Acceptability, feasibility, and outcomes of a clinical pilot program for video observation of methadone take-home dosing during the COVID-19 pandemic

Barriers to accessing medications for opioid use disorder among rural individuals

BACKGROUND

Individuals with opioid use disorder living in rural areas face barriers to accessing medications for treatment (MOUD), including finding prescribing clinicians and difficulties with transportation. This study sought to describe self-reported barriers to MOUD access in rural areas and associations between desired MOUD type and barriers encountered or perceived.

METHODS

We performed a cross-sectional study of Rural Opioid Initiative participants who ever used opioids and sought MOUD treatment, who were surveyed from 2018 to 2020 about access to MOUD. Multivariable logistic regressions explored the association between MOUD type and barriers while controlling for age, gender, race, and study site.

RESULTS

Of 2906 participants who used opioids and sought MOUD, 826 (28.4 %) were unable to access MOUD. In logistic regression models, lack of transportation was a more common barrier for those seeking methadone versus sublingual buprenorphine (adjusted odds radio [aOR] 1.87, 95 % confidence interval (CI) 1.24-2.81). A long wait list was more common for those seeking injectable naltrexone than sublingual buprenorphine (aOR 1.68, 95 % CI 1.05-2.69). Lack of doctors or programs and affordability were more common for those seeking injectable versus sublingual buprenorphine (aOR 7.84, 95 % CI 4.87-12.63 and aOR 1.89, 95 % CI 1.26-2.83, respectively).

CONCLUSIONS

Access barriers vary by MOUD type for rural individuals with OUD. Compared to sublingual buprenorphine, methadone access was hindered more by transportation difficulties, while injectable long-acting buprenorphine was hindered more by affordability and finding a doctor or program. These barriers highlight the need to de-regulate and expand locations for methadone access and prescribing, and to improve affordability and prescriber uptake of newer MOUDs, such as injectable buprenorphine.

Retention and dropout from sublingual and extended-release buprenorphine treatment: A comparative analysis of data from a nationally representative sample of commercially-insured people with opioid use disorder in the United States

BACKGROUND AND AIMS

Maintenance on medications for opioid use disorder, particularly buprenorphine, is critical for reducing overdose risk and improving health outcomes in the United States. This study evaluates retention and dropout probabilities between sublingual buprenorphine (SL-BUP) and extended-release buprenorphine (XR-BUP) among commercially-insured individuals with opioid use disorder (OUD).

DESIGN AND SETTING

A retrospective cohort study using Meretive™ Markeskan® claims data from 2019 to 2020. A multi-state Markov model assessed transitions between treatment states over 12 months.

PARTICIPANTS

The study included 58,933 individuals aged 18-64 years with OUD, initiating SL-BUP (n = 57,520) or XR-BUP (n = 1,413). XR-BUP patients were divided into XR-BUP only (n = 684; 49 %) and XR-BUP with supplemental SL-BUP (XR-BUP+sSL; n = 729; 51 %).

MEASUREMENTS

Primary outcomes included probabilities of remaining in treatment or transitioning between states at 1, 3, 6, and 12 months. The impact of dosage and days of supply on retention was also examined.

RESULTS

The probability of permanent treatment dropout at 6 months was similar for SL-BUP (38.59 %, 95 % CI: 37.9 %-39.4 %) and XR-BUP (41.3 % 95 %CI: 36.8 %-46.1 %), yet the probability of remaining in treatment was significantly higher for SL-BUP than XR-BUP (49.5 %; 95 %CI: 48.8 %-50.1 % vs. 13.5 % 95 % CI: 10.5 %-16.5 %). The high proportion of individuals initially prescribed XR-BUP later transitioned to SL-BUP. Higher doses and longer days supplied of SL-BUP reduced dropout rates. Among patients receiving ≥16 mg/day and ≥28 days, dropout probabilities were 5.7 % (95 % CI: 5.4 %-6.0 %) at 1 month, 15.4 % (95 % CI: 14.8 %-16.2 %) at 3 months, 28.0 % (95 % CI: 26.9 %-29.2 %) at 6 months, and 47.8 % (95 %CI: 45.2 %-49.5 %) at 12 months. In contrast, patients prescribed <16 mg/day and <28 days had a 46.3 % (95 %CI: 45.0 %-47.6 %) dropout rate by 6 months.

