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1.
Rural Remote Health ; 21(4): 6770, 2021 11.
Article in English | MEDLINE | ID: covidwho-1513371

ABSTRACT

CONTEXT: The COVID-19 pandemic led to several changes to methadone treatment protocols at federal opioid treatment programs in the USA. ISSUE: Protocol changes were designed to reduce transmission of COVID-19 while allowing for continuity of care, but those changes also demonstrated that many policies surrounding opioid use disorder care in the USA cause unnecessary burdens to patients. In this commentary, we describe how current policies create and maintain fatal barriers to methadone treatment for people in rural communities who have opioid use disorder, and highlight how COVID-19 adaptations and more flexible methadone models in other countries can better allow for effective and accessible care. Reasons and ways to address these issues to create lasting solutions for rural communities are discussed. LESSONS LEARNED: We focus on three lessons: (1) methadone dispensing and take-home schedules during COVID-19, (2) telehealth services during COVID-19, and (3) international models in use prior to COVID-19. We then outline recommendations for each lesson to improve access to methadone treatment long term for rural communities in the USA. There is an urgent need to implement recommendations that maintain flexible approaches and address methadone treatment barriers in the rural USA. To achieve lasting health policy change and combat stigma about addiction and methadone treatment, there is a need for advocacy efforts that give voice to rural residents impacted by inequitable access to methadone treatment and rural-tailored educational initiatives that promote the evidence base for methadone. We hope opioid treatment program directors, regulatory authorities, and health policymakers consider our recommendations.


Subject(s)
COVID-19/psychology , Delivery of Health Care/organization & administration , Health Services Accessibility , Methadone/therapeutic use , Opiate Substitution Treatment/statistics & numerical data , Opioid-Related Disorders/rehabilitation , Rural Population , COVID-19/epidemiology , Humans , Opiate Substitution Treatment/methods , Opioid-Related Disorders/psychology , Pandemics , SARS-CoV-2 , United States
4.
J Addict Med ; 15(2): 93-95, 2021 04 01.
Article in English | MEDLINE | ID: covidwho-1284900

ABSTRACT

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.


Subject(s)
Analgesics, Opioid/therapeutic use , Health Policy , Methadone/therapeutic use , Opiate Substitution Treatment/methods , Opioid-Related Disorders/drug therapy , Pregnancy Complications/drug therapy , Analgesics, Opioid/administration & dosage , Analgesics, Opioid/adverse effects , Dose-Response Relationship, Drug , Female , Humans , Methadone/administration & dosage , Methadone/adverse effects , Pregnancy , United States
5.
BMJ ; 373: n784, 2021 05 19.
Article in English | MEDLINE | ID: covidwho-1238499

ABSTRACT

Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.


Subject(s)
Analgesics, Opioid/therapeutic use , Narcotic Antagonists/therapeutic use , Opiate Substitution Treatment/methods , Opioid-Related Disorders/drug therapy , Primary Health Care/methods , Behavior Therapy , Combined Modality Therapy , Counseling , Crisis Intervention , Global Health , Health Status Disparities , Humans , Opioid-Related Disorders/diagnosis , Opioid-Related Disorders/epidemiology , Opioid-Related Disorders/therapy , Psychiatric Rehabilitation/methods , Treatment Outcome , United States/epidemiology
6.
Curr Opin Psychiatry ; 34(4): 357-362, 2021 07 01.
Article in English | MEDLINE | ID: covidwho-1228583

ABSTRACT

PURPOSE OF REVIEW: Opioid use is prevalent in the United Kingdom and prior to the COVID-19 pandemic it had been recognized that the safety of opioids was an important issue to be monitored by the UK medicines regulatory agency. With the emergence of COVID-19, this requirement has been even greater. This review was undertaken to determine the impact of the pandemic on safety and surveillance of opioids in the United Kingdom. RECENT FINDINGS: During the COVID-19 pandemic, the surveillance of opioids in the United Kingdom continued, although primary research was often conducted with data prior to the pandemic. Of those studies that were conducted while the pandemic was ongoing, access to opioids (or opioid substitution therapy) and the subsequent effect on patient safety was the main theme. SUMMARY: In the United Kingdom, changes in accessibility to the healthcare system and how healthcare providers operated during the COVID-19 pandemic may have had unintended consequences on use and safety of opioids, due to the shift in focus to preventing COVID-19 from overwhelming the healthcare system. The findings from this review support the need to continue surveillance in the United Kingdom, including the impact of the COVID-19 pandemic on opioid utilization and safety.


