The impact of relaxation of methadone take-home protocols on treatment outcomes in the COVID-19 era

Amram, Ofer; Amiri, Solmaz; Panwala, Victoria; Lutz, Robert; Joudrey, Paul J.; Socías, M. Eugenia

doi:10.1080/00952990.2021.1979991

Cited by 54 publications

(44 citation statements)

References 24 publications

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“…In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S.A., issued guidance allowing for the expansion of take-home methadone doses. This led to a near-doubling of take-home racmethadone doses during the COVID-19 exemption period; the increase in take-home doses was not associated with negative treatment outcomes in methadone-adherent clients [32]. No changes in the rate of overdose cases, in our setting, were reported, in line with the recent report [33].…”

Section: Discussionsupporting

confidence: 86%

“…The take-home dosage procedure, applied during the pandemic with contrasting expert opinions/experiences [30,31], did not affect patient stability in our setting, despite the increase of the mean doses of all drugs, especially for rac-methadone, that we observed, in line with some reports [32]. The coronavirus pandemic (COVID-19) has introduced many concerns surrounding access to opioid treatment.…”

Section: Discussionsupporting

confidence: 81%

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Multicenter Observational/Exploratory Study Addressed to the Evaluation of the Effectiveness and Safety of Pharmacological Therapy in Opioid-Dependent Patients in Maintenance Therapy in Southern Italy

et al. 2022

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A multicenter-observational study was performed to assess the effectiveness of rac-methadone, levomethadone, and buprenorphine in opioid-dependent patients in polytherapy in Southern Italy. The primary endpoint was the reduction of urinary positivity to the substances and the maintaining doses. Patients (N = 266, age = 44.80 ± 5.65, male = 79.70%, female = 20.30%) have been recruited. At recruitment, 75% of them were on treatment with rac-methadone, levomethadone, and buprenorphine/naloxone. The patients were grouped into three clusters. The levomethadone patients of Cluster A (N patients = 211), after 180 days, showed stability in urinary methadone positivity, with a marked decrease in heroin −53 ± 4%, cannabinol’s −48 ± 2%, and cocaine −37 ± 6% positivity, with no differences between treatments. A lower QTcF value of 426 ± 8.4 ms was recorded in the levomethadone patients (delta = −19 ms) vs. rac-methadone, at significantly lower doses of levomethadone (−34%, −50.2% in males) (p < 0.05). The Cluster B data were collected from 37 patients, with a high prevalence of comorbidity infections (HIV/HCV/HPV), monitored for 21 months during COVID-19. High doses of levomethadone (58.33 ± 31.58 mg/day) were needed to stabilize those that were negative for opioids and cannabinoids, in contrast to the rac-methadone and buprenorphine/naloxone patients that showed positive toxicology. Eighteen patients of the Cluster C in double diagnosis (major depressive 38.90%, bipolar 27.78%, and schizophrenia 16.67%) were stabilized with high doses of racemate 97.5 ± 8 mg/day, 51.8 ± 5 mg/day of levomethadone (−46.8% vs. rac-methadone; −71% in men), and 2.5 ± 1 mg/day of buprenorphine/naloxone. Three patients in remission were treated with tapering doses of levomethadone. Significantly reduced QTcF values were recorded with levomethadone (delta −32 ms vs. rac-methadone) in the bipolar patients, as well as the schizophrenia patients in remission (delta −45.19 ms vs. rac-methadone). Our patients were safely stabilized. Levomethadone, compared to the racemate, contributes to reducing the illicit use, especially of opioids and cannabinoids at significantly lower doses with cardiovascular safety, which, in bipolar patients, is clinically significant.

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Section: Discussionsupporting

confidence: 86%

Section: Discussionsupporting

confidence: 81%

Multicenter Observational/Exploratory Study Addressed to the Evaluation of the Effectiveness and Safety of Pharmacological Therapy in Opioid-Dependent Patients in Maintenance Therapy in Southern Italy

et al. 2022

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“…Given the recognized risk of adverse health outcomes for patients with OUD, and the risks prescribers reported for patients with additional unsupervised doses, all patients on OAT should receive harm reduction counseling and supports. Although risks of adverse outcomes related to OAT are always present, recent evidence from Ukraine and the United States show that despite changes in OAT prescribing practices (i.e., more unsupervised doses prescribed) during the pandemic, overdoses ( Amram et al, 2021 ) or deaths due to OAT have not increased ( Brothers, Viera, & Heimer, 2021 ; Meteliuk et al, 2021 ). The results from our study contribute to a growing body of research that suggests relaxing the criteria for unsupervised doses is not associated with significant negative health outcomes and may be a feasible approach to increasing patient engagement in care.…”

Section: Discussionmentioning

confidence: 99%

Evaluating how has care been affected by the Ontario COVID-19 Opioid Agonist Treatment Guidance: Patients’ and prescribers’ experiences with changes in unsupervised dosing

