Individualizing methadone treatment with split dosing: An underutilized tool.

Methadone's long half-life typically allows for once daily dosing. However, a growing body of evidence and clinical experience shows that some patients may benefit from twice-daily ("split") dosing to produce more stable symptoms and minimize side effects, independent of serum peak-to-trough levels. Concerns regarding split dosing typically center on diversion and poor adherence and must be taken seriously. However, policy changes during COVID-19 demonstrate that the rigidity historically applied to methadone may be unnecessarily stringent. Given clinical advances and policy updates, we believe clinicians should weigh the risks and benefits of this underutilized tool for select patients, as we await the evidence-based recommendations our patients deserve.

COVID-19 and treating incarcerated populations for opioid use disorder.

The Franklin County Sheriff's Office (FCSO), in Greenfield, Massachusetts, is among the first jails nationwide to provide correctional populations with access to all three medications to treat opioid use disorder (MOUD, i.e., buprenorphine, methadone, naltrexone). In response to the COVID-19 pandemic, FCSO quickly implemented comprehensive mitigation policies and adapted MOUD programming. Two major challenges for implementation of the MOUD program were the mandated rapid release of nonviolent pretrial individuals, many of whom were being treated with MOUD and released too quickly to conduct continuity of care planning; and establishing how to deliver physically distanced MOUD services in jail. FCSO implemented and adapted a hub-and-spoke MOUD model, developed telehealth capacity, and experimented with take-home MOUD at release to facilitate continuity-of-care as individuals re-entered the community. Experiences underscore how COVID-19 accelerated the uptake and diffusion of technology-infused OUD treatment and other innovations in criminal justice settings. Looking forward, to address both opioid use disorder and COVID-19, jails and prisons need to develop capacity to implement mitigation strategies, including universal and rapid COVID-19 testing of staff and incarcerated individuals, and be resourced to provide evidence-based addiction treatment. FCSO quickly pivoted and adapted MOUD programming because of its history of applying public health approaches to address the opioid epidemic. Utilizing public health strategies can enable prisons and jails to mitigate the harms of the co-occurring epidemics of OUD and COVID-19, both of which disproportionately affect criminal justice populations, for persons who are incarcerated and the communities to which they return.