Subject(s)
Analgesics, Opioid/administration & dosage , COVID-19/prevention & control , Drug Misuse/prevention & control , Opiate Substitution Treatment/methods , Opioid-Related Disorders/prevention & control , Analgesics, Opioid/adverse effects , Health Services Accessibility , Humans , Opioid-Related Disorders/therapy , Palliative Care/methods , Pandemics , SARS-CoV-2 , Terminal Care/methods , United Kingdom/epidemiology
7.
Curr Opin Psychiatry ; 34(4): 369-375, 2021 07 01.
Article in English | MEDLINE | ID: covidwho-1189538

ABSTRACT

PURPOSE OF REVIEW: The current article reviews the impact of the biggest health crisis for many decades, coronavirus disease 2019 (COVID-19), on opioid treatment programs and the strategies adopted for maintaining opioid treatment programs during the pandemic. RECENT FINDINGS: The difficulty of access to opioid treatment services and the mental health problems accompanying opioid use disorders are the two main challenges to maintaining accessible and effective opioid treatment. Many countries and institutions issued guidance and recommendations to address these challenges. General coping strategies, loosening of policies, telemedicine, and depot buprenorphine are four main strategies to cope with the challenges posed by the pandemic. SUMMARY: There were considerable obstacles to maintaining opioid intervention programs during the COVID-19 pandemic. Strategies addressing the obstacles are identified. Research in this area needs to be strengthened.


Subject(s)
COVID-19/prevention & control , Opiate Substitution Treatment/methods , Opioid-Related Disorders/prevention & control , Opioid-Related Disorders/therapy , Telemedicine/methods , Humans , Pandemics , SARS-CoV-2
8.
Subst Abus ; 42(2): 148-152, 2021.
Article in English | MEDLINE | ID: covidwho-1182932

ABSTRACT

The novel coronavirus has thrown large sections of our healthcare system into disarray, with providers overburdened by record breaking number of hospitalizations and deaths. The U.S., in particular, has remained the nation with one of the fastest growing case counts in the world. As a consequence, many other critical healthcare needs have not received the necessary resources or consideration. This commentary draws attention to substance use and opioid access during the ongoing crisis, given the potential for breakdowns in treatment access for addiction, the growing concern of mental health comorbidities, and the lack of access for those who require opioids for adequate pain management. Further, the commentary will offer policy and practice recommendations that may be implemented to provide more equitable distribution of care.


Subject(s)
Analgesics, Opioid/therapeutic use , COVID-19 , Health Services Accessibility , Opioid-Related Disorders/drug therapy , Practice Guidelines as Topic , Public Policy , Alcoholism , Buprenorphine/therapeutic use , Electronic Health Records , Harm Reduction , Humans , Internet of Things , Opiate Overdose/prevention & control , Opiate Substitution Treatment/methods , Opioid Epidemic , Pain Management , Palliative Care , Psychosocial Support Systems , SARS-CoV-2 , Telemedicine , United States , United States Substance Abuse and Mental Health Services Administration
9.
Subst Abus ; 42(2): 205-212, 2021.
Article in English | MEDLINE | ID: covidwho-1120629

