Clinician perspectives on methadone service delivery and the use of telemedicine during the COVID-19 pandemic: A qualitative study

Hunter, Sarah B.; Dopp, Alex R.; Ober, Allison J.; Uscher‐Pines, Lori

doi:10.1016/j.jsat.2021.108288

Cited by 67 publications

(104 citation statements)

References 19 publications

(14 reference statements)

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“…Given study participant responses to take-home methadone, policymakers should reconsider criteria for determination of patient stability and long timelines for earning increased take-home doses used pre-pandemic [ 42 ]. Concerns around diversion or methadone-related overdoses motivate maintaining the status quo [ 43 ], and have been expressed by OTP staff and leadership during the pandemic [ 28 , 44 ]. Alternatives to physically presenting to OTPs to dose include technology-assisted dosing via tele-monitoring or automated home medication dispensers [ 45 , 46 ].…”

Section: Discussionmentioning

confidence: 99%

Rural opioid treatment program patient perspectives on take-home methadone policy changes during COVID-19: a qualitative thematic analysis

Levander

Hoffman

McIlveen

et al. 2021

Addict Sci Clin Pract

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Background In the United States, methadone for opioid use disorder (OUD) is highly regulated. Federal agencies announced guidelines in March 2020 allowing for relaxation of take-home methadone dispensing at opioid treatment programs (OTPs) to improve treatment access and reduce COVID-19 transmission risk during the public health emergency. We explored patient perspectives at three OTPs serving rural communities on how take-home policy changes were received and implemented and how these changes impacted their addiction treatment and recovery. Methods We completed semi-structured individual qualitative interviews in 2 phases: (1) August–October 2020 and (2) November 2020–January 2021 (total n = 46), anticipating possible policy changes as the pandemic progressed. We interviewed patients with OUD enrolled at 3 rural OTPs in Oregon. Participants received varying take-home methadone allowances following the COVID-19-related policy changes. All interviews were conducted via phone, audio-recorded, and transcribed. We conducted a thematic analysis, iteratively coding transcripts, and deductively and inductively generating codes. Results The 46 participants included 50% women and 89% had Medicaid insurance. Three main themes emerged in the analysis, with no differences between study phases: (1) Adapting to changing OTP policies throughout the pandemic; (2) Recognizing the benefits, and occasional struggles, with increased take-home methadone dosing; and (3) Continuing policies and procedures post-pandemic. Participants described fears and anxieties around ongoing methadone access and safety concerns prior to OTP policy changes, but quickly adapted as protocols soon seemed “natural.” The majority of participants acknowledged significant benefits to increased take-homes independent of reducing COVID-19 infection risk including feeling “more like a normal person,” improved recovery support, reduced time traveling, and having more time with family and for work. Looking to a post-pandemic future, participants thought some COVID-19-related safety protocols should continue that would reduce risk of other infections, make OTP settings less stressful, and result in more individualized care. Conclusions As the pandemic progressed, study participants adapted to rapidly changing OTP policies. Participants noted many unanticipated benefits to increased take-home methadone and other COVID-19 protocols including strengthened self-efficacy and recovery and reduced interpersonal conflict, with limited evidence of diversion. Patient perspectives should inform future policies to better address the ongoing overdose epidemic.

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Section: Discussionmentioning

confidence: 99%

Rural opioid treatment program patient perspectives on take-home methadone policy changes during COVID-19: a qualitative thematic analysis

Levander

Hoffman

McIlveen

et al. 2021

Addict Sci Clin Pract

View full text Add to dashboard Cite

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“…Nevertheless, provider fear of overdose persists in the context of MMT during COVID-19. Hunter et al (2021) documented U.S. provider perceptions of COVID-19 MMT policy changes in 13 states, finding concern with reduced patient monitoring (e.g., urine toxicology frequency) and concerns of “medication abuse,” seemingly referring to diversion and non-prescribed use of methadone.…”

Section: Discussionmentioning

confidence: 99%

Treatment provider perceptions of take-home methadone regulation before and during COVID-19