Corace

Suschinsky

Wyman

et al. 2022

International Journal of Drug Policy

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Background The COVID-19 pandemic has exacerbated the opioid crisis. Opioid-related deaths have increased and access to treatment services, including opioid agonist treatment (OAT), has been disrupted. The Ontario COVID-19 OAT Treatment Guidance document was developed to facilitate access to OAT and continuity of care during the pandemic, while supporting physical distancing measures. In particular, the Guidance expanded access to unsupervised OAT dosing. It is important to evaluate the changes in unsupervised OAT dosing after the release of the Ontario COVID-19 OAT Guidance based on patients’ and prescribers’ reports. Method Online questionnaires were developed collaboratively with people with lived and living expertise, prescribers, clinical experts, and researchers. Patients ( N =402) and prescribers ( N =100) reported their experiences with changes in unsupervised dosing during the first six months of the pandemic. Results Many patients (57%) reported receiving additional unsupervised OAT doses (i.e., take away doses). Patients who received additional unsupervised doses were not significantly more likely to report adverse health outcomes compared to patients who did not receive additional unsupervised doses. Patients with additional unsupervised doses and prescribers agreed that changes in OAT care were positive (e.g., reported an improved patient-prescriber relationship and more openness between patient and prescriber). Prescribers and some patients reported the need for continued flexibility in unsupervised doses after the pandemic restrictions lift. Conclusions Results support the need to re-evaluate historical approaches to OAT care delivery, particularly unsupervised doses. It is crucial to implement policies, regulations, and supports to reduce barriers to OAT care during the pandemic and once the pandemic response restrictions are eased. Flexibility in OAT care delivery, particularly unsupervised dosing, will be key to providing patient-centred care for persons with opioid use disorder.

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“…During the COVID-19 pandemic, OTPs were allowed to provide up to 28 days of take-home methadone doses to patients, greatly reducing barriers. During these COVID-19 pandemic-related changes to OTP prescribing, there were no changes in positive urine drug tests for methadone [ 31 ]. Allowing these COVID-19 pandemic-related changes to continue long term may help patients stay retained on methadone with adequate dosing [ 30 ].…”

Section: Discussionmentioning

confidence: 99%

Factors associated with retention on medications for opioid use disorder among a cohort of adults seeking treatment in the community

Biondi

Wyk

Schlossberg

et al. 2022

Addict Sci Clin Pract

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Background Medication treatment for opioid use disorder (OUD) (MOUD; buprenorphine and methadone) reduces opioid use and overdose. Discontinuation of MOUD can quickly lead to relapse, overdose and death. Few persons who initiate MOUD are retained on treatment, thus it is critical to identify factors associated with retention. Methods Evaluated data was from an ongoing prospective cohort study of adults aged 18 or older with DSM-5 moderate to severe OUD seeking MOUD in the community and followed for 6 months. Participants were considered retained on MOUD through 6 months if they reported taking MOUD at every study interview without discontinuation. A high dose of MOUD was defined as a methadone dose > 85 mg or buprenorphine dose ≥ 16 mg. Multivariable logistic regression was conducted to assess factors associated with 6-month MOUD retention. Results A total of 118 participants (73% male, 58% white, 36% with HIV) were included. Buprenorphine was initiated by 58% and 42% started methadone. MOUD retention was 49% and 58% among buprenorphine and methadone, respectively, at 6-months. In adjusted models, a high MOUD dose (OR = 4.71, 95% CI 2.05–10.84) and higher pain interference (OR = 1.59, 95% CI 1.15–2.19) was associated with MOUD retention. Conclusions Adequate dosing of MOUD leads to improved retention on MOUD. Further, persons with high pain interference at baseline had higher odds of retention on MOUD. Both methadone and buprenorphine have analgesic effects, thus those with high pain interference could have dual benefits of MOUD for treating OUD and pain. Interventions should be tailored to improve adequate MOUD dosing to improve retention on MOUD.

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The impact of relaxation of methadone take-home protocols on treatment outcomes in the COVID-19 era

Cited by 54 publications

References 24 publications

Multicenter Observational/Exploratory Study Addressed to the Evaluation of the Effectiveness and Safety of Pharmacological Therapy in Opioid-Dependent Patients in Maintenance Therapy in Southern Italy

Multicenter Observational/Exploratory Study Addressed to the Evaluation of the Effectiveness and Safety of Pharmacological Therapy in Opioid-Dependent Patients in Maintenance Therapy in Southern Italy

Evaluating how has care been affected by the Ontario COVID-19 Opioid Agonist Treatment Guidance: Patients’ and prescribers’ experiences with changes in unsupervised dosing

Factors associated with retention on medications for opioid use disorder among a cohort of adults seeking treatment in the community

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