Recent modifications to the US methadone treatment system are a Band-Aid-not a solution-to the nation's broken opioid use disorder treatment system

State sequence analysis of daily methadone dispensing trajectories among individuals at United States opioid treatment programs before and following COVID-19 onset

BACKGROUND AND AIMS

US regulatory changes allowed for additional methadone take-home doses following COVID-19 onset. How dispensing practices changed and which factors drove variation remains unexplored. We determined daily methadone dispensing trajectories over six months before and after regulatory changes due to COVID-19 using state sequence analysis and explored correlates.

DESIGN

Retrospective chart review of electronic health records.

SETTINGS

Nine opioid treatment programs (OTPs) across nine US states.

PARTICIPANTS

Adults initiating treatment in 2019 (n = 328) vs. initiating 1 month after the COVID-19 regulatory changes of March 2020 (n = 376).

MEASUREMENTS

Type of daily methadone medication encounter (in-clinic, weekend/holiday take-home, take-home, missed dose, discontinued) based on OTP clinic; cohort (pre vs. post-COVID-19); and patient substance use, clinical and sociodemographic characteristics.

FINDINGS

Following COVID-19 regulatory changes, allotted methadone take-home doses increased from 3.5% to 13.8% of total person-days in treatment within the first 6 months in care. Clinic site accounted for the greatest variation in methadone dispensing (6.2% and 9.5% of the variation of discrepancy between sequences pre- and post-COVID-19, respectively). People who co-use methamphetamine had a greater increase in take-homes than people who did not use methamphetamine (from 3.7% pre-pandemic to 21.2% post-pandemic vs. 3.5% to 12.5%) and higher discontinuation (average 3.6 vs. 4.7 months among people who did not use methamphetamine pre-COVID-19; average 3.3 vs. 4.6 months post-COVID-19). In the post-COVID-19 cohort, females had a higher proportion of missed doses (17.2% vs. 11.9%) than males. People experiencing houselessness had a higher proportion of missed doses (19% vs. 12.3%) and shorter stays (average 3.5 vs. 4.5 months) when compared with those with stable housing.

CONCLUSION

Daily methadone dispensing trajectories in the US both before and following COVID-19 regulatory changes appeared to depend more on the opioid treatment programs' practices than individual patient characteristics or response to treatment.

Drug treatment and support service utilization amidst the COVID-19 pandemic among people who inject drugs in Baltimore, Maryland: An interrupted time-series analysis, 2015-2022

BACKGROUND

The COVID-19 pandemic prompted many structural and social changes including adaptations to drug treatment policies and provision (e.g., take-home methadone flexibilities and telehealth services), but their collective impact on drug treatment use among people who inject drugs in the US remains unclear. This study characterized trends in drug treatment and support service utilization before and during the pandemic among current and former people who inject drugs in Baltimore, Maryland.

METHODS

An interrupted time-series analysis was conducted using longitudinal survey data collected between December 2015 and November 2022 among 780 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study-a community-based cohort of adults who have injected drugs in Baltimore (n = 7036 semi-annual person-visits). Average marginal changes in service utilization were estimated following logistic regression with generalized estimating equations.

RESULTS

At participants' first pre-pandemic visit, 46.8 % attended group counseling/support group services, 13.5 % were prescribed buprenorphine, and 38.8% were prescribed methadone. After the onset of the pandemic, there was an immediate reduction in attending group services (-13.4 % [95%CI = -17.8 %, -8.9 %]) and a change in the trajectory of attendance (difference in quarterly percentage point change [QPPC] comparing before vs. during the pandemic = -0.9 % [95 %CI = -1.6 %, -0.1 %]). In contrast, there was a small immediate increase in buprenorphine use (2.3 % [95 %CI = 0.1 %, 4.6 %]) and no change in its trajectory (QPPC difference = -0.1 % [95 %CI = -0.6 %, 0.3 %]) after the pandemic's onset. A declining trajectory in methadone use before the pandemic accelerated during the pandemic, but this change was not statistically significant (QPPC difference = -0.5 % [95 %CI = -1.2 %, 0.2 %]). When prescribed buprenorphine/methadone during the pandemic, 28.8 % reported engagement in telehealth services (50.0 % for buprenorphine; 16.7 % for methadone).

