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

Abstract

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.

Treatment retention, return to use, and recovery support following COVID-19 relaxation of methadone take-home dosing in two rural opioid treatment programs: A mixed methods analysis

“…The OTP had been established two years prior to the other site. These findings provide additional data on how patients adapted to COVID-19-related policy changes, the benefits and challenges with increased take-home doses, and possibilities for future directions of OTP-related regulations ( Harris et al, 2021 ; Levander, Hoffman, et al, 2021 ). Qualitative reports of continued recovery in the context of fewer restrictions suggest feasibility and desirability of enhanced access to take-homes without detrimental harm particularly in OTPs serving rural communities.…”

Opioid agonist treatment take-home doses (‘carries’): Are current guidelines resulting in low treatment coverage among high-risk populations in Canada and the USA?

“…Preliminary data highlight that those who were able to access OAT carries due to the revised policies benefitted from this change, particularly as access to carries permitted them to stabilize their routines, physically distance to reduce the risk of virus transmission, and subsequently decrease their substance use [18,64,68,[70][71][72]. For instance, in a US-based qualitative study emphasizing patient's perspectives, many individuals acknowledged significant benefits of receiving carries during COVID-19 including experiencing feelings of normalcy and stability, improvements to recovery support, and increased time with family and work-benefits which increased their self-confidence and commitment to OAT adherence [73]. Early Canadian data further indicate that most people who received additional carries were no more likely to experience adverse outcomes (e.g., self-reported opioid overdoses, emergency department visits, etc.)…”

Established Tables and Emergent Huddles: Exploring the Processes of Participation Associated With the Policy Changes to Opioid Pharmacotherapy Treatment in Australia in the Context of COVID-19

“…In terms of the regulatory changes, many countries temporarily allowed for more flexible service delivery models in the context of COVID-19, for instance, allowing clients to obtain more takeaway (take-home) doses of methadone and buprenorphine, using telemedicine for reviews and evaluations, accelerating the expansion of long-acting injectables (e.g., depot buprenorphine), delivering medications to clients where possible, extending the duration of prescriptions, and increasing access to take-home naloxone (British Columbia Centre on Substance Use, 2020; Farhoudian et al, 2020; Lintzeris et al, 2020; Substance Abuse and Mental Health Services Administration [SAMHSA], 2020). Despite some concerns around policy implementation (Becker et al, 2021; Pérez-Chiqués et al, 2021), early evaluations suggest that these regulatory changes have led to few if any unintended consequences (Brothers et al, 2021; Caton et al, 2021; Kitchen et al, 2022; Lintzeris et al, 2021; Saloner et al, 2022; Welsh et al, 2022), and clients have reported greater self-efficacy and recovery capital as a result of the increased flexibility in treatment (Levander et al, 2021). There have been calls to sustain and expand these improvements to treatment delivery beyond the pandemic (Corace et al, 2022; Durand et al, 2022; Grebely et al, 2020; Green et al, 2020), and in the US the Substance Abuse and Mental Health Services Administration have recently extended the temporary policy changes for another year, and also have plans to make them permanent (SAMHSA, 2021).…”