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Relaxing restrictions on take-home methadone doses does not increase risk of treatment dropout or positive drug tests

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Long-standing restrictions on methadone treatment limited the amount of take-home doses patients could receive at one time. COVID-19 public health guidelines (e.g., physical distancing), however, led federal agencies to relax these restrictions during the pandemic. This naturalistic study examined how relaxing methadone dose restrictions affected take-home doses, treatment retention, drug test positivity rates, and patient reactions.

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recovery science
with the free, monthly
Recovery Bulletin

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WHAT PROBLEM DOES THIS STUDY ADDRESS?

The opioid use disorder medication methadone keeps people in treatment longer and reduces mortality risk. Before the COVID-19 pandemic, federal regulations required patients to receive their doses in-person at a treatment facility. While take-home doses were available, there were limitations on the amount of take-home methadone doses patients could receive at one time.

These limitations were based on the number of days the patient was in treatment, with those in treatment for a longer time being eligible to receive more doses. For instance, patients in treatment for 1-90 days could receive up to 1 take-home dose per week, while those in treatment for more than 2 years could receive up to 27 every month. Patients could receive more take-homes based on the following considerations: absence of recent alcohol or drug use, clinic attendance pattern, behavioral problems occurring simultaneously, recent criminal activity, stability of the home environment, treatment duration, safe storage of the take-home dosages, and the benefit to the patient outweighs the risk.

When the COVID-19 pandemic began in March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) relaxed these restrictions with the goal of improving treatment access and reducing the risk of COVID-19 transmission that can occur at crowded opioid treatment facilities. This allowed patients who were considered “clinically stable” as defined by the considerations above to receive up to 27 take-home doses and those who were less stable to receive to receive up to 13 take-home doses, regardless of their time in treatment.

Early studies that have investigated the impact of relaxing the take-home dosing restrictions showed a 50% decrease in the number of monthly clinic visits and a 100% increase in the amount of take-home doses dispensed monthly. There were also early concerns about how the pandemic may negatively affect mental health and substance use, particularly in rural communities where patients likely live further away from treatment facilities and are accordingly more burdened by travel time and distance. While the relaxation of restrictions may reduce some of these burdens and improve treatment access, there may also be unintended consequences such as lower treatment retention and an increased number of positive drug tests, though such concerns require more investigation.

This study examined how relaxing methadone dose restrictions affects take-home doses, treatment retention, and drug test positivity rates in 2 opioid treatment programs, as well as how patients responded to them. Studies such as these can help us understand how enhancing access to take-home methadone doses impacts important treatment outcomes.


HOW WAS THIS STUDY CONDUCTED?

The research team used mixed methods (i.e., both quantitative and qualitative approaches) to examine how relaxing methadone dose restrictions affects take-home doses, treatment retention, drug test positivity rates, and patient reactions in 2 opioid treatment programs that serve 5 rural counties in Oregon. These programs followed the federal guidelines and distributed up to 27 take-home doses for patients who met the criteria for being clinically stable and 13 take-home doses for those who were considered to be less stable.

The study first examined differences in take-home doses before and after the COVID-19 policy changes and the associations with treatment discontinuation and urine drug test positivity. The pre-COVID period was defined September 1, 2019 to February 28, 2020 and the post-COVID period was defined as April 1, 2020 to September 30, 2020. March 2020 was excluded from the study because the restriction relaxation was made effective in the middle of the month. Data for the analysis was drawn from the electronic health records of 377 patients and was grouped into 3 categories depending on the amount time the patient has spent in treatment: 0-90 days, 91-180 days, or 181 days or more.

Participants in this analysis examining differences in take-home dose effects before and after the pandemic were about half women (49%) and men (51%) who identified as mostly non-Hispanic White (93%). They had an average age of 40 years and the median duration of treatment was 532 days from treatment entry to the end of the study period. Sixty-five percent of patients were in treatment at the beginning of the study period and approximately half (47%) remained through the end of the study period.

Researchers also examined what would have happened in a hypothetical scenario where there was no policy change. To do this, they drew data from 216 of the 377 patients who had at least 3 months of pre-COVID data and one month of post-COVID data available. The 3 months of pre-COVID data allowed them to estimate treatment trends before the policy change. These participants had a longer time in treatment than the overall patient population, with a median treatment duration of 688 days. Prior to COVID, 42% of their methadone doses were take-home, which increased to 57% post-COVID.

Finally, the research team also sought to understand patient reactions to the policy change by interviewing 32 patients. The interviews were conducted by trained researchers who have experience administering these types of interviews in 2 waves: August-September 2020 and November- December 2020. Interviews were recorded and transcribed. A systematic process was then used to group responses into overarching themes.

Participants who were interviewed were 50% women and the majority identified as non-Hispanic White (81%). They were 42.6 years old on average.


WHAT DID THIS STUDY FIND?

Longer-term patients benefitted from relaxed take-home guidelines, though shorter-term patients had worse outcomes.