ABSTRACT

BACKGROUND: COVID-19 has exacerbated income inequality, structural racism, and social isolation-issues that drive addiction and have previously manifested in the epidemic of opioid-associated overdose. The co-existence of these epidemics has necessitated care practice changes, including the use of telehealth-based encounters for the diagnosis and management of opioid use disorder (OUD). METHODS: We describe the development of the "Addiction Telehealth Program" (ATP), a telephone-based program to reduce treatment access barriers for people with substance use disorders staying at San Francisco's COVID-19 Isolation and Quarantine (I&Q) sites. Telehealth encounters were documented in the electronic medical record and an internal tracking system for the San Francisco Department of Public Health (SFDPH) COVID-19 Containment Response. Descriptive statistics were collected on a case series of patients initiated on buprenorphine at I&Q sites and indicators of feasibility were measured. RESULTS: Between April 10 and May 25, 2020, ATP consulted on the management of opioid, alcohol, GHB, marijuana, and stimulant use for 59 I&Q site guests. Twelve patients were identified with untreated OUD and newly prescribed buprenorphine. Of these, all were marginally housed, 67% were Black, and 58% had never previously been prescribed medications for OUD. Four self-directed early discharge from I&Q-1 prior to and 3 after initiating buprenorphine. Of the remaining 8 patients, 7 reported continuing to take buprenorphine at the time of I&Q discharge and 1 discontinued. No patients started on buprenorphine sustained significant adverse effects, required emergency care, or experienced overdose. CONCLUSIONS: ATP demonstrates the feasibility of telephone-based management of OUD among a highly marginalized patient population in San Francisco and supports the implementation of similar programs in areas of the U.S. where access to addiction treatment is limited. Legal changes permitting the prescribing of buprenorphine via telehealth without the requirement of an in-person visit should persist beyond the COVID-19 public health emergency.


Subject(s)
Alcoholism/therapy , COVID-19 , Homeless Persons , Marijuana Abuse/therapy , Opiate Substitution Treatment/methods , Opioid-Related Disorders/therapy , Quarantine , Telemedicine/methods , Adult , Analgesics, Opioid/therapeutic use , Buprenorphine/therapeutic use , Delivery of Health Care , Feasibility Studies , Female , Health Services Accessibility , Humans , Male , Methadone/therapeutic use , Middle Aged , Public Health , SARS-CoV-2 , San Francisco , Sodium Oxybate , Substance-Related Disorders/therapy , Telemedicine/organization & administration , Telephone
10.
Subst Abuse Treat Prev Policy ; 16(1): 22, 2021 03 05.
Article in English | MEDLINE | ID: covidwho-1119431

ABSTRACT

BACKGROUND: In North America the opioid poisoning crisis currently faces the unprecedented challenges brought by the COVID-19 pandemic, further straining people and communities already facing structural and individual vulnerabilities. People with opioid use disorder (OUD) are facing unique challenges in response to COVID-19, such as not being able to adopt best practices (e.g., physical distancing) if they're financially insecure or living in shelters (or homeless). They also have other medical conditions that make them more likely to be immunocompromised and at risk of developing COVID-19. In response to the COVID-19 public health emergency, national and provincial regulatory bodies introduced guidance and exemptions to mitigate the spread of the virus. Among them, clinical guidance for prescribers were issued to allow take home opioid medications for opioid agonist treatment (OAT). Take Home for injectable opioid agonist treatment (iOAT) is only considered within a restrictive regulatory structure, specific to the pandemic. Nevertheless, this risk mitigation guidance allowed carries, mostly daily dispensed, to a population that would not have access to it prior to the pandemic. In this case it is presented and discussed that if a carry was possible during the pandemic, then the carry could continue post COVID-19 to address a gap in our approach to individualize care for people with OUD receiving iOAT. CASE PRESENTATION: Here we present the first case of a patient in Canada with long-term OUD that received take home injectable diacetylmorphine to self-isolate in an approved site after being diagnosed with COVID-19 during a visit to the emergency room where he was diagnosed with cellulitis and admitted to receive antibiotics. CONCLUSION: In the present case we demonstrated that it is feasible to provide iOAT outside the community clinic with no apparent negative consequences. Improving upon and making permanent these recently introduced risk mitigating guidance during COVID-19, have the potential not just to protect during the pandemic, but also to address long-overdue barriers to access evidence-based care in addiction treatment.


