Reimagining patient-centered care in opioid treatment programs: Lessons from the Bronx during COVID-19

Joseph, Giliane; Torres-Lockhart, Kristine; Stein, Marjorie W.; Mund, Pamela A.; Nahvi, Shadi

doi:10.1016/j.jsat.2020.108219

Cited by 51 publications

(72 citation statements)

References 3 publications

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“…Open-access model adoption does not require removal of regulatory restrictions and US and Canadian agencies should consider implementation interventions and reimbursement changes to expand adoption. 38 Delays in access due to insufficient clinic capacity may be more likely within the US relative to Canada, 36 which has allowed methadone provision within a greater variety of clinical settings and has reduced regulatory restrictions in response to the overdose epidemic. 15 The greater complexity of the US multiple payer system may also delay access relative to Canada, and the cost of a first appointment may create an additional barrier within the US.…”

Section: Discussionmentioning

confidence: 99%

Methadone Access for Opioid Use Disorder During the COVID-19 Pandemic Within the United States and Canada

et al. 2021

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IMPORTANCE Methadone access may be uniquely vulnerable to disruption during COVID-19, and even short delays in access are associated with decreased medication initiation and increased illicit opioid use and overdose death. Relative to Canada, US methadone provision is more restricted and limited to specialized opioid treatment programs. OBJECTIVE To compare timely access to methadone initiation in the US and Canada during COVID-19. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was conducted from May to June 2020. Participating clinics provided methadone for opioid use disorder in 14 US states and territories and 3 Canadian provinces with the highest opioid overdose death rates. Statistical analysis was performed from July 2020 to January 2021. EXPOSURES Nation and type of health insurance (US Medicaid and US self-pay vs Canadian provincial). MAIN OUTCOMES AND MEASURES Proportion of clinics accepting new patients and days to first appointment. RESULTS Among 268 of 298 US clinics contacted as a patient with Medicaid (90%), 271 of 301 US clinics contacted as a self-pay patient (90%), and 237 of 288 Canadian clinics contacted as a patient with provincial insurance (82%), new patients were accepted for methadone at 231 clinics (86%) during US Medicaid contacts, 230 clinics (85%) during US self-pay contacts, and at 210 clinics (89%)during Canadian contacts. Among clinics not accepting new patients, at least 44% of 27 clinics reported that the COVID-19 pandemic was the reason. The mean wait for first appointment was greater among US Medicaid contacts (3.5 days [95% CI, 2.9-4.2 days]) and US self-pay contacts (4.1 days [95% CI, 3.4-4.8 days]) than Canadian contacts (1.9 days [95% CI, 1.7-2.1 days]) (P < .001).Open-access model (walk-in hours for new patients without an appointment) utilization was reported by 57 Medicaid (30%), 57 self-pay (30%), and 115 Canadian (59%) contacts offering an appointment. CONCLUSIONS AND RELEVANCEIn this cross-sectional study of 2 nations, more than 1 in 10 methadone clinics were not accepting new patients. Canadian clinics offered more timely methadone access than US opioid treatment programs. These results suggest that the methadone access shortage was exacerbated by COVID-19 and that changes to the US opioid treatment program model are needed to improve the timeliness of access. Increased open-access model adoption may increase timely access.

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Section: Discussionmentioning

confidence: 99%

Methadone Access for Opioid Use Disorder During the COVID-19 Pandemic Within the United States and Canada

et al. 2021

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“…23 Meanwhile, in "hot spot" cities hit hardest by COVID-19 such as Seattle and the Bronx in New York City, OTPs described rapidly expanding take-homes to the majority of patients to reduce COVID-19 spread. 24,25 Despite differences in approaches, the experiences of providers in our study mirror those described by providers in the Bronx, where clinicians sought to balance access to MOUD, risk of COVID-19 exposure, and risk of MOUD misuse and overdose, and used a team-based approach to balance safety and treatment equity. 24 Our findings of increased benefits from take-home expansion without many apparent adverse events align with early reports from domestic and international methadone programs, [26][27][28] and how flexibility in take-home exemptions allowed individual OTPs to decide which approaches best suited the needs of their patients, staff, and local environments.…”

Section: Discussionmentioning

confidence: 87%

“…Generalizability of these findings is unclear as we collected data only from a single clinic, though reports from other OTPs across the country describe similar findings. [23][24][25][26] We also conducted interviews during a period of frequent changes in clinic policy, and the impact of changes in take-home prescribing may not have yet reached steady state at the time of interviews. Despite these limitations, our study is one of the first to qualitatively describe the impact of expanded take-home prescribing practices on MOUD treatment with considerations for future research and policy.…”

Section: Discussionmentioning

confidence: 99%

“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

Suen

Castellanos

Joshi

et al. 2021

Preprint

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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 and 20 patients receiving MOUD. We transcribed, coded, and analyzed all interviews to identify emergent themes. Results 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.

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“…Although the COVID-19 pandemic has prompted innovations in the care and treatment of persons who use substances [ 31 ], continued surveillance is urgently needed to examine trends in substance use patterns during the pandemic. Published research in the past year discussed the rising prevalence of substance use around the world [ 3 ▪ , 4 ▪ , 6 ▪ , 7 ▪▪ , 8 ▪ ] and suggested that individuals who use substances may be at an increased risk for COVID-19 [ 32 ▪ , 33 ▪▪ ].…”

Section: Discussionmentioning

confidence: 99%

“…Other COVID-related adaptions may include offering virtual appointments, modifying outreach efforts, and lengthening prescription durations [ 28 ▪ ]. Reducing or eliminating toxicology screenings were also discussed [ 28 ▪ , 31 ].…”

Section: Barriers and Modifications To Health Servicesmentioning

confidence: 99%

Converging public health crises: substance use during the coronavirus disease 2019 pandemic

Striley

Hoeflich

2021

Current Opinion in Psychiatry

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Purpose of review The international, public health crisis caused by the rapid spread of SARS-CoV-2 has resulted in unforeseen medical and psychiatric consequences. We reviewed publications from January 2020 to January 2021, given that earlier documents were not relevant, to review findings on changes in substance use and overdoses during the pandemic. Additionally, this review of the literature also documents advocacy efforts, health service modification and challenges, as well as COVID-related health complications associated with substance use. Recent findings Recent work focused on identifying changes in the distribution and use of substances as well as the unique challenges to promoting the health of persons who use substances in the current pandemic. Although COVID-19 has triggered unprecedented innovations in the organizational and public policy, the use of certain substances (alcohol, cannabis, cigarettes, fentanyl, heroin, and opiates) is increasing internationally. Unique associations between substance use and pandemic-related adverse health outcomes were identified. In addition, the pandemic precipitated significant barriers and disruptions to care. Summary Given increased overdose rates and infections among people who use drugs, continued surveillance and vigilance are needed to assess changes and reduce use and adverse consequences during the continuing COVID-19 crisis. Changes are urgently needed to reduce adverse health outcomes because of treatment barriers and lack of adequate treatment options. Additionally, integrative approaches are necessary to promote the public health of persons who use substances.

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Reimagining patient-centered care in opioid treatment programs: Lessons from the Bronx during COVID-19

Cited by 51 publications

References 3 publications

Methadone Access for Opioid Use Disorder During the COVID-19 Pandemic Within the United States and Canada

Methadone Access for Opioid Use Disorder During the COVID-19 Pandemic Within the United States and Canada

“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

Converging public health crises: substance use during the coronavirus disease 2019 pandemic

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