CONCLUSION

SL-BUP demonstrates higher retention rates and lower dropout compared to XR-BUP in real-world settings. Optimizing SL-BUP dosing and providing extended supplies can improve retention and reduce treatment discontinuation.

mHealth Incentivized Adherence Plus Patient Navigation (MIAPP): protocol for a pilot randomized controlled trial to improve linkage and retention on buprenorphine for hospitalized patients with methamphetamine use and opioid use disorder

BACKGROUND

Initiation of buprenorphine for treatment of opioid use disorder (OUD) in acute care settings improves access and outcomes, however patients who use methamphetamine are less likely to link to ongoing treatment. We describe the intervention and design from a pilot randomized controlled trial of an intervention to increase linkage to and retention in outpatient buprenorphine services for patients with OUD and methamphetamine use who initiate buprenorphine in the hospital.

METHODS

The study is a two-arm pilot randomized controlled trial (N = 40) comparing the mHealth Incentivized Adherence Plus Patient Navigation (MIAPP) intervention to treatment as usual. Development of the MIAPP intervention was guided by the information-motivation-behavioral skills model and combines financial rewards via mobile health-based adherence monitoring with the "human touch" of a patient navigator. Participants receive financial incentives for submitting videos of themselves taking buprenorphine via smartphone. The Patient Navigator reviews videos and provides treatment adherence coaching, care coordination and motivational enhancement. The intervention is introduced prior to hospital discharge and is offered for 30 days. The primary outcome is linkage to outpatient buprenorphine care within 30 days of hospital discharge. Secondary outcomes include retention on buprenorphine 90 days post discharge, hospital readmissions, and past 30-day methamphetamine use.

DISCUSSION

Interventions are needed to increase linkage and retention to outpatient buprenorphine among hospitalized patients with OUD, especially for people who co-use methamphetamine. We will examine the MIAPP intervention to improve buprenorphine adherence and linkage to outpatient treatment in a pilot randomized controlled trial which will provide valuable insights about research approaches for hospitalized patients with substance use disorder.

TRIAL REGISTRATION NUMBER

NCT06027814. Date of Initial Release: 08/30/2023.

PROTOCOL VERSION

03/21/2024.

Disruption of Opioid Treatment Program Services Due to an Extreme Weather Event: An Example of Climate Change Effects on the Health of Persons Who Use Drugs

ABSTRACT

Climate change and the opioid epidemic in combination may pose significant challenges for individuals with opioid use disorder due to potential disruptions in access to essential addiction treatment services caused by extreme weather events. Despite concerns over the escalating health impacts of climate change, limited research has documented and explored the vulnerability of patients enrolled in opioid treatment programs to disruptions caused by climate change and particularly extreme cold events. In this commentary, we describe the impact of a catastrophic flooding event during record-setting cold temperatures at an opioid treatment program in Seattle, WA. By examining this event, we highlight the potential vulnerabilities the methadone treatment infrastructure faces regarding climate change and future extreme weather events. In doing so, we hope to draw attention to a critical need for research that describes, plans for, and addresses disruptions to opioid use disorder treatment resulting from climate change-related weather events.

Study protocol for ADHERE (Applying Directly observed therapy to HydroxyurEa to Realize Effectiveness): Using small business partnerships to deliver a scalable and novel hydroxyurea adherence solution to youth with sickle cell disease

Sickle cell disease (SCD) is an inherited blood disorder that affects approximately 100,000 Americans, primarily from underrepresented racial minority populations, and results in costly, multi-organ complications. Hydroxyurea, the primary disease-modifying therapy for SCD, is effective at reducing most complications; however, adherence to hydroxyurea remains suboptimal and is the primary barrier to clinical effectiveness. Video directly observed therapy (VDOT) has shown promise as an adherence-promoting intervention for hydroxyurea, yet previous VDOT trials were limited by high attrition from gaps in technology access, use of unvalidated adherence measures, and healthcare system limitations of delivering VDOT to patients. As such, we fostered a small business partnership to compare VDOT for hydroxyurea to attention control to address previous shortcomings, promote equitable trial participation, and maximize scalability. VDOT will be administered by Scene Health (formerly emocha Health) and adherence monitoring will be performed using a novel electronic adherence monitor developed to meet the unique needs of the target population. Adolescent and young adult patients as well as caregivers of younger patients (<11 years of age) will be recruited. In addition to visit incentives, all participants will be offered a smartphone with a data plan to ensure all participants have equal opportunity to complete study activities. The primary objectives of this pilot, multi-center, randomized controlled trial (RCT) are to assess retention and sustained engagement and to explore needs and preferences for longer-term adherence monitoring and interventions. This RCT is registered with the National Institutes of Health (NCT06264700). Findings will inform a future efficacy RCT applying VDOT to hydroxyurea to address adherence gaps and improve outcomes within this vulnerable population.

