Unlocking Access: The Impact and Implications of Methadone Take-Home Policy Changes during the COVID-19 Pandemic

Posted on by BUJPH

By Alison Lu

 

More than 400,000 people with opioid use disorders (OUD) receive effective methadone treatment (MT). However, federal regulations of methadone take-home flexibilities have always been incredibly strict, requiring patients to engage in daily in-person MT for at least one or two years to receive up to 14 methadone take-home doses (MTHD) or 28 MTHD, respectively.1 This restriction proved to be a significant inconvenience and time barrier that prevented people who use drugs (PWUD) from being able to access and engage in MT for a long time. Research showed that before the COVID-19 pandemic, retention in MT was low, with national estimates placing the retention rate at less than 50% six months after treatment initiation.1 However, the COVID-19 pandemic led to policies that reduced virus transmission and promoted social distancing. This initiated a shift from in-person visits to virtual ones and decreased the restrictions on take-home flexibilities.1 On March 16, 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued guidelines that allowed states to request an exception to the previously stringent requirements regarding methadone take-home privileges, which 34 states did.3 This exception allowed “stable” patients in those states to receive up to 28 days of MTHD and “less stable” patients to receive up to 14 days of MTHD automatically.2 Instead of take-home eligibility being determined by federal guidelines of how long a patient had been in treatment, the opioid treatment program (OTP) was allowed to make stability determinations based on patients’ urine toxicology screening results and appointment adherence. This allowed many PWUD to receive more MTHD faster.1 The policy change also allowed PWUD to continue MT without risking exposure to COVID-19. Moreover, the policy had extra benefits for PWUD, increasing the effectiveness it had in maintaining MT engagement among PWUD during the height of the pandemic. However, this policy change is not permanent, as it has only been extended one year after the COVID-19 public health emergency officially ended, meaning that the policy change will expire by May 11, 2024, unless extended.3 SAMHSA has not announced whether they will make this policy change permanent, despite an extensive number of research studies demonstrating the effectiveness of this policy change. 

In addition to being successful at reducing COVID-19 transmission among patients, making MTHD more accessible had many positive benefits for the patients. Several extensive research studies have demonstrated the benefits that this policy change has brought for PWUD. A study conducted in Nashville, Tennessee aiming to describe PWUD’s experiences with the MTHD policy change found that 94.1% of the patients prefer having MTHD over daily in-person visits, and 91.2% cited that MTHD has had a positive effect on their quality of life.4 This was due to the alleviation of prior inconveniences that daily in-person visits had on patients’ abilities to hold a job, find childcare, or commute if the OTP was too far. As such, the methadone take-home flexibilities introduced by the policy change during COVID-19 have had a significant positive impact on reducing barriers to MT adherence and retention, allowing patients to engage with MT, reduce their use of illicit opioids, and maintain a good quality of life. These statistics demonstrate the significant preference that patients have for this policy change and the effectiveness it has on improving their quality of life because they no longer have to schedule their lives around treatment. It also allows PWUD to have the autonomy to choose when in the day to take their MTHD.4 Another study in Connecticut looking at the number of methadone-involved overdose fatalities from April to August 2020 after the policy change to the same period in the years 2015 to 2019 before the policy change found that there was no significant increase in methadone-involved overdose fatalities or severity in methadone poisoning exposure.5 This demonstrates that increased take-home doses do not lead to increased methadone-involved doses and suggests that patients can be responsible with their daily MTHD even though they are at home and not under the supervision of OTP staff. Even some OTP directors were pleasantly surprised by the level of responsibility that patients showed regarding their methadone take-homes with a study reporting that 64% of staff members expressed a positive view towards methadone take-home flexibilities.6 Interviews with OTP directors reported that the majority of patients were doing very well with their MTHD with one respondent saying “Patients we never would have put on once a month…have done really well with this.”6 Similar sentiments were expressed by other OTP staff members around the US interviewed, who emphasized the effectiveness that this policy change has had in allowing patients to receive more MTHD earlier than the previous SAMHSA federal regulations would have allowed. 

Moreover, one of the main reasons for the strict MTHD policies before COVID-19 was the fear of PWUD diverting their methadone and methadone-related overdoses. However, several studies have been conducted since show that in the time that the MTHD policy has been changed, there has been minimal diversion of methadone and no increases in methadone-related overdoses.7 For example, one study focusing on OTP in North Carolina found that only 7% of participants reported diverting their methadone doses.8 The small percentage of PWUD who are diverting their methadone is relatively insignificant, challenging the notion that PWUD cannot be trusted with their MTHD. The percentage of PWUD diverting their methadone is minimal and has not significantly changed since before the methadone-take-home policy change. Another study looking at the change in methadone-involved overdose deaths before and after COVID-19 found that they remained stable with the percentage of methadone-involved overdose deaths actually declining from 4.5% in January 2019 to 3.2% in August 2021.9 This underscores the positive impact that the methadone take-home policy change had on PWUD and refutes the notion that increased deaths involving methadone would occur because of the policy change. The exact opposite happened with methadone-involved deaths decreasing, suggesting that this policy is beneficial in many different factors beyond improved quality of life for PWUD, and should be permanent. 