Among the patients who had been in care for longer than 180 days, there was an increase in the amount of take-home methadone doses received per month from 8 doses pre-COVID to 13 doses post-COVID. There were no changes the proportion of positive drug test results or retention rate in treatment pre- and post-COVID.

Among the patients who were in treatment for 90 to 180 days and fewer than 90 days, there were no increases in the amount of take-home methadone doses received per month pre- and post-COVID. However, those in treatment for 90 to 180 days had a higher drug test positivity rate post-COVID (33%) than pre-COVID (19%) and those in treatment for less than 90 days were more likely to discontinue treatment post-COVID (26%) than pre-COVID (13%).

In a sub-group of individuals in treatment for at least 3 months before, and 1 month after, the guidelines were relaxed, take-home dosing increased an average of 15%. This increase in take-home doses above expectation was associated with better outcomes, including lower opioid-positive drug test rates and a lower likelihood of discontinuing treatment.

Patient reactions to the relaxed guidelines were overall positive.

Patient reactions to the relaxation of take home dose restrictions were positive and grouped into 3 themes: (1) they valued feeling trusted with increased responsibility; (2) they experienced reduced travel time, allowing more time for working or recreation; and (3) they were exposed less to other patients who had less time in recovery and other potential triggers for returning to substance use.


WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

Researchers in this study examined how relaxing the methadone dose restrictions during the COVID-19 pandemic affected take-home doses, treatment retention, drug test positivity rates, and patient reactions. Results varied by time in treatment, with patients who had more than 180 days in treatment getting more take-home doses post-COVID than pre-COVID, but not showing any increases in positive drug test rates or treatment discontinuation rates. However, those in treatment for less than 180 days did not have an increase in take-home doses post-COVID compared to pre-COVID, had a higher drug test positivity rate, and were more likely to discontinue treatment. This suggests that enhancing access to take-home methadone treatment may benefit patients who have been in recovery for a longer time and builds on prior studies showing similar results.

Further, results suggest that those in recovery for less time may have been vulnerable to the stressors and isolation caused by the pandemic. This points to the need for individuals who are earlier in recovery to have greater supports in place to prevent returning to substance use when unexpected difficulties occur. Additionally, they may have faced greater systemic barriers to care that need to be addressed in order to promote greater treatment retention.

Results from the interviews assessing patients’ reactions to the relaxation of restrictions highlight the burdens and potential consequences experienced by patients attending in-person appointments to receive their dose pre-COVID.

Traveling to appointments as much as 6 times per week greatly reduces the amount of time patients have for working and recreational activities, especially for those in rural communities who have further to travel.

Frequent visits to treatment programs in areas with high proportions of people who use drugs can expose patients to others with less time in recovery and other triggers, including drug use-related cues. Patients who were interviewed reported appreciating reduced travel time and less exposure to triggers. They also reported that they valued feeling trusted with more doses.

Taken together, the study’s findings suggest the potential for modifying federal regulations on take-home methadone dosing. Specifically, changing regulations to allow patients with more than 180 days in treatment to receive 27 take-home doses instead of the 3 doses allowed prior to COVID-19 may be beneficial, particularly for those living in rural communities. However, patients with less than 180 days in recovery may face barriers to care and appear to need more support to promote their recovery long-term.


  1. The sub-group analysis of 216 participants may be individuals who were particularly committed to methadone treatment, given that they were in treatment for at least 3 months before the policy change and 1 month after the policy change. It is unclear then if these findings will apply to other patients receiving methadone who have been in treatment for less time.
  2. The results may not apply to other groups of people. Specifically, participants in the study mostly identified as non-Hispanic White, so results may not apply to other races or ethnicities. Likewise, the results may be limited to the geographic region the study was conducted in.
  3. Because data were drawn from electronic health records and were not collected initially for research purposes, some important variables are not available, such as patients’ reasons for treatment discontinuation or their treatment history.
  4. The 2 opioid treatment programs where the study took place were small. The extent to which small programs adhere to the dosage guidelines may differ in larger programs.

BOTTOM LINE

The study findings show that patients who were in treatment for more than 180 days had an increase in the amount of take-home methadone doses received with no changes in other treatment outcomes pre- and post-COVID, while those in treatment for less than 180 days did not have an increase in dosing and showed adverse treatment outcomes. This suggests that modifying federal regulations to enhance access to take-home methadone for those in treatment for this longer period of time can be beneficial with no unintended consequences, but those in treatment for less time may need additional support.