CONCLUSION

There were pandemic-related disruptions in group-based support service utilization. Meanwhile, service adaptations may have blunted the pandemic's impact on buprenorphine and methadone treatment, suggesting adaptive systems have the potential to optimize treatment delivery. Nonetheless, the observed declines in methadone treatment uptake warrant investigation.

Toward a Consensus on Strategies to Support Opioid Use Disorder Care Transitions Following Hospitalization: A Modified Delphi Process

BACKGROUND

Despite proliferation of acute-care interventions to initiate medications for opioid use disorder (MOUD), significant challenges remain to supporting care continuity following discharge. Research is needed to inform effective hospital strategies to support patient transitions to ongoing MOUD in the community.

OBJECTIVE

To inform a taxonomy of care transition strategies to support MOUD continuity from hospital to community-based settings and assess their perceived impact and feasibility among experts in the field.

DESIGN

A modified Delphi consensus process through three rounds of electronic surveys.

PARTICIPANTS

Experts in hospital-based opioid use disorder (OUD) treatment, care transitions, and hospital-based addiction treatment.

MAIN MEASURES

Delphi participants rated the impact and feasibility of 14 OUD care transition strategies derived from a review of the scientific literature on a scale from 1 to 9 over three survey rounds. Panelists were invited to suggest additional care transition strategies. Agreement level was calculated based on proportion of ratings within three points of the median.

KEY RESULTS

Forty-five of 71 invited panelists participated in the survey. Agreement on impact was strong for 12 items and moderate for 10. Agreement on feasibility was strong for 11 items, moderate for 7, and poor for 4. Strategies with highest ratings on impact and feasibility included initiation of MOUD in-hospital and provision of buprenorphine prescriptions or medications before discharge. All original 14 strategies and 8 additional strategies proposed by panelists were considered medium- or high-impact and were incorporated into a final taxonomy of 22 OUD care transition strategies.

CONCLUSIONS

Our study established expert consensus on impactful and feasible hospital strategies to support OUD care transitions from the hospital to community-based MOUD treatment, an area with little empirical research thus far. It is the hope that this taxonomy serves as a stepping-stone for future evaluations and clinical practice implementation toward improved MOUD continuity and health outcomes.

"Un attracteur de soins": Bringing People Into Care. Interdisciplinary Health Care Professionals' Attitudes Toward Opioid Agonist Therapy in France: a Qualitative Study with Implications for the United States

BACKGROUND

Opioid agonist therapies (OAT), including methadone and buprenorphine, are first-line care in national and international guidelines, yet many countries, including the United States, frequently fail to effectively engage and retain people in OAT. How OAT is delivered-including the goals and culture of care-matters to patient engagement, treatment retention, and health outcomes. France has among the highest OAT receipt and lowest opioid-related morbidity and mortality worldwide. This study explored French interprofessional health care clinicians' approach to OAT, drawing lessons to improve OAT implementation in the United States and elsewhere.

METHODS

We recruited interprofessional participants (eg, physicians, pharmacists, nurses, administrators) from diverse health care settings (eg, specialty addiction care, hospitals, public health) and regions and conducted in-depth semi-structured qualitative interviews. We conducted a reflexive thematic analysis using an inductive approach at a semantic level, identifying themes that held meaning to study participants and had implications for the United States and other contexts.

RESULTS

Twenty-one people participated. Participants described patient engagement as the primary goal of OAT, which has potential to draw people to care. They felt imposing or expecting abstinence was harmful and might obligate patients to lie or "lead a double life," resulting in mistrust, missed care opportunities, and "losing patients" who disengaged from care. Participants described balancing flexibility and structure. They felt that flexibility promotes OAT access and engagement and that clinicians should contextualize decisions within patients' risk environments, including those of an illicit drug supply and the black market. Participants described that structure should be offered as support, not punishment or control. Finally, they described that practices prioritizing engagement are sustained by policies and professional norms.