Despite the extensive research conducted focusing on the benefits that the methadone take-home policy change has had on PWUD’s lives in terms of their MT, there is a significant lack of research regarding the quality of telehealth during the pandemic and potential interventions to reduce barriers that PWUD experienced when accessing telehealth services. OTPs not only provide patients with MTHD but also psychosocial counseling that is crucial to helping PWUD recover. SAMHSA’s policy change expanded both MTHD flexibility and telehealth services to continue counseling for PWUD, though research primarily focused on MTHD.3 Though there have been studies demonstrating the many barriers to telehealth implementation on the patient side (e.g., lack of internet access, data, or even a smartphone) and on the OTP side (e.g.,s lack of infrastructure and issues with HIPAA compliance on some telehealth platforms), few studies have been conducted to find innovative solutions to these barriers to improve the access to and quality of telehealth counseling.10 Studies aiming to understand the utilization of OTP telehealth counseling among PWUD during the pandemic have identified the lack of research on possible solutions to address these barriers as a limitation and researchers have called for further research on implementing telehealth services after the methadone take-home policy change.10 This lack of research regarding potential solutions to the barriers underscores the importance of continuing research to understand the effectiveness of the methadone take-home policy change beyond the MTHD benefits and address the already established barriers to telehealth implementation to ensure that PWUD has access to quality telehealth counseling services.

The benefits of this policy change allowing for methadone take-home flexibilities has had significant positive impacts on PWUD in general but it has had an exceptionally positive impact on PWUD who live in rural or remote areas. Even before the pandemic hit, extensive research indicated that geographical distance to OTPs negatively impacted PWUD’s ability to engage in MT. One study found that only 4% of OTPs are located in rural areas.11 Another research study from before the COVID-19 pandemic found that in the US, there are significant disparities in drive times when comparing rural and urban census tracts.12 The study found that the median drive time to OTPs increased from 16.1 minutes in urban census tracts to 48.4 minutes in rural census tracts, decreasing MT engagement and retention among rural PWUD.12 This underscores the significant barriers that PWUD living in rural areas experienced before this policy change, disproportionately affecting rural PWUD in their recovery. Various studies focusing on the impact that the methadone take-home policy change during the pandemic has had on rural PWUD found many positive effects in different aspects of PWUD’s lives.13,14 A qualitative thematic analysis found that PWUD in rural areas significantly appreciated having increased take-homes after the policy change because they were able to spend less time in the OTPs with potentially unstable patients. They also did not have to go through confusing processes to get extra take-homes and were instead able to spend more time at home with their family and friends, which helped in their recovery.13 Other patients also noted that after the methadone take-home policy change was enacted, they no longer had to spend  time and money traveling to the OTPs daily when those resouces could be better spent with family or doing daily house tasks. They described long commutes and increased gas prices as significant barriers to engaging in MT prior the policy change.13 Another qualitative study found that PWUD appreciated the increased sense of responsibility, normalcy, and dignity they were given to take care of their own doses.14 These themes highlight the many benefits that the methadone take-home policy change has had on the lives of rural PWUD, who already experience significant barriers to MT engagement with the disproportionately low percentage of OTPs in rural areas. The research also illuminates the numerous benefits that this policy change has had on rural PWUD in helping them improve their quality of life, increasing their satisfaction with and likelihood of continuing MT treatment. 

As the scientific literature has shown, the policy change allowing PWUD to have increased methadone take-home flexibilities has had significant positive effects on PWUD, particularly  among rural PWUD. As rural PWUD face more barriers to engaging with MT due to the lack of OTPs in rural areas, the policy change had a greater positive impact on this population by decreasing the need to commute daily and allowing PWUD to have more time to spend with their friends and family. Despite the extensive number of research studies describing the effectiveness of this policy, the positive impact it has had on improving the quality of life among PWUD and little to no negative effects on PWUD as demonstrated by the low percentage of diversion and decrease in methadone-involved overdose deaths, SAMHSA has not yet decided whether or not it will make this policy change permanent. SAMHSA must consider the substantial benefits this policy change has had since its implementation in improving different aspects of PWUD lives, increasing MT engagement, retention, and satisfaction among PWUD. Another factor to consider is the significant lack of literature focusing on telehealth counseling services that were offered as a part of their MT, especially because research identified many barriers to telehealth implementation, and very few studies looked at interventions to combat these barriers. Future research needs to be conducted to understand how telehealth, a crucial part of MT, can be better implemented to help guide PWUD in their recovery and improve provider-patient relationships.

