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.

OBJECTIVES: In March 2020, the Substance Abuse and Mental Health Services Administration permitted Opioid Treatment Programs (OTPs) to relax restrictions on take-home methadone and promoted telehealth to minimize potential exposures to COVID-19. We assessed the effects of COVID-19-related changes on take-home methadone dosing in two OTPs serving five rural Oregon counties. METHODS: We used a mixed-methods convergent design. The OTPs extracted urine drug test (UDT) results, take-home methadone regimens, and treatment retention from the electronic health record (EHR) for patients (n = 377). A mixed-effects negative binomial regression model assessed patient-level differences in take-home doses before and after the COVID-19 policy changes and the associations with treatment discontinuation, and UDT positivity. Semi-structured qualitative interviews (n = 32) explored patient reactions to increased take-home dosing and reduced clinic visits to provide context for quantitative findings. RESULTS: The number of take-home doses increased in the post-COVID-19 period for patients engaged in treatment for more than 180 days (median: 8 vs 13 take-home doses per month, p = 0.011). Take-homes did not increase for patients with fewer days of treatment. Each percentage point increase in take-home dosing above what would be expected without COVID-19 policy changes was negatively associated with the percent of UDT positive for opioids (B = -0.12, CI [-0.21, -0.04], p = 0.005) and the probability of treatment discontinuation (aOR = 0.97, CI [0.95, 0.99], p = 0.003). Qualitative analysis revealed three themes explaining how increased take-home dosing supported recovery: 1) value of feeling trusted with increased responsibility; 2) reduced travel time permitted increased employment and recreation; and 3) reduced exposure to individuals less stable in recovery and potential triggers. CONCLUSIONS: Take-home methadone dose relaxations were associated with increased methadone take-home doses, improved retention, and decreased UDT opioid positive results among clinically stable patients. Qualitative findings suggest that fewer take-home restrictions are feasible and desirable and do not pose safety or public health harms.

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

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.

Reduction in Oregon's Medication Dosing Visits After the SARS-CoV-2 Relaxation of Restrictions on Take-home Medication.

To slow the spread of SARS-CoV-2 in opioid treatment programs (OTPs), SAMHSA notified State Opioid Treatment Authorities that stable patients could receive up to 27 days of take-homes, less stable patients could receive up to 13 days with fewer take-homes for other patients. An analysis assessed how the relaxed standards affected the number of patient dosing visits and the amount of take-home medications dispensed in Oregon's 20 public, nonprofit, and for-profit OTPs. OTPs reported the number of patients receiving take homes pre and post federal policy change at 3 time points: pre SARS-CoV-2 (February or first half of March), post 1 SARS-CoV-2 (March, April, or May), and post 2 SARS-CoV-2 (April, May, or June). The patients receiving each quantity of take-homes were counted and means calculated for visits and take-homes per patient per month. A negative binomial mixed-effects regression model assessed change in mean dosing visits per patient. During the pre SARS-CoV-2 period, OTPs served 7792 patients monthly with 120,513 medication visits and dispensed 44,883 take-home doses. Mean patient visits per month were 15.5 with 5.8 take-homes per patient per month. Following the policy change, medication visits declined 33% and take-home medication increased 97% with 10.4 mean visits per patient and 11.3 mean take-homes per patient. The negative binomial mixed-effects regression model estimated a 54% reduction in mean visits per patient. The policy change had the intended effect. More research is needed to assess unintended consequences associated with increased access to take-home medication.

Medicaid expansion and treatment for opioid use disorders in Oregon: an interrupted time-series analysis.

BACKGROUND: The study examined the association of the Affordable Care Act's 2014 Medicaid expansion on the use of psychosocial services and pharmacotherapies for opioid use disorders among Oregon Medicaid recipients. METHODS: Logistic regression analysis examined utilization of care before (January 1, 2010-December 31, 2013) and after Medicaid expansion in Oregon (January 1, 2014-December 31, 2016). RESULTS: Adult membership in the Oregon Health Plan (Medicaid) increased 180% following Medicaid expansion (2013 = 172,539; 2014 = 482,081) and the number with a diagnosis of OUD nearly doubled (2013 = 6808; 2014 = 13,418). More individuals received psychosocial services (2013 = 4714; 2014 = 8781) and medications (2013 = 3464; 2014 = 6093) for opioid use disorder. The percent of patients receiving psychosocial services (69% to 65%) and the percent of individuals receiving pharmacotherapy (57% to 45%) declined primarily because of a decline in the proportion receiving care in an opioid treatment program (2013 = 41%; 2014 = 33%). Odds of accessing any psychosocial service increased by 8% per year from 2010 to 2013 (AOR = 1.08; 95% CI 1.06-1.11) with an 18% immediate decline associated with Medicaid expansion in 2014 (AOR = 0.82; 95% CI 0.76-0.87). Following Medicaid expansion, the odds of accessing psychosocial services increased 8% per year (2014 through 2016) (AOR = 1.08; 95% CI 1.06-1.11). Use of medications for opioid use disorder found no change in the odds of use in the years prior to Medicaid expansion, an immediate 36% (AOR = 0.64; 95% CI 0.60-0.68) decline in 2014, and a 13% increase per year in 2015 and 2016 (AOR = 1.13; 95% CI 1.09-1.16). CONCLUSION: The number of Medicaid recipients with an opioid use disorder who received psychosocial and pharmacological services increased substantially following Oregon's Medicaid expansion in 2014. There was a decline, however, in the proportion of individuals with an opioid use disorder receiving care in opioid treatment programs.