUD (365 per 100,000 adults 12+). This implies approximately 86.6% of individuals with OUD nationwide who may benefit from MOUD treatment do not receive it. MOUD receipt increased across states over the past decade, but most regions still experience wide gaps between OUD prevalence and MOUD receipt.

CONCLUSIONS

Despite some progress in expanding access to MOUD, a substantial gap between OUD prevalence and treatment receipt highlights the critical need to increase access to evidence-based services.

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

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.

Treatment retention, return to use, and recovery support following COVID-19 relaxation of methadone take-home dosing in two rural opioid treatment programs: A mixed methods analysis

Objectives

In March 2020, the Substance Abuse and Mental Health Services Administration permitted Opioid Treatment Programs (OTPs) to relax restrictions on take-home methadone and promoted telehealth to minimize potential exposures to COVID-19. We assessed the effects of COVID-19-related changes on take-home methadone dosing in two OTPs serving five rural Oregon counties.

Methods

We used a mixed-methods convergent design. The OTPs extracted urine drug test (UDT) results, take-home methadone regimens, and treatment retention from the electronic health record (EHR) for patients (n = 377). A mixed-effects negative binomial regression model assessed patient-level differences in take-home doses before and after the COVID-19 policy changes and the associations with treatment discontinuation, and UDT positivity. Semi-structured qualitative interviews (n = 32) explored patient reactions to increased take-home dosing and reduced clinic visits to provide context for quantitative findings.

Results

The number of take-home doses increased in the post-COVID-19 period for patients engaged in treatment for more than 180 days (median: 8 vs 13 take-home doses per month, p = 0.011). Take-homes did not increase for patients with fewer days of treatment. Each percentage point increase in take-home dosing above what would be expected without COVID-19 policy changes was negatively associated with the percent of UDT positive for opioids (B = −0.12, CI [−0.21, −0.04], p = 0.005) and the probability of treatment discontinuation (aOR = 0.97, CI [0.95, 0.99], p = 0.003). Qualitative analysis revealed three themes explaining how increased take-home dosing supported recovery: 1) value of feeling trusted with increased responsibility; 2) reduced travel time permitted increased employment and recreation; and 3) reduced exposure to individuals less stable in recovery and potential triggers.

Conclusions

Take-home methadone dose relaxations were associated with increased methadone take-home doses, improved retention, and decreased UDT opioid positive results among clinically stable patients. Qualitative findings suggest that fewer take-home restrictions are feasible and desirable and do not pose safety or public health harms.

Factors associated with retention on medications for opioid use disorder among a cohort of adults seeking treatment in the community

Background

Medication treatment for opioid use disorder (OUD) (MOUD; buprenorphine and methadone) reduces opioid use and overdose. Discontinuation of MOUD can quickly lead to relapse, overdose and death. Few persons who initiate MOUD are retained on treatment, thus it is critical to identify factors associated with retention.

Methods

Evaluated data was from an ongoing prospective cohort study of adults aged 18 or older with DSM-5 moderate to severe OUD seeking MOUD in the community and followed for 6 months. Participants were considered retained on MOUD through 6 months if they reported taking MOUD at every study interview without discontinuation. A high dose of MOUD was defined as a methadone dose > 85 mg or buprenorphine dose ≥ 16 mg. Multivariable logistic regression was conducted to assess factors associated with 6-month MOUD retention.

Results

A total of 118 participants (73% male, 58% white, 36% with HIV) were included. Buprenorphine was initiated by 58% and 42% started methadone. MOUD retention was 49% and 58% among buprenorphine and methadone, respectively, at 6-months. In adjusted models, a high MOUD dose (OR = 4.71, 95% CI 2.05–10.84) and higher pain interference (OR = 1.59, 95% CI 1.15–2.19) was associated with MOUD retention.

