“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

Abstract

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.

Nothing really changed: Arizona patient experience of methadone and buprenorphine access during COVID

“…To our knowledge, this study is among a very few to report direct patient experience with policy changes in MOUD access during COVID. A telehealth satisfaction survey was conducted in one Rhode Island provider setting [ 35 ], a survey study of North Carolina patients in three methadone clinics was reported [ 36 ], and a very small, non-peer reviewed study in one San Francisco methadone clinic with 10 providers and 20 patients reported views about methadone take-home dosing [ 37 ]. The North Carolina study found that take-home doses increased from pre-COVID periods to the time of the study (summer 2020) from 56–82% to 78–100%, though notably, the clinic-level percent of patients receiving a week or longer (>6 days) ranged from 11–56%.…”

Changes to methadone maintenance therapy in the United States, Canada, and Australia during the COVID-19 pandemic: A narrative review

“…Since this exemption has been in effect, the number of patients receiving increases in take-home methadone doses has varied between OTPs, however multiple analyses show that a large proportion of patients received an increase in take-home doses after the onset of the pandemic ( Amram, Amiri, Thorn, et al, 2021 ; Figgatt et al, 2021 ; Hoffman et al, 2022 ; Hunter et al, 2021 ; Joseph et al, 2021 ). Evidence from numerous studies has shown that increases in take-home methadone doses following the SAMHSA exemption have not been associated with higher overdose rates, worse treatment outcomes, increased health care utilization, lower adherence to treatment, increased use of illicit opioids or significant diversion of doses among patients on methadone maintenance therapy ( Amram et al, 2021a ; Brothers et al, 2021 ; Figgatt et al, 2021 ; Jones et al, 2022 ; Joseph et al, 2021 ; Knopf, 2020 ; Suen et al, 2021 ). One mixed-methods analysis of patients on MMT in five rural Oregon counties found that each percentage point increase in take-home dosing due to COVID-19 era policy changes was negatively associated with the percent of UDTs positive for opioids other than methadone, as well as the probability of treatment discontinuation ( Hoffman et al, 2022 ).…”

“…Even prior to COVID-19, some experts have questioned the utility of regular urinalysis and the lack of take-home dosing, and have posited that financial incentives rather than clinical utility are responsible for driving some of these practices ( Frank et al, 2021 ). Some emerging evidence suggests both clinicians and patients have positive views on these policy changes ( Goldsamt et al, 2021 ; Harris et al, 2021 ; Hunter et al, 2021 ; Madden et al, 2021 ; Suen et al, 2021 ; Treitler et al, 2021 ). A qualitative study of 25 OTP program directors found that most had a generally positive view of the regulatory changes necessitated by the COVID-19 pandemic ( Goldsamt et al, 2021 ).…”

“…Similarly, qualitative interviews conducted with 20 MOUD patients in Boston identified that one group of patients reported increased flexibility, freedom, and safety from COVID-19 post-treatment exemption, while another group felt destabilized by changes in addiction treatment, or found that it exacerbated existing iniquities in housing and access to social supports ( Harris et al, 2021 ). Finally, a qualitative study of both MOUD patients and providers found that both groups perceived benefits to expanding access to take-homes post-COVID-19 and experienced few adverse outcomes ( Suen et al, 2021 ).…”

“That Line Just Kept Moving”: Motivations and Experiences of People Who Use Methamphetamine

“…10,11 The reasons for seeking ED care when using methamphetamine varies with patients requiring anything from medical evaluation for chest pain to sedation and psychiatric evaluation for agitation and psychosis. 12 In some areas, behavioral crises related to methamphetamine use account for half of psychiatric emergency services visits. 13 Additionally, patients who inject drugs, such as methamphetamine, seek ED care for injection-related medical complications.…”