Medication take-home doses and contingency management

Did drug use increase following COVID-19 relaxation of methadone take-out regulations? 2020 was a complicated year

Background

Relaxation of federal regulations for methadone take-out dosing during the COVID-19 pandemic is unprecedented. The impact of this change on drug use is unknown. This study explores the impact of the federal take-out variance on drug use in one urban opioid treatment program as measured by drug testing.

Methods

This study collected drug test results from 613 patients receiving methadone from July 2020, following COVID-19-related take-out dose adjustments, and July 2019 for comparison. Using a generalized linear mixed model, we computed the average estimated probability of a positive drug test for each year for each take-out phase. To isolate the effect of changing take-out, we removed the main effect of year, while retaining the main effect of take-out phase and the interaction between year and phase.

Results

The percent of drug tests positive for opiates, benzodiazepines, and methamphetamine was greater in July 2020 than in July 2019 (p < 0.001 for each), while the percent of tests negative for methadone increased (p < 0.001). Oxycodone, barbiturate, and cocaine positive tests remained stable. In a separate analysis of opioid and non-opioid test results, take-out phase was associated with both opioid and non-opioid positive results (p < 0.001, each outcome). The association of take-out phase with opioid and non-opioid positive results differed in the two years (year-by-phase interaction p < 0.025, each outcome). After removing the year main effect, the rate of positive tests was lower in 2020 for the smallest number of take-out doses, higher for a moderate number of take-out doses, and about the same for the highest number of take-out doses.

Conclusions

Positive opioid and non-opioid drug tests increased following the federal variance allowing more methadone take-out doses, but these findings cannot fully be attributed to alterations in the take-out schedule.

Suboxone Treatment and Recovery Trial (STAR-T): Study Protocol for a Randomised Controlled Trial of Opioid Medication Assisted Treatment with Adjunctive Medication Management Using Therapeutic Drug Monitoring and Contingency Management

INTRODUCTION

Opioid assisted treatment (OAT) with buprenorphine (BUP) is front-line medical maintenance intervention for illicit and prescription opioid use disorder (OUD). In many clinics, opioid medication is dispensed for several days for self-administration. This provides flexibility to the patient but may compromise the effectiveness of OAT because of nonadherence or medication diversion. OAT can be delivered as an entirely supervised intervention, but many patients discontinue treatment under this arrangement and dispensing costs may be prohibitive. An alternative is to enable patients to receive take-home doses contingent on OAT adherence guided by a medication management framework using Therapeutic Drug Monitoring (TDM) alongside negative urine drug screens (UDS) to provide evidence of abstinence. TDM is recommended to monitor adherence with BUP but it has not been applied in OAT programs and evaluation research to date.

METHODS

The Suboxone Treatment and Recovery Trial (STAR-T) is a single site, 16-week, parallel-group, randomised controlled trial. The aim of the study is to determine the effectiveness of a medication management framework including TDM and UDS to enable patients enrolled on outpatient OAT (with buprenorphine/naloxone [sublingual film formulation; BUP/NX-F; Suboxone™]) to receive stepped take-home doses. Following stabilisation during inpatient care, adult participants with illicit or prescription OUD were allocated (1:1) to receive (1) BUP/NX-F plus medication management for take-home doses based on TDM, UDS, and contingency management protocol (the experimental group) or (2) BUP/NX-F plus UDS only (treatment-as-usual, the control group). The primary outcome is the mean percentage of negative UDS over 16 weeks. The secondary outcome is treatment retention defined as completion of 16 weeks of OAT without interruption. There will be an exploratory analysis of the association between participant characteristics, clinical data, and outcomes.

CONCLUSIONS

Providing BUP/NX-F take-home doses contingent on adherence and opioid abstinence may enable OAT to be delivered flexibly and effectively.

TRIAL REGISTRATION

ISRCTN41645723 is retrospectively registered on 15/11/2015.

A randomized controlled trial of fluoxetine in the treatment of cocaine dependence among methadone-maintained patients

BACKGROUND

Cocaine abuse and dependence continue to be widespread. Currently, there are no pharmacotherapies shown to be effective in the treatment of cocaine dependence.

METHODS

A 33-week outpatient clinical trial of fluoxetine (60 mg/day, po) for cocaine dependence that incorporated abstinence-contingent voucher incentives was conducted. Participants (N = 145) were both cocaine and opioid dependent and treated with methadone. A stratified randomization procedure assigned subjects to one of four conditions: fluoxetine plus voucher incentives (FV), placebo plus voucher incentives (PV), fluoxetine without vouchers (F), and placebo without vouchers (P). Dosing of fluoxetine/placebo was double blind. Primary outcomes were treatment retention and cocaine use based on thrice-weekly urine testing.

RESULTS

The PV group had the longest treatment retention (M = 165 days) and lowest probability of cocaine use. The adjusted predicted probabilities of cocaine use were 65% in the P group, 60% in the F group, 56% in the FV group, and 31% in the PV group.

CONCLUSIONS

Fluoxetine was not efficacious in reducing cocaine use in patients dually dependent on cocaine and opioids.