CONCLUSIONS

Our findings challenge OAT practices and policies centered on abstinence and control. They suggest that approaches that prioritize patient engagement and balance flexibility and structure may be central to achieving high rates of OAT across a population.

Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone on treatment interruption: Comparing findings from a reanalysis of the X:BOT RCT and harmonized target trial emulation using population-based observational data

BACKGROUND AND AIMS

It is unclear if findings from randomized controlled trials (RCT) of medications for opioid use disorder apply to real-world settings. We estimated the effectiveness of buprenorphine-naloxone (BUP-NX) versus extended-release naltrexone (XR-NTX) on treatment interruption in a RCT and an observational study based on real-world data.

DESIGN

Target trial emulation to harmonize the protocol and statistical analyses of X:BOT (target trial) and the observational study (observational emulation). Baseline was randomization in the target trial and medically managed opioid withdrawal (MMOW) discharge in the observational emulation.

SETTINGS

X:BOT trial and Massachusetts Public Health Data Warehouse observational data (United States).

PARTICIPANTS

The target trial included all X:BOT participants. The observational emulation trial included MMOW discharges from January 2014 to May 2016.

MEASUREMENTS

Treatment strategies were BUP-NX versus XR-NTX initiation within 28 days of baseline. The outcome was treatment interruption (earliest of treatment discontinuation, incarceration, MMOW readmission, death). We estimated the 24-week risk and risk difference.

FINDINGS

In the target trial, 94% (269/287) and 66% (187/283) of participants randomized to BUP-NX or XR-NTX initiated their assigned treatment within 28 days, respectively. In the observational emulation, BUP-NX and XR-NTX were initiated within 28 days in 9% (5209/59 076) and 3% (1813/59 076) of MMOW discharges, respectively. The adjusted 24-week treatment interruption risks (95% confidence interval) for BUP-NX and XR-NTX were 68% (60%,77%) and 72% (60%,83%) in the target trial [risk difference, -4 percentage points (pp; -17 pp,11 pp)] and 82% (81%,83%) and 93% (92%,95%) in the observational emulation [risk difference,-11 pp (-13 pp,-10 pp)].

CONCLUSIONS

Buprenorphine-naloxone might be superior to extended-release naltrexone in real-world settings where the majority of people struggle to remain on medications for opioid use disorder. Buprenorphine-naloxone initiators had a lower risk of treatment interruption than extended-release naltrexone initiators in an observational emulation, but similar risks in a randomized controlled trial, although confidence intervals were wide. Trial participation, study size and residual confounding may explain these differences.

Medication experiences in the treatment of opioid use disorders: Insights from Reddit

BACKGROUND AND AIMS

Better understanding the challenges faced by patients on medications for opioid use disorder (MOUD), including methadone and buprenorphine, is critical to increasing their use/retention. Social media platforms such as Reddit offer a space for patients to share their experiences with medications. We aimed to identify and characterize challenges faced by patients taking MOUD through analysis of discussions from the r/Methadone and r/suboxone subreddits.

DESIGN, SETTING AND PARTICIPANTS

Mixed methods study applying natural language processing methods to 37 278 posts from both subreddits from their origin in 2011 until 31 December 2022. Independent topic analyses used Correlated Topic Models to extract the main themes discussed.

MEASUREMENTS

We labeled, validated and grouped the topics into macro classes and computed topic shares. We interpreted and compared topics across subreddits informed by the patient-centered medication experience framework.

FINDINGS

We found 27 and 34 challenge-related topics for the r/Methadone and r/suboxone subreddits, respectively. Topics were grouped into three macro-topics: (i) healthcare-related issues, including misunderstandings/confusion around appointments, prescriptions, bottle checks, telehealth technology and health insurance coverage; (ii) medication-related issues, including withdrawal, cravings, dosage, side effects, mixing with other medications/drugs; and (iii) treatment discontinuation, including tapering protocols. Patients conveyed highly specialized knowledge about dosage and tapering strategies and spoke from experience. Key differences between r/Methadone and r/suboxone were driven by their dispensing requirements (clinic-based vs. take-home), with 20.05% vs 14.74% of posts related to healthcare service, primarily for logistic and interpersonal issues with healthcare providers.