Madden

Christian

Lagisetty

et al. 2021

Drug and Alcohol Dependence

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Background The loosening of U.S. methadone regulations during the COVID-19 pandemic expanded calls for methadone reform. This study examines professional perceptions of methadone take-home dose regulation before and during the COVID-19 pandemic to understand responses to varied methadone distribution policies. Methods Fifty-nine substance use disorder treatment professionals were interviewed between 2017 and 2020 in-person or over video call. An inductive iterative coding process was used to analyze the data. Constructivist grounded theory guided the collection and analysis of in-depth interviews. Results Treatment professionals expressed mixed views toward methadone take-home regulations. Participants justified regulation using several arguments: 1) patient care benefitting from supervision, 2) attributing improved patient safety to take-home regulation, 3) fearing liability for methadone-related harms, and 4) relying on buprenorphine as an “escape hatch” for patients who cannot manage MMT policies. Other professionals suggested partial deregulation, while others strongly opposed pre-pandemic take-home regulation, explaining such regulations impede medication access and hinder patient-centered care. Some professionals supported the COVID-19 policy changes and saw these as a test run for broader deregulation, while others framed the changes as temporary and cautiously applied deregulation to their services, at times revoking looser rules for patients they perceived as nonadherent. Conclusion Treatment professionals working in a range of modalities, including opioid treatment programs, expressed hesitation toward expanded take-home methadone access. While some participants also supported forms of deregulation, post-pandemic efforts to extend looser methadone distribution policies will have to address apprehensive professionals if such policy changes are to be meaningfully adopted in community services.

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“…24 Our findings of increased benefits from take-home expansion without many apparent adverse events align with early reports from domestic and international methadone programs, [26][27][28] and how flexibility in take-home exemptions allowed individual OTPs to decide which approaches best suited the needs of their patients, staff, and local environments. 29 Our study is one of the first to describe the expansion of take-home privileges for patients with wellcontrolled OUD and active stimulant use, as this was one of the populations providers in this OTP defined as "stable" and therefore newly eligible for take-homes. OTPs traditionally are abstinence-oriented programs, previously disqualifying patients with any other non-prescribed drug or heavy alcohol use from take-homes even in the setting of well-controlled OUD.…”

Section: Discussionmentioning

confidence: 99%

“The idea is to help people achieve greater success and liberty”: a qualitative study of expanded methadone take-home access in opioid use disorder treatment

Suen

Castellanos

Joshi

et al. 2021

Preprint

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Background Prior to the COVID-19 pandemic, the United States (US) was already facing an epidemic of opioid overdose deaths. Overdose deaths continued to surge during the pandemic. To limit COVID-19 spread and to avoid disruptions in access to medications for opioid use disorder (MOUD), including buprenorphine and methadone, US federal and state agencies granted unprecedented exemptions to existing MOUD guidelines for Opioid Treatment Programs (OTPs), including loosening criteria for unsupervised take-home doses. We conducted a qualitative study to evaluate the impact of these policy changes on MOUD treatment experiences for providers and patients at an OTP in California. Methods We interviewed 10 providers and 20 patients receiving MOUD. We transcribed, coded, and analyzed all interviews to identify emergent themes. Results Providers discussed clinical decision-making processes and experiences providing take-homes. Implementation of expanded take-home policies was cautious. Providers reported making individualized decisions, using patient factors to decide if benefits outweighed risks of overdose and misuse. Decision-making factors included patient drug use, overdose risk, housing status, and vulnerability to COVID-19. New patient groups started receiving take-homes and providers noted few adverse events. Patients who received take-homes reported increased autonomy and treatment flexibility, which in turn increased likelihood of treatment stabilization and engagement. Patients who remained ineligible for take-homes, usually due to ongoing non-prescribed opioid or benzodiazepine use, desired greater transparency and shared decision-making. Conclusion Federal exemptions in response to COVID-19 led to the unprecedented expansion of access to MOUD take-homes within OTPs. Providers and patients perceived benefits to expanding access to take-homes and experienced few adverse outcomes, suggesting expanded take-home policies should remain post-COVID-19. Future studies should explore whether these findings are generalizable to other OTPs and assess larger samples to quantify patient-level outcomes resulting from expanded take-home policies.

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Clinician perspectives on methadone service delivery and the use of telemedicine during the COVID-19 pandemic: A qualitative study

Cited by 67 publications

References 19 publications

Rural opioid treatment program patient perspectives on take-home methadone policy changes during COVID-19: a qualitative thematic analysis

Rural opioid treatment program patient perspectives on take-home methadone policy changes during COVID-19: a qualitative thematic analysis

Treatment provider perceptions of take-home methadone regulation before and during COVID-19

“The idea is to help people achieve greater success and liberty”: a qualitative study of expanded methadone take-home access in opioid use disorder treatment

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