Pilot investigation of an electronic pillbox at a community opioid treatment program

Background: Opioid treatment programs (OTPs) permit patients to ingest daily methadone doses unsupervised and away from the clinic, a strategy that enhances treatment access and convenience but has the potential for mismanagement.Objective: This retrospective review, conducted during the COVID-19 pandemic (5/2020-1/2022), evaluates the feasibility and acceptability of a commercially available electronic pillbox to safely administer methadone take-home tablets in a large community-based OTP (census >500 people).Methods: Study participants (n = 24; 54% male, 46% female; M age = 63 years) had recently received more take-homes per visit to support national social distancing directives, and were instructed that they could maintain these privileges by agreeing to use the pillbox.Results: Results demonstrate good demand feasibility as most participants (71%) agreed to use the pillbox. Good implementation feasibility was observed through safe and reliable delivery of most take-home tablets, with a staff support line to resolve technical issues. Acceptability was modest as six participants (25%) requested to return the pillbox despite losing some take-home privileges.Conclusion: Results support continued use and study of the electronic pillbox to safely deliver and increase access to methadone take-home doses.

Estimated effectiveness and cost-effectiveness of opioid use disorder treatment under proposed U.S. regulatory relaxations: A model-based analysis

AIM

To assess the effectiveness and cost-effectiveness of buprenorphine and methadone treatment in the U.S. if exemptions expanding coverage for substance use disorder services via telehealth and allowing opioid treatment programs to supply a greater number of take-home doses of medications for opioid use disorder (OUD) continue (Notice of Proposed Rule Making, NPRM).

DESIGN SETTING AND PARTICIPANTS

Model-based analysis of buprenorphine and methadone treatment for a cohort of 100,000 individuals with OUD, varying treatment retention and overdose risk among individuals receiving and not receiving methadone treatment compared to the status quo (no NPRM).

INTERVENTION

Buprenorphine and methadone treatment under NPRM.

MEASUREMENTS

Fatal and nonfatal overdoses and deaths over five years, discounted lifetime per person QALYs and costs.

FINDINGS

For buprenorphine treatment under the status quo, 1.21 QALYs are gained at a cost of $19,200/QALY gained compared to no treatment; with 20% higher treatment retention, 1.28 QALYs are gained at a cost of $17,900/QALY gained compared to no treatment, and the strategy dominates the status quo. For methadone treatment under the status quo, 1.11 QALYs are gained at a cost of $17,900/QALY gained compared to no treatment. In all scenarios, methadone provision cost less than $20,000/QALY gained compared to no treatment, and less than $50,000/QALY gained compared to status quo methadone treatment.

CONCLUSIONS

Buprenorphine and methadone OUD treatment under NPRM are likely to be effective and cost-effective. Increases in overdose risk with take-home methadone would reduce health benefits. Clinical and technological strategies could mitigate this risk.

Novel Therapeutic and Program-Based Approaches to Opioid Use Disorders

Opioid use disorder continues to drive overdose deaths in many countries, including the United States. Illicit fentanyl and its analogues have emerged as key contributors to the complications and mortality associated with opioid use disorder. Medications for opioid use disorder treatment, such as methadone and buprenorphine, are safe and substantially reduce opioid use, infectious complications, and mortality risk, but remain underutilized. Polysubstance use and emerging substances such as xylazine and designer benzodiazepines create additional treatment challenges. Recent clinical and policy innovations in treatment delivery, including telemedicine, bridge clinics, and expanded models for accessing methadone have the potential to increase access to life-saving care for people living with opioid use disorder.