CONCLUSION

People who post on the r/Methadone and r/suboxone subreddits appear to have detailed knowledge of medications for opioid use disorder and want more control over their dosing, effects, side effects and discontinuation. Acknowledging this expertise and establishing stronger patients' partnerships with the healthcare team and system might result in better treatment outcomes.

"I still can feel the sickness": Withdrawal experiences of people on methadone maintenance treatment

INTRODUCTION

Opioid withdrawal is a regular occurrence for many people who use illicit opioids (PWUIO) involving acute physical and psychological pain. Yet, there is very little data on the withdrawal experience of people in methadone maintenance treatment (MMT) and almost none from the patients' experience. Learning more about patients' withdrawal experiences can help to inform policies and practices that are better suited to address withdrawal and may improve patient satisfaction as well as uptake and retention.

METHODS

This article is based on 29 semi-structured interviews with people who use illicit opioids who reported recent withdrawal experience. The study conducted interviews remotely via Zoom between April and August 2022 and later transcribed them professionally. The study team then coded data thematically using Atlas.ti, based on a combination of inductive and deductive coding strategies and informed by the literature and study aims.

RESULTS

Participants described withdrawal as a significant issue that negatively impacts their treatment experience and increases the likelihood of treatment cessation. Their accounts of withdrawal were complex and often involved multiple factors; however, feeling underdosed and missing clinic dosing hours were seen as important vectors that led to their withdrawal experiences. Importantly, participants framed feeling underdosed and missing clinic dosing hours as institutional problems, resulting primarily from clinic policies, practices, and culture rather than from patients' decisions or individual behavior. Specifically, they cited restricted access to take-home doses, limited hours of operation, and a punitive focus on complete abstinence as factors that made withdrawal difficult to avoid.

CONCLUSIONS

Patients' accounts demonstrate a disconnect between providers' focus on promoting complete abstinence and patients, who were often using MMT for more pragmatic reasons that did not include complete abstinence from all drugs. These findings support growing calls for the integration of MMT into the mainstream healthcare system by making it available via prescription from office-based medical settings and dispensed through pharmacies.

Attributes of higher- and lower-performing hospitals in the Consult for Addiction Treatment and Care in Hospitals (CATCH) program implementation: A multiple-case study

INTRODUCTION

Six hospitals within the New York City public hospital system implemented the Consult for Addiction Treatment and Care in Hospitals (CATCH) program, an interprofessional addiction consult service. A stepped-wedge cluster randomized controlled trial tested the effectiveness of CATCH for increasing initiation and engagement in post-discharge medication for opioid use disorder (MOUD) treatment among hospital patients with opioid use disorder (OUD). The objective of this study was to identify facility characteristics that were associated with stronger performance of CATCH.

METHODS

This study used a mixed methods multiple-case study design. The six hospitals in the CATCH evaluation were each assigned a case rating according to intervention reach. Reach was considered high if ≥50 % of hospitalized OUD patients received an MOUD order. Cross-case rating comparison identified attributes of high-performing hospitals and inductive and deductive approaches were used to identify themes.

RESULTS

Higher-performing hospitals exhibited attributes that were generally absent in lower-performing hospitals, including (1) complete medical provider staffing; (2) designated office space and resources for CATCH; (3) existing integrated OUD treatment resources; and (4) limited overlap between the implementation period and COVID-19 pandemic.

CONCLUSIONS

Hospitals with attributes indicative of awareness and integration of OUD services into general care were generally higher performing than hospitals that had siloed OUD treatment programs. Future implementations of addiction consult services may benefit from an increased focus on hospital- and community-level buy-in and efforts to integrate MOUD treatment into general care.

Hospital Provider's Perspectives on MOUD Initiation and Continuation After Inpatient Discharge

BACKGROUND

Individuals with opioid use disorder have high rates of hospital admissions, which represent a critical opportunity to engage patients and initiate medications for opioid use disorder (MOUD). However, few patients receive MOUD and, even if MOUD is initiated in the hospital, patients may encounter barriers to continuing MOUD in the community.