Conclusions

Adequate dosing of MOUD leads to improved retention on MOUD. Further, persons with high pain interference at baseline had higher odds of retention on MOUD. Both methadone and buprenorphine have analgesic effects, thus those with high pain interference could have dual benefits of MOUD for treating OUD and pain. Interventions should be tailored to improve adequate MOUD dosing to improve retention on MOUD.

Examining the impact of the first wave of COVID-19 and associated control measures on interventions to prevent blood-borne viruses among people who inject drugs in Scotland: an interrupted time series study

BACKGROUND

COVID-19 has likely affected the delivery of interventions to prevent blood-borne viruses (BBVs) among people who inject drugs (PWID). We examined the impact of the first wave of COVID-19 in Scotland on: 1) needle and syringe provision (NSP), 2) opioid agonist therapy (OAT) and 3) BBV testing.

METHODS

An interrupted time series study design; 23rd March 2020 (date of the first 'lockdown') was chosen as the key date.

RESULTS

The number of HIV tests and HCV tests in drug services/prisons, and the number of needles/syringes (N/S) distributed decreased by 94% (RR=0.062, 95% CI 0.041-0.094, p < 0.001), 95% (RR=0.049, 95% CI 0.034-0.069, p < 0.001) and 18% (RR = 0.816, 95% CI 0.750-0.887, p < 0.001), respectively, immediately after lockdown. Post-lockdown, an increasing trend was observed relating to the number of N/S distributed (0.6%; RR = 1.006, 95% CI 1.001-1.012, p = 0.015), HIV tests (12.1%; RR = 1.121, 95% CI 1.092-1.152, p < 0.001) and HCV tests (13.2%; RR = 1.132, 95 CI 1.106-1.158, p < 0.001). Trends relating to the total amount of methadone prescribed remained stable, but a decreasing trend in the number of prescriptions (2.4%; RR = 0.976, 95% CI 0.959-0.993, p = 0.006) and an increasing trend in the quantity prescribed per prescription (2.8%; RR = 1.028, 95% CI 1.013-1.042, p < 0.001) was observed post-lockdown.

CONCLUSIONS

COVID-19 impacted the delivery of BBV prevention services for PWID in Scotland. While there is evidence of service recovery; further effort is likely required to return some intervention coverage to pre-pandemic levels in the context of subsequent waves of COVID-19.

"The idea is to help people achieve greater success and liberty": A qualitative study of expanded methadone take-home access in opioid use disorder treatment

Background: Prior to the COVID-19 pandemic, the United States (US) was already facing an epidemic of opioid overdose deaths. Overdose deaths continued to surge during the pandemic. To limit COVID-19 spread and to avoid disruptions in access to medications for opioid use disorder (MOUD), including buprenorphine and methadone, US federal and state agencies granted unprecedented exemptions to existing MOUD guidelines for Opioid Treatment Programs (OTPs), including loosening criteria for unsupervised take-home doses. We conducted a qualitative study to evaluate the impact of these policy changes on MOUD treatment experiences for providers and patients at an OTP in California. Methods: We interviewed 10 providers (including two physicians, five social worker associates, and three nurse practitioners) and 20 patients receiving MOUD. We transcribed, coded, and analyzed all interviews to identify emergent themes. Results: Patient participants were middle-aged (median age 51 years) and were predominantly men (53%). Providers discussed clinical decision-making processes and experiences providing take-homes. Implementation of expanded take-home policies was cautious. Providers reported making individualized decisions, using patient factors to decide if benefits outweighed risks of overdose and misuse. Decision-making factors included patient drug use, overdose risk, housing status, and vulnerability to COVID-19. New patient groups started receiving take-homes and providers noted few adverse events. Patients who received take-homes reported increased autonomy and treatment flexibility, which in turn increased likelihood of treatment stabilization and engagement. Patients who remained ineligible for take-homes, usually due to ongoing non-prescribed opioid or benzodiazepine use, desired greater transparency and shared decision-making. Conclusion: Federal exemptions in response to COVID-19 led to the unprecedented expansion of access to MOUD take-homes within OTPs. Providers and patients perceived benefits to expanding access to take-homes and experienced few adverse outcomes, suggesting expanded take-home policies should remain post-COVID-19. Future studies should explore whether these findings are generalizable to other OTPs and assess larger samples to quantify patient-level outcomes resulting from expanded take-home policies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Living Under Coronavirus and Injecting Drugs in Bristol (LUCID-B): A qualitative study of experiences of COVID-19 among people who inject drugs

