Operationalizing the new DEA exception: A novel process for dispensing of methadone for opioid use disorder at discharge from acute care settings

PURPOSE

To describe one strategy for dispensing of methadone at emergency department (ED) and hospital discharge implemented within 2 urban academic medical centers.

SUMMARY

Expanding access to medications for opioid use disorder (OUD) is a national priority. ED visits and hospitalizations offer an opportunity to initiate or continue these lifesaving medications, including methadone and buprenorphine. However, federal regulations governing methadone treatment and significant gaps in treatment availability have made continuing methadone upon ED or hospital discharge challenging. To address this issue, the Drug Enforcement Administration (DEA) granted an exception allowing hospitals, clinics, and EDs to dispense a 72-hour supply of methadone while continued treatment is arranged. Though this exception addresses a critical unmet need, guidance for operationalizing this service is limited. To facilitate expanded patient access to methadone on ED or hospital discharge at 2 Baltimore hospitals, key stakeholders within the parent health system were identified, and a workgroup was formed. Processes were established for requesting, approving, preparing, and dispensing the methadone supply using an electronic health record order set. Multidisciplinary educational materials were created to support end users of the workflow. In the first 3 months of implementation, 42 requests were entered, of which 36 were approved, resulting in 79 dispensed methadone doses.

CONCLUSION

This project demonstrates feasibility of methadone dispensing at hospital and ED discharge. Further work is needed to evaluate impact on patient outcomes, such as hospital and ED utilization, length of stay, linkage to treatment, and retention in treatment.

COVID-19: A new barrier to treatment for opioid use disorder in the emergency department

OBJECTIVE

Start Treatment and Recover (STAR) is an emergency department (ED) program that expands access to medication for opioid use disorder by identifying patients with opioid use disorder and offering ED-initiated buprenorphine/naloxone and rapid access to outpatient treatment. We sought to determine the impacts of the coronavirus disease 2019 pandemic on STAR and the patients with opioid use disorder it serves.

METHODS

We conducted a retrospective review of records comparing 2 periods: pre-pandemic (February 1, 2019-February 29, 2020) and pandemic (March 1, 2020-May 31, 2020). Variables evaluated included the number of STAR enrollments, ED census, percentage of census screening positive for opioid use disorder, number and percentage of ED overdose visits, and overdose fatalities by month. All analyses were conducted using 2-sample t tests to calculate the mean and 95% confidence intervals (CIs).

RESULTS

Comparing the pre-pandemic to the pandemic period, the mean monthly ED visits decreased from 5126.9 to 3306.7 (difference = -1820.3; 95% CI, -3406.3 to -234.2), STAR mean monthly enrollments decreased from 9.7 to 1.3 (difference = -8.4; 95% CI, -12.8 to -4.0), and statewide monthly opioid-related fatalities increased from 9.4 to 15.3 (difference = 5.9; 95% CI, 0.8 to 11.1). However, the percentage of individuals who presented to the ED with opioid use disorder or overdose remained unchanged.

CONCLUSION

Although overall ED visits declined during the pandemic period, the percentage of patients presenting with opioid use disorder or overdose remained constant, yet there was a dramatic decline in enrollment in ED-initiated medication for opioid use disorder and an increase in statewide monthly opioid-related fatalities. Strategies to maintain medication for opioid use disorder treatment options must be implemented for this vulnerable population during the ongoing pandemic.

Depressive symptoms and use of HIV care and medication-assisted treatment among people with HIV who inject drugs

OBJECTIVE

Vietnam, Indonesia, and Ukraine have major burdens of IDU and HIV. We estimated the prevalence of depressive symptoms at baseline among people living with HIV who inject drugs, evaluated associations between depression at baseline and 12-month HIV care outcomes and medication-assisted treatment (MAT), and evaluated the study intervention effect by baseline depression subgroups.

DESIGN

HPTN 074 was a randomized study. The study intervention included psychosocial counseling, systems navigation, and antiretroviral treatment (ART) at any CD4+ cell count.

METHODS

Moderate-to-severe depression was defined as a Patient Health Questionnaire-9 score of 10 or above. ART and MAT were self-reported. Eligibility criteria were: 18-60 years of age, active IDU, and viral load of at least 1000 copies/ml. Adjusted probability differences (aPD) were estimated using inverse-probability weighting.

RESULTS

A total of 502 participants enrolled from April 2015 to June 2016. Median age was 35 years; 85% identified as men. Prevalence of baseline moderate-to-severe depression was 14% in Vietnam, 14% in Indonesia, and 56% in Ukraine. No evident associations were detected between baseline depression and ART, viral suppression, or MAT at 12-month follow-up. The study intervention improved the proportions of people who inject drugs achieving 12-month viral suppression in both the depressed [intervention 44%; standard of care 24%; estimated aPD = 25% (95% confidence interval: 4.0%, 45%)] and nondepressed subgroups [intervention 38%; standard of care 24%; aPD = 13% (95% confidence interval: 2.0%, 25%)].

CONCLUSION

High levels of depressive symptoms were common among people living with HIV who inject drugs in Ukraine but were less common in Vietnam and Indonesia. The study intervention was effective among participants with or without baseline depression symptoms.