OBJECTIVE

Describe hospital providers' experiences and perspectives to inform initiatives and policies that support hospital-based MOUD initiation and continuation in community treatment programs.

DESIGN

As part of a broader implementation study focused on inpatient MOUD (NCT#04921787), we conducted semi-structured interviews with hospital providers.

PARTICIPANTS

Fifty-seven hospital providers from 12 community hospitals.

APPROACH

Thematic analysis examined an emergent topic on challenges transitioning patients to outpatient MOUD treatment and related impacts on MOUD initiation by inpatient providers.

KEY RESULTS

Participants described structural barriers to transitioning hospitalized patients to continuing outpatient MOUD including (a) limited outpatient buprenorphine prescriber availability, (b) the siloed nature of addiction treatment, and (c) long wait times. As a result of observing these structural barriers, participants experienced a sense of futility that deterred them from initiating MOUD. Participants proposed strategies that could better support these patient transitions, including developing partnerships between hospitals and outpatient addiction treatment and supporting in-reach services from community providers.

CONCLUSIONS

We identified concerns about inadequate and inaccessible community-based care and transition pathways that discouraged hospital providers from prescribing MOUD. As hospital-based opioid treatment models continue to expand, programmatic and policy strategies to support inpatient transitions to outpatient addiction treatment are needed.

NCT TRIAL NUMBER

04921787.

Patient Challenges in Utilization of Methadone to Treat Opioid Use Disorder and Perspectives on a Solution for Improved Security and Convenience in Take-home Dosing

Background

Methadone is commonly utilized to treat opioid use disorder (OUD). Requirements to visit an opioid treatment provider (OTP) clinic for methadone treatment limits access to treatment, impacts quality of life, and reduces OUD treatment program retention. The Computerized Oral Prescription Administration (COPA) system is a dual-biometric dispensing device for take-home dosing that could reduce the impacts of methadone administration on patients and clinic staff.

Objective

To identify challenges for patients treated with methadone for OUD and gain their perspectives on COPA.

Methods

Adult patients treated with methadone at a single-site OTP clinic were recruited to complete a qualitative interview regarding their experience with methadone and the impact that expansion of take-home doses would have on their life. Participants were provided printed resources describing COPA and handled a COPA device before being asked for their perspectives.

Results

Participants (n=12) were 58.33 percent male and 41.67 percent female, and had no take-home doses (n=5), 2 to 5 days of take-home doses (n=4), or six or more days of take-home doses (n=3). Most (91.67%) participants desired more take-home doses, and 66.7 percent stated more take-home doses would reduce the negative impact of OUD treatment on their ability to work. Average time and cost per trip to obtain their methadone dose at the clinic was 75 minutes and $36.58, respectively. Participants responded positively toward COPA. Participants with no take-home privileges would pay $126.88 per month to obtain take-home privileges by using COPA, and those with take-home privileges would pay $30.31 per month to keep the same level of take-home doses and $117.50 per month to expand their take-home doses using COPA.

Conclusion

Participants endured a monetary and time burden to access their methadone treatment, and wished to have more take-home doses to reduce the frequency of their visits to the OTP clinic. Participants viewed take-home doses as having a positive impact on their ability to care for family members, hold a job, and travel, and they appreciated the key attributes of COPA and were willing to invest their own funds to gain access to the device. COPA is a potential solution to expand take-home methadone access to patients while ensuring safety, adherence, retention, and appropriate use.

Comparing methadone policy and practice in France and the US: Implications for US policy reform

