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).

Changing Outdated Methadone Regulations That Harm Pregnant Patients.

Methadone regulations have changed minimally since 1974, despite advances in the understanding of the nature of opioid use disorder (OUD) and the role of medications in its treatment. At that time, most patients with OUD were considered to have anti-social personality disorders and the regulations aimed to exert maximal control over medication access. Six- or seven-day clinic attendance is required for months, regardless of distance, or childcare and other social responsibilities. Take home medications are not allowed unless rigid and formulaic conditions are met. Although addiction medicine has rejected the "criminal" paradigm in favor of OUD as a treatable medical disorder, methadone regulations have not kept pace with the science. Pregnancy is characterized by an ultra-rapid metabolic state, but regulations prevent the use of daily divided doses of methadone to maintain stability. This results in repeated episodes of maternal/fetal opioid withdrawal, as well as other fetal physiologic abnormalities. Interference with dose regimen adjustments prevents optimal outcomes. Further, methadone clinics are mostly urban, leaving patients in rural areas without access. This led to excessive morbidity and mortality when the opioid crisis hit. The response of merely expanding capacity in overcrowded urban clinics created a contagion menace when Covid-19 arrived. Pregnant women (and parents with children) were forced to negotiate dosing in dangerous conditions. A revised methadone system must provide treatment that is local, flexible, and limited in size to manage viral contagion risks. This regulatory change can most easily be started by changing regulations that adversely affect pregnant women.

Take-home dosing experiences among persons receiving methadone maintenance treatment during COVID-19.

PURPOSE: Methadone maintenance treatment is a life-saving treatment for people with opioid use disorders (OUD). The coronavirus pandemic (COVID-19) has introduced many concerns surrounding access to opioid treatment. In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued guidance allowing for the expansion of take-home methadone doses. We sought to describe changes to treatment experiences from the perspective of persons receiving methadone at outpatient treatment facilities for OUD. METHODS: We conducted an in-person survey among 104 persons receiving methadone from three clinics in central North Carolina in June and July 2020. Surveys collected information on demographic characteristics, methadone treatment history, and experiences with take-home methadone doses in the context of COVID-19 (i.e., before and since March 2020). RESULTS: Before COVID-19, the clinic-level percent of participants receiving any amount of days' supply of take-home doses at each clinic ranged from 56% to 82%, while it ranged from 78% to 100% since COVID-19. The clinic-level percent of participants receiving a take-homes days' supply of a week or longer (i.e., ≥6 days) since COVID-19 ranged from 11% to 56%. Among 87 participants who received take-homes since COVID-19, only four reported selling their take-home doses. CONCLUSIONS: Our study found variation in experiences of take-home dosing by clinic and little diversion of take-home doses. While SAMSHA guidance should allow expanded access to take-home doses, adoption of these guidelines may vary at the clinic level. The adoption of these policies should be explored further, particularly in the context of benefits to patients seeking OUD treatment.

Use of an electronic pillbox to increase number of methadone take-home doses during the COVID-19 pandemic.

This study describes use of the commercially available Medminder electronic pillbox at a community substance use disorder treatment program to safely increase the number of methadone take-home doses administered during the COVID-19 pandemic. The pillbox contains 28 cells that lock independently and can be opened only during preprogrammed time windows. This study provided patients (n = 42) deemed vulnerable to take-home mismanagement or more severe symptoms from COVID-19 infection the pillbox and observed them for 11 weeks. A telephone support line was staffed daily to manage technical issues. Overall, patients received about 14 more take-home doses per month after receiving the pillbox. Most medication was dispensed within scheduled windows. The study observed few incidents of suspected tampering, though five patients had their pillbox rescinded to allow more intensive on-site clinical monitoring. The study supports use of an electronic pillbox with a telephone support line to help vulnerable patients to better observe stay-at-home guidelines during the COVID-19 pandemic. The pillbox may offer public health and clinical benefits that extend beyond the pandemic by increasing program treatment capacity and patient satisfaction.

Harm reduction in the time of COVID-19: Case study of homelessness and drug use in Dublin, Ireland.

Dublin appears to have performed very well as compared to various scenarios for COVID-19 mortality amongst homeless and drug using populations. The experience, if borne out by further research, provides important lessons for policy discussions on the pandemic, as well as broader lessons about pragmatic responses to these key client groups irrespective of COVID-19. The overarching lesson seems that when government policy is well coordinated and underpinned by a science-driven and fundamentally pragmatic approach, morbidity and mortality can be reduced. Within this, the importance of strategic clarity and delivery, housing, lowered thresholds to methadone provision, Benzodiazepine (BZD) provision and Naloxone availability were key determinants of policy success. Further, this paper argues that the rapid collapse in policy barriers to these interventions that COVID-19 produced should be secured and protected while further research is conducted.

The provision of counseling to patients receiving medications for opioid use disorder: Telehealth innovations and challenges in the age of COVID-19.

Historically, federal and state policies have narrowly defined treatment models that have resulted in limited access to and engagement in counseling for individuals receiving medications for opioid use disorder (MOUD; e.g., methadone and buprenorphine). In response to the coronavirus pandemic, outpatient MOUD treatment providers rapidly transitioned from traditional, in-person care delivery models to revised COVID-19 protocols that prioritized telehealth counseling to protect the health of patients and staff and ensure continuity in MOUD care. These telehealth innovations appear to mitigate many of the longstanding barriers to counseling in the traditional system and have the potential to forever alter MOUD care delivery. Drawing on data from a Rhode Island-based clinic, we argue that MOUD counseling is achievable via telehealth and outline the need for, and anticipated benefits of, hybrid telehealth/in-person MOUD treatment models moving forward.

Increased flexibility in methadone take-home scheduling during the COVID-19 pandemic: Should this practice be incorporated into routine clinical care?

In the context of the COVID-19 pandemic and the state of emergency that the government of Spain declared, the rapid adaptation of health services is of paramount importance to preserve access to and continuity of service delivery. This research note underscores the importance of ensuring a sufficient quantity of methadone take-home doses for patients on methadone maintenance treatment (MMT) to maximize their adherence to government-imposed lockdown restrictions and social distancing measures designed to curtail the spread of SARS-CoV-2. We evaluate the impact of COVID-19 on take-home medication (number of days provided) in a methadone clinic in Barcelona (Catalonia, Spain). This work conveys that we should consider maintaining the take-home practices that we adopted in response to the pandemic, even after the pandemic has abated.

Revising our attitudes towards agonist medications and their diversion in a time of pandemic.

The COVID-19 pandemic led government regulators to relax prescribing rules for buprenorphine and methadone, the agonist medications that effectively treat opioid use disorder, allowing for take home supplies of up to 28 days. These changes prioritized the availability of these medications over concerns about their misuse and diversion, and they provided a means for overdose prophylaxis during the highly uncertain conditions of the pandemic. In considering how to capitalize on this shift, research should determine the extent to which increased diversion has occurred as a result, and what the consequences may have been. The shifts also set the stage to consider if methadone can be safely prescribed in primary care settings, and if the monthly injectable formulation of buprenorphine is a suitable alternative to increased supplies of sublingual strips if concerns about diversion persist. The disruptions of the pandemic have caused a surge in overdose deaths, so carefully considering the prophylactic potential of agonist medications, in addition to their role as a treatment, may help us address this mortality crisis.