Subject(s)
Analgesics, Opioid/therapeutic use , COVID-19/epidemiology , Heroin/therapeutic use , Opiate Substitution Treatment/methods , Opioid-Related Disorders/drug therapy , Administration, Intravenous , Administration, Oral , Analgesics, Opioid/administration & dosage , Heroin/administration & dosage , Humans , Male , Middle Aged , Pandemics , SARS-CoV-2
12.
J Subst Abuse Treat ; 120: 108149, 2021 01.
Article in English | MEDLINE | ID: covidwho-1023673

ABSTRACT

The Youth Opioid Recovery Support (YORS) intervention is a novel treatment for young adults with opioid use disorder (OUD) that uses developmentally informed strategies to reduce barriers to treatment engagement. YORS strategies, such as home delivery of extended-release buprenorphine and extended-release naltrexone for OUD, are designed to increase engagement in treatment, but with the COVID-19 pandemic these strategies increase risk of virus exposure and spread to patients and staff entering homes. We present mobile van service delivery as a potential solution to continuing to provide low-barrier care for young adults with OUD while reducing risk associated with COVID-19. Initial feedback from patients and staff is positive and lays the groundwork to test feasibility and acceptability of this intervention rigorously in future work. Mobile van delivery of extended-release medications for OUD may be a promising treatment modification for mitigating risk of COVID-19, as well as a useful option for ongoing enhancement of care.


Subject(s)
Buprenorphine/administration & dosage , COVID-19 , Mobile Health Units , Naltrexone/administration & dosage , Delayed-Action Preparations , Humans , Opiate Substitution Treatment/methods , Opioid-Related Disorders/drug therapy , Young Adult
14.
Harm Reduct J ; 17(1): 88, 2020 11 17.
Article in English | MEDLINE | ID: covidwho-925497

ABSTRACT

OBJECTIVES: The COVID-19 pandemic led to the closure of the IDEA syringe services program medical student-run free clinic in Miami, Florida. In an effort to continue to serve the community of people who inject drugs and practice compassionate and non-judgmental care, the students transitioned the clinic to a model of TeleMOUD (medications for opioid use disorder). We describe development and implementation of a medical student-run telemedicine clinic through an academic medical center-operated syringe services program. METHODS: Students advertised TeleMOUD services at the syringe service program on social media and created an online sign-up form. They coordinated appointments and interviewed patients by phone or videoconference where they assessed patients for opioid use disorder. Supervising attending physicians also interviewed patients and prescribed buprenorphine when appropriate. Students assisted patients in obtaining medication from the pharmacy and provided support and guidance during home buprenorphine induction. RESULTS: Over the first 9 weeks in operation, 31 appointments were requested, and 22 initial telehealth appointments were completed by a team of students and attending physicians. Fifteen appointments were for MOUD and 7 for other health issues. All patients seeking MOUD were prescribed buprenorphine and 12/15 successfully picked up medications from the pharmacy. The mean time between appointment request and prescription pick-up was 9.5 days. CONCLUSIONS: TeleMOUD is feasible and successful in providing people who inject drugs with low barrier access to life-saving MOUD during the COVID-19 pandemic. This model also provided medical students with experience treating addiction during a time when they were restricted from most clinical activities.


Subject(s)
COVID-19/prevention & control , Opiate Substitution Treatment/methods , Opioid-Related Disorders/drug therapy , Program Evaluation/methods , Students, Medical , Telemedicine/methods , Adult , Female , Florida , Humans , Male , Middle Aged , Pandemics
15.
Tex Med ; 116(10): 32-35, 2020 Oct 01.
Article in English | MEDLINE | ID: covidwho-892694

ABSTRACT

COVID-19 inflamed the crisis; telemedicine helps Texas physicians cope with the fallout.


Subject(s)
Coronavirus Infections , Opiate Substitution Treatment/methods , Opioid Epidemic , Opioid-Related Disorders/drug therapy , Pandemics , Pneumonia, Viral , Betacoronavirus , COVID-19 , Delivery of Health Care , Humans , SARS-CoV-2 , Telemedicine , Texas
16.
J Subst Abuse Treat ; 120: 108163, 2021 01.
Article in English | MEDLINE | ID: covidwho-844331

ABSTRACT

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.