Treatment Updates for Pain Management and Opioid Use Disorder

The medical community has proposed several clinical recommendations to promote patient safety and health amid the opioid overdose public health crisis. For a frontline practicing physician, distilling the evidence and implementing the latest guidelines may prove challenging. This article aims to highlight pertinent updates and clinical care pearls as they relate to primary care management of chronic pain and opioid use disorder.

Workload, Usability, and Engagement with a Mobile App Supporting Video Observation of Methadone Take-Home Dosing: Usability Study

BACKGROUND

Methadone, a cornerstone of opioid use disorder treatments for many decades, is an essential tool for combatting the opioid epidemic. However, requirements for observing methadone dosing in person through direct observed therapy (DOT) impose significant barriers for many patients. Digital technology can facilitate remote DOT, which could reduce barriers to methadone treatment. Currently, there are limited data on the usability of such technology among patients and counselors in methadone treatment settings.

OBJECTIVE

The primary objective of this study was to assess the workload, usability, and engagement of a video-based DOT mobile app for patients with opioid use disorder receiving methadone treatment. The secondary objective was to assess the workload, usability, and engagement of the provider-facing app portal used by counselors.

METHODS

Patients (n=12) and counselors (n=3) who previously tried video DOT for methadone through a smartphone app in an opioid treatment program participated in usability testing sessions. Participants completed essential tasks for video DOT, then provided ratings of workload (NASA Task Load Index), usability (modified System Usability Scale), and engagement (modified Engagement Scale) with the core features of the video DOT program.

RESULTS

Patients and counselors reported low mental, physical, and temporal demands, successful performance, low effort, and low frustration associated with activities. Patients reported high usability (mean 85, SD 9.5) and engagement (mean 3.8, SD 1.1); counselors reported moderate usability (mean 43.3, SD 17.7) and engagement (mean 2.81, SD 0.63).

CONCLUSIONS

A mobile health app that facilitates video-based DOT for methadone required a low workload for patients and counselors and was highly usable for patients in an opioid treatment program; however, there are opportunities to improve usability and engagement for the counselor-facing portal.

"Sign Me Up": a qualitative study of video observed therapy (VOT) for patients receiving expedited methadone take-homes during the COVID-19 pandemic

BACKGROUND

Federal and state regulations require frequent direct observation of methadone ingestion at an Opioid Treatment Program (OTP)-a requirement that creates barriers to patient access. Video observed therapy (VOT) may help to address public health and safety concerns of providing take-home medications while simultaneously reducing barriers to treatment access and long-term retention. Evaluating user experiences with VOT is important for understanding the acceptability of this strategy.

METHODS

We conducted a qualitative evaluation of a clinical pilot program of VOT via smartphone that was rapidly implemented between April and August 2020 during the COVID-19 pandemic within three opioid treatment programs. In the program, selected patients submitted video recordings of themselves ingesting methadone take-home doses, which were asynchronously reviewed by their counselor. We recruited participating patients and counselors for semi-structured, individual interviews to explore their VOT experiences after program completion. Interviews were audio recorded and transcribed. Transcripts were analyzed using thematic analysis to identify key factors influencing acceptability and the effect of VOT on the treatment experience.

RESULTS

We interviewed 12 of the 60 patients who participated in the clinical pilot and 3 of the 5 counselors. Overall, patients were enthusiastic about VOT, noting multiple benefits over traditional treatment experiences, including avoiding frequent travel to the clinic. Some noted how this allowed them to better meet recovery goals by avoiding a potentially triggering environment. Most appreciated having increased time to devote to other life priorities, including maintaining consistent employment. Participants described how VOT increased their autonomy, allowed them to keep treatment private, and normalized treatment to align with other medications that do not require in-person dosing. Participants did not describe major usability issues or privacy concerns with submitting videos. Some participants reported feeling disconnected from counselors while others felt more connected. Counselors felt some discomfort in their new role confirming medication ingestion but saw VOT as a useful tool for select patients.

CONCLUSIONS

VOT may be an acceptable tool to achieve equipoise between lowering barriers to treatment with methadone and protecting the health and safety of patients and their communities.