Despite being among the most effective treatments for opioid use disorder, methadone is largely unavailable in the United States, due primarily to federal and other policies that limit its availability and regulate clinical decisions about doses, visit frequency, and drug testing. There is unprecedented momentum to change decades-old US methadone policies. Yet uncertainty remains as to whether reforms will be adopted and how policies will be implemented. France has among the best methadone access and lowest overdose death rates worldwide. 87 % of French people with opioid use disorder receive methadone or buprenorphine, versus an estimated 13-20 % in the US. France's opioid-related overdose rates are far lower than the US. This article compares French and US systems, including current and proposed US policies, and underscores potential implications for US policymakers. In France, methadone can be initiated in specialty addiction settings and hospitals, with subsequent handoff to primary care. Methadone can be dispensed in community pharmacies and filled like other opioids, without requirements for supervised dosing. Decisions about visit frequency, medication doses, and drug testing are governed by clinical best practices and patient-clinician shared decision-making. In the US, methadone for opioid use disorder is regulated unlike any other medication (including methadone for pain) and is governed by strict federal controls, including from law enforcement and healthcare. With few exceptions, methadone for opioid use disorder is only available in Opioid Treatment Programs. US clinicians cannot prescribe methadone for opioid use disorder. Federal rules determine minimum visit frequency, initial dose limits, and other conditions of treatment, which states may further limit. Policies assert strong influence on patient experience, treatment access, and health outcomes. Despite being less restrictive than the US, the French model includes limits designed to avoid or minimize potential harms. French policies have important implications for potential US reforms.

Methadone's Resurgence in Bridging the Treatment Gap in the Overdose Crisis: Position Statement of AMERSA, Inc (Association for Multidisciplinary Education, Research, Substance Use, and Addiction)

BACKGROUND

The United States is grappling with an unprecedented overdose crisis, exacerbated by the proliferation of potent synthetic opioids like illicitly manufactured fentanyl. Despite the efficacy of methadone treatment in managing opioid use disorder, regulatory barriers hinder its widespread utilization. This article examines the complex landscape of methadone regulation across federal, state, and local levels, highlighting disparities and opportunities for reform.

ISSUE

The COVID-19 public health emergency prompted temporary flexibility in methadone regulations, including expanded take-home doses and telehealth counseling, leading to improved treatment experiences and retention. Permanent revisions to federal guidelines have since been introduced by the Substance Abuse and Mental Health Services Administration, reflecting a progressive shift toward patient-centered care and streamlined access. State regulations, managed by Single State Agencies and State Opioid Treatment Authorities, vary widely, often imposing additional restrictions that impede access to methadone treatment. Local OTP clinics further exacerbate barriers through stringent policies, despite federal and state guidelines advocating for flexibility.

RECOMMENDATIONS

Coordinated efforts among policymakers, healthcare providers, and communities are needed to promote the development of accountability measures, incentives, and community involvement to ensure equitable access and quality of care. To truly meet the demand needed to end the existing overdose crisis and enhance accessibility and comprehensive healthcare services, methadone treatment expansion beyond traditional OTP settings into primary care offices and community pharmacies should take place.

Impact of jail-based methadone or buprenorphine treatment on non-fatal opioid overdose after incarceration

BACKGROUND

Non-fatal overdose is a leading predictor of subsequent fatal overdose. For individuals who are incarcerated, the risk of experiencing an overdose is highest when transitioning from a correctional setting to the community. We assessed if enrollment in jail-based medications for opioid use disorder (MOUD) is associated with lower risk of non-fatal opioid overdoses after jail release among individuals with opioid use disorder (OUD).

METHODS

This was a retrospective, observational cohort study of adults with OUD who were incarcerated in New York City jails and received MOUD or did not receive any MOUD (out-of-treatment) within the last three days before release to the community in 2011-2017. The outcome was the first non-fatal opioid overdose emergency department (ED) visit within 1 year of jail release during 2011-2017. Covariates included demographic, clinical, incarceration-related, and other characteristics. We performed multivariable cause-specific Cox proportional hazards regression analysis to compare the risk of non-fatal opioid overdose ED visits within 1 year after jail release between groups.

RESULTS

MOUD group included 8660 individuals with 17,119 incarcerations; out-of-treatment group included 10,163 individuals with 14,263 incarcerations. Controlling for covariates and accounting for competing risks, in-jail MOUD was associated with lower non-fatal opioid overdose risk within 14 days after jail release (adjusted HR=0.49, 95% confidence interval=0.33-0.74). We found no significant differences 15-28, 29-56, or 57-365 days post-release.

CONCLUSION

MOUD group had lower risk of non-fatal opioid overdose immediately after jail release. Wider implementation of MOUD in US jails could potentially reduce post-release overdoses, ED utilization, and associated healthcare costs.