Subject(s)
COVID-19 , Counseling/methods , Opioid-Related Disorders/drug therapy , Telemedicine/organization & administration , Buprenorphine/administration & dosage , Continuity of Patient Care/organization & administration , Delivery of Health Care/organization & administration , Humans , Methadone/administration & dosage , Opiate Substitution Treatment/methods , Rhode Island
17.
J Addict Med ; 14(6): e372-e374, 2020 12.
Article in English | MEDLINE | ID: covidwho-841712

ABSTRACT

OBJECTIVES: To measure the change in the daily number of patients receiving buprenorphine and buprenorphine prescribers during the early phase of the COVID-19 (SARS-CoV-2) pandemic in Texas. METHODS: Counts of the number of patients filling and number of providers prescribing buprenorphine were calculated for each weekday between November 4, 2019 and May 12, 2020. The change in daily patients and prescribers between March 2, 2020 and May 12, 2020, was modeled as a change in slope compared to the baseline period using autoregressive, interrupted time series regression. RESULTS: The rate of change of daily buprenorphine prescriptions (ß = -1.75, 95% CI = -5.8-2.34) and prescribers (ß = -0.32, 95% CI = -1.47-0.82) declined insignificantly during the COVID-19 period compared to the baseline. CONCLUSIONS: Despite a 57% decline in ambulatory care utilization in the south-central US during March and April of 2020, health services utilization related to buprenorphine in Texas remained robust. Protecting access to buprenorphine as the COVID-19 pandemic continues to unfold will require intensive efforts from clinicians and policy makers alike. While the presented results are promising, researchers must continue monitoring and exploring the clinical and humanistic impact of COVID-19 on the treatment of substance use disorders.


Subject(s)
Buprenorphine/therapeutic use , Coronavirus Infections/epidemiology , Health Policy , Narcotic Antagonists/therapeutic use , Pneumonia, Viral/epidemiology , COVID-19 , Drug Prescriptions/statistics & numerical data , Humans , Interrupted Time Series Analysis , Opiate Substitution Treatment/methods , Opiate Substitution Treatment/statistics & numerical data , Pandemics , Practice Patterns, Physicians'/statistics & numerical data , Texas
18.
J Addict Med ; 14(6): e290-e292, 2020 12.
Article in English | MEDLINE | ID: covidwho-835177

ABSTRACT

: Correctional settings can be vectors of infectious diseases due to overcrowding, unsanitary living conditions, and very little capacity to engage in social distancing. In the US, COVID-19 outbreaks were first identified in the New York City and Cook County jails, with infection rates far exceeding community rates. Each day new cases are being identified across the country in correctional facilities. People who are incarcerated are at increased risk of experiencing severe COVID-19 symptoms because of the increased prevalence of other underlying illnesses. Jails and prisons have begun initiating facility-level policies to help stop the spread of COVID-19. As a result, correctional agencies have reoriented staff to stem transmission in their facilities. This could translate into limited resources for other programming such as medications for opioid use disorder (MOUD) programs. In this commentary, we highlight risk mitigation practices for delivering MOUD in correctional settings during COVID-19 and note how to ensure quality of care while still preparing for the possibility of future pandemics.


Subject(s)
Coronavirus Infections/epidemiology , Opiate Substitution Treatment , Pneumonia, Viral/epidemiology , Prisons , COVID-19 , Coronavirus Infections/prevention & control , Humans , Infection Control/methods , Opiate Substitution Treatment/methods , Opioid-Related Disorders/drug therapy , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , Prisoners , Prisons/organization & administration , Telemedicine
19.
J Subst Abuse Treat ; 119: 108154, 2020 12.
Article in English | MEDLINE | ID: covidwho-813713

ABSTRACT

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.


Subject(s)
Coronavirus Infections , Methadone/administration & dosage , Opiate Substitution Treatment/methods , Opioid-Related Disorders/rehabilitation , Pandemics , Pneumonia, Viral , Ambulatory Care Facilities , COVID-19 , Health Services Accessibility , Humans , Methadone/supply & distribution , Spain
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