 

References

  1. Abidogun TM, Cole TO, Massey E, et al. Patient experiences of COVID-19-induced changes to methadone treatment in a large community-based opioid treatment program in Baltimore. J Subst Use Addict Treat. 2023;145:208946. doi:10.1016/j.josat.2022.208946
  2. Amram O, Amiri S, Panwala V, Lutz R, Joudrey PJ, Socias E. The impact of relaxation of methadone take-home protocols on treatment outcomes in the COVID-19 era. Am J Drug Alcohol Abuse. 2021;47(6):722-729. doi:10.1080/00952990.2021.1979991
  3. Substance Abuse and Mental Health Services Administration (SAMHSA) Opioid Treatment Program (OTP) guidance. 2020. https://www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf 
  4. Adams Z, El-Sabawi T, Coe WH, Batchelor H, Wyatt J, Gandhi M, Santana I, Jordan A. Changes in the Provision of Take-Home Methadone for People with Opioid Use Disorder During the COVID-19 Pandemic: Implications for Future Policymaking. Florida International University Legal Studies Research Paper No. 22-17, in COVID-19 and the Law: Disruption, Impact, and Legacy, (I. Glenn Cohen, Abbe R. Gluck, Katherine L. Kraschel, Carmel Shachar, eds., Cambridge University Press. 2022. Available at SSRN: https://ssrn.com/abstract=4276877
  5. Brothers S, Viera A, Heimer R. Changes in methadone program practices and fatal methadone overdose rates in Connecticut during COVID-19. J Subst Abuse Treat. 2021;131:108449. doi:10.1016/j.jsat.2021.108449 
  6. Goldsamt LA, Rosenblum A, Appel P, Paris P, Nazia N. The impact of COVID-19 on opioid treatment programs in the United States. Drug Alcohol Depend. 2021;228:109049. doi:10.1016/j.drugalcdep.2021.109049
  7. Welsh, C., Doyon, S., & Hart, K. (2022). Methadone exposures reported to poison control centers in the United States following the COVID-19-related loosening of federal methadone regulations. The International journal on drug policy, 102, 103591. https://doi.org/10.1016/j.drugpo.2022.103591
  8. Welsh C, Doyon S, Hart K. Methadone exposures reported to poison control centers in the United States following the COVID-19-related loosening of federal methadone regulations. Int J Drug Policy. 2022;102:103591. doi:10.1016/j.drugpo.2022.103591
  9. Jones CM, Compton WM, Han B, Baldwin G, Volkow ND. Methadone-Involved Overdose Deaths in the US Before and After Federal Policy Changes Expanding Take-Home Methadone Doses From Opioid Treatment Programs. JAMA Psychiatry. 2022;79(9):932-934. doi:10.1001/jamapsychiatry.2022.1776
  10. Hunter SB, Dopp AR, Ober AJ, Uscher-Pines L. Clinician perspectives on methadone service delivery and the use of telemedicine during the COVID-19 pandemic: A qualitative study. J Subst Abuse Treat. 2021;124:108288. doi:10.1016/j.jsat.2021.108288
  11. Lister JJ, Lister HH. Improving methadone access for rural communities in the USA: lessons learned from COVID-19 adaptations and international models of care. Rural Remote Health. 2021;21(4):6770. doi:10.22605/RRH6770
  12. Joudrey PJ, Chadi N, Roy P, et al. Pharmacy-based methadone dispensing and drive time to methadone treatment in five states within the United States: A cross-sectional study. Drug Alcohol Depend. Published online March 27, 2020. doi:10.1016/j.drugalcdep.2020.107968
  13. Levander XA, Hoffman KA, McIlveen JW, McCarty D, Terashima, JP, Korthuis, PT. Rural opioid treatment program patient perspectives on take-home methadone policy changes during COVID-19: a qualitative thematic analysis. Addiction science & clinical practice, 2021;16(1), 72. https://doi.org/10.1186/s13722-021-00281-3
  14. Hoffman KA, Foot C, Levander XA, et al. Treatment retention, return to use, and recovery support following COVID-19 relaxation of methadone take-home dosing in two rural opioid treatment programs: A mixed methods analysis. J Subst Abuse Treat. 2022;141:108801. doi:10.1016/j.jsat.2022.108801
Alison Lu