COVID-19-related policy changes for methadone take-home dosing: A multistate survey of opioid treatment program leadership

Abstract

Background: In the United States, methadone for treatment of opioid use disorder is dispensed via highly-regulated accredited opioid treatment programs (OTP). During the COVID-19 pandemic, federal regulations were loosened, allowing for greater use of take-home methadone doses. We sought to understand how OTP leaders responded to these policy changes. Methods: We distributed a multistate electronic survey from September to November 2020 of OTP leadership to members of the American Association for the Treatment of Opioid Dependence (AATOD) who self-identified as leaders of OTPs. We asked study participants about how their OTP(s) implemented COVID-19-related policy changes into their clinical practice focusing on provision of take-home methadone doses, factors used to determine patient stability, and potential concerns about increased take-home doses. We used Chi-square test to compare survey responses between characterizations of the OTPs. Results: Of 170 survey respondents (17% response rate), the majority represented leadership of for-profit OTPs (69%) and were in a Southern state (54%). Routine allowances and practices related to take-home methadone doses varied across OTPs during the COVID-19 pandemic: 80 (47%) reported 14 days for newly enrolled patients (within past 90 days), 89 (52%) reported 14 days for "less stable" patients, and 112 (66%) reported 28 days for "stable" patients. Conclusions: We found that not all eligible OTP leaders adopted the practice of routinely allowing newly enrolled, "less stable," and "stable" patients on methadone to have increased take-home doses up to the limit allowed by federal regulations during COVID-19. The pandemic provides an opportunity to critically re-evaluate long-established methadone and OTP regulations in preparation for future emergencies.

Keywords: COVID-19; Methadone; opioid treatment programs; opioid-related disorders; survey.

Figure 1.

Flow diagram of study participants. *American Association for the Treatment of Opioid Dependence (AATOD) is comprised of 29 regional chapters with each chapter made up of opioid treatment program (OTP) members. OTP members potentially have multiple individuals in leadership positions who were included in the sampling frame. AATOD leadership estimated 1015 potential participants. The percentages are calculated using the number of potential participants as the denominator.

Figure 2.

Participants’ top-3 patient factors to consider in determining patient stability. Participants were shown a list of factors (verbatim text is below) and asked to pick the top-3 they believed were most important when determining patient stability. The percentages represent how often each factor was chosen in the top-3 most important factors by participants (n = 170). ¹“Patient report or drug testing suggesting ongoing illicit opioid use.” ²“Patient report or drug testing suggesting ongoing benzodiazepine or sedative use.” ³“Concern for patient possibly diverting take-home methadone.” ⁴“Confidence that patient will take methadone take-home medication daily as directed.” ⁵“Length of time on current treatment episode (time enrolled at your OTP).” ⁶“Presence of other chronic medical conditions (i.e heart or lung disease) that make the patient at higher risk of morbidity/mortality from COVID-19.” ⁷“Counselor’s assessment of stability.” ⁸“Patient report or drug testing suggesting ongoing alcohol use.” ⁹“Housing assessment (i.e. stable housing, safe storage, or other substance use in household).” ¹⁰“Length of time on current methadone dose.” ¹¹“Prior Group and/or clinic attendance.” ¹²“Presence of inadequately controlled/treated co-occurring psychiatric disorders.” ¹³“How high the patient’s dose of methadone is (total mg per day).” ¹⁴“Patient report or drug testing suggesting ongoing stimulant use (i.e cocaine or methamphetamine use).” ¹⁵“Patient must use public transportation to travel.” ¹⁶ “A trusted third party (or proxy) to manage doses.” ¹⁷“Patient report or drug testing suggesting ongoing cannabis/marijuana use.”

Figure 3.

Level of concern of increased take-home doses. Participants were shown a list of potential outcomes (verbatim text below) and reported on a 5-point Likert scale their level of concern. Left column percentages represent the cumulative percentage reporting “No Concern” or “Slight concern.” Right column percentages represent the cumulative percentage reporting “Moderate Concern”, “Concerned” or “Very Concerned.” ¹“Inability to identify when patient’s relapse/return to drug use” ²“Potential legal liabilities for diversion of, or overdose from, extra take-home doses of methadone” ³“Decreased patient engagement in counseling” ⁴“Difficulty around reinstating policies after the health emergency is over (i.e. taking back take-homes or reinforcing previous policies).” ⁵“Financial impact from decreased billable services.” ⁶“Potential for increased scrutiny from SOTA/DEA.”