  • For individuals and families seeking recovery: The study findings show that individuals who are in treatment for a longer time may benefit from receiving additional doses of take-home methadone by feeling more trusted, reducing travel time, and reducing potential exposures to triggers during appointments, and there does not appear to be unintended consequences of receiving more doses. Accordingly, these individuals should continue to take advantage of the restriction relaxation for as long as possible. However, individuals earlier in their recovery may still be vulnerable and are encouraged to seek out additional support and strategize ways to reduce barriers to receiving care. 
  • For treatment professionals and treatment systems: There were no unintended consequences and some benefits of providing additional take-home methadone doses to individuals further along in recovery. Accordingly, by following the relaxed guidelines for individuals with more time in methadone treatment (e.g., 180 days or more), treatment providers and programs may improve patient outcomes and experiences without unintended consequences. For those newer to treatment, the relaxed guidelines could have unintended negative effects, though programs may be able to provide additional supports to buffer against those negative outcomes.
  • For scientists: More research on the effects of enhancing access to take-home methadone doses among different populations and in different geographic regions would help shed light on the extent to which the current study’s results apply to other populations. Similarly, research on these effects in larger clinics would help to uncover whether the size of the clinic is associated with adherence to federal guidelines and if it has an impact on treatment outcomes. Finally, examining some of the variables that were not able to be investigated in the present study would provide a greater understanding of the restriction relaxation’s effects on treatment outcomes. 
  • For policy makers: By making the relaxed restrictions a permanent policy change, access to take-home methadone doses will be enhanced, which can benefit individuals who have been stable in recovery for a longer time. However, funding for additional research on these effects with different populations, in different regions, and with different clinics would provide a greater understanding of what the impacts may be. Further, funding for research to better understand the needs of individuals earlier in recovery could help promote their treatment retention, reduce mortality, and improve lives. Finally, by being aware of the numerous barriers to care that individuals with opioid use disorders face, policymakers can work to implement policies that address them.

CITATIONS

Hoffman, K. A., Foot, C., Levander, X. A., Cook, R., Terashima, J. P., McIlveen, J. W., . . . & McCarty, D. (2022). 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. Journal of Substance Abuse Treatment, 108801. doi: 10.1016/j.jsat.2022.108801


Stay on the Frontiers of
recovery science
with the free, monthly
Recovery Bulletin

l

WHAT PROBLEM DOES THIS STUDY ADDRESS?

The opioid use disorder medication methadone keeps people in treatment longer and reduces mortality risk. Before the COVID-19 pandemic, federal regulations required patients to receive their doses in-person at a treatment facility. While take-home doses were available, there were limitations on the amount of take-home methadone doses patients could receive at one time.

These limitations were based on the number of days the patient was in treatment, with those in treatment for a longer time being eligible to receive more doses. For instance, patients in treatment for 1-90 days could receive up to 1 take-home dose per week, while those in treatment for more than 2 years could receive up to 27 every month. Patients could receive more take-homes based on the following considerations: absence of recent alcohol or drug use, clinic attendance pattern, behavioral problems occurring simultaneously, recent criminal activity, stability of the home environment, treatment duration, safe storage of the take-home dosages, and the benefit to the patient outweighs the risk.

When the COVID-19 pandemic began in March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) relaxed these restrictions with the goal of improving treatment access and reducing the risk of COVID-19 transmission that can occur at crowded opioid treatment facilities. This allowed patients who were considered “clinically stable” as defined by the considerations above to receive up to 27 take-home doses and those who were less stable to receive to receive up to 13 take-home doses, regardless of their time in treatment.

Early studies that have investigated the impact of relaxing the take-home dosing restrictions showed a 50% decrease in the number of monthly clinic visits and a 100% increase in the amount of take-home doses dispensed monthly. There were also early concerns about how the pandemic may negatively affect mental health and substance use, particularly in rural communities where patients likely live further away from treatment facilities and are accordingly more burdened by travel time and distance. While the relaxation of restrictions may reduce some of these burdens and improve treatment access, there may also be unintended consequences such as lower treatment retention and an increased number of positive drug tests, though such concerns require more investigation.

This study examined how relaxing methadone dose restrictions affects take-home doses, treatment retention, and drug test positivity rates in 2 opioid treatment programs, as well as how patients responded to them. Studies such as these can help us understand how enhancing access to take-home methadone doses impacts important treatment outcomes.


HOW WAS THIS STUDY CONDUCTED?

The research team used mixed methods (i.e., both quantitative and qualitative approaches) to examine how relaxing methadone dose restrictions affects take-home doses, treatment retention, drug test positivity rates, and patient reactions in 2 opioid treatment programs that serve 5 rural counties in Oregon. These programs followed the federal guidelines and distributed up to 27 take-home doses for patients who met the criteria for being clinically stable and 13 take-home doses for those who were considered to be less stable.

The study first examined differences in take-home doses before and after the COVID-19 policy changes and the associations with treatment discontinuation and urine drug test positivity. The pre-COVID period was defined September 1, 2019 to February 28, 2020 and the post-COVID period was defined as April 1, 2020 to September 30, 2020. March 2020 was excluded from the study because the restriction relaxation was made effective in the middle of the month. Data for the analysis was drawn from the electronic health records of 377 patients and was grouped into 3 categories depending on the