BACKGROUND

People who inject drugs (PWID) are a high-risk group for COVID-19 transmission and serious health consequences. Restrictions imposed in the UK in response to the pandemic led to rapid health and housing service alterations. We aimed to examine PWID experiences of: 1) challenges relating to the COVID-19 public health measures; 2) changes to opioid substitution therapy (OST) and harm reduction services; and 3) perceived effects of COVID-19 on drug use patterns and risk behaviour.

METHODS

Telephone semi-structured interviews were conducted with 28 PWID in Bristol, Southwest of England. Analysis followed a reflexive thematic analysis.

RESULTS

Concern about COVID-19 and adherence to public health guidance varied. Efforts made by services to continue providing support during the pandemic were appreciated and some changes were preferred, such as less frequent OST collection, relaxation of supervised consumption and needle and syringe programmes (NSP) home delivery. However, remote forms of contact were highlighted as less beneficial and more difficult to engage with than in-person contact. Public health guidance advising people to 'stay home' led to increased isolation, boredom, and time to ruminate which impacted negatively on mental health. Lockdown restrictions directly impacted on sources of income and routine. Changes in drug use were explained as a consequence of isolation and fewer interactions with peers, problems accessing drugs, reduced drug purity and reduced financial resources.

CONCLUSION

This study captures the significant impacts and challenges of the COVID-19 pandemic on the lives of PWID. While rapid adaptations to service delivery to help mitigate the risks of COVID-19 were appreciated and some changes such as relaxation of supervised daily OST consumption were viewed positively, barriers to access need further attention. Going forwards there may be opportunities to harness the positive aspects of some changes to services.

Implementing a Methadone Delivery System in New York City in Response to COVID-19

Opioid agonist medication, including methadone, is considered the first-line treatment for opioid use disorder. Methadone, when taken daily, reduces the risk of fatal overdose; however, overdose risk increases following medication cessation. Amid an overdose epidemic accelerated by the proliferation of fentanyl, ensuring continuity of methadone treatment during the COVID-19 pandemic is a vital public health priority. (Am J Public Health. 2021;111(12):2115-2117. https://doi.org/10.2105/AJPH.2021.306523).

The impact of COVID-19 on opioid treatment programs in the United States

BACKGROUND

The COVID-19 pandemic had the potential to severely disrupt the delivery of methadone and buprenorphine, as social distancing and other public health regulations made in-person services difficult to maintain. Federal and state regulators changed requirements regarding the dispensing of medication and in-person counseling at opioid treatment programs. Understanding staff and patient reactions to these changes can help determine whether they should be maintained.

METHODS

We interviewed 25 directors of OTP programs located throughout the United States. Note takers wrote summaries of each interview which were coded for topics and themes covered in the interview guide, including changes to clinic practices, take-home medications, telehealth, patient and staff reactions to new COVID-related protocols, and financial concerns for programs.

RESULTS

Most programs rapidly incorporated new regulatory requirements, and directors were generally positive about the impact of increased take-home doses of medication and increased reliance on telehealth. Some directors voiced concerns about these changes, and some reported that patients missed the daily clinical contact with staff. Directors also suggested that more time was needed to assess the full impact of these changes. Financial impacts varied, although many directors were quick to point out that the ongoing opioid epidemic has delivered a steady stream of new patients, thus offsetting potential financial losses.

CONCLUSIONS

Overall, this study demonstrated the generally positive view of OTP directors to the regulatory changes necessitated by the COVID-19 pandemic. More time is needed to fully evaluate the impact of these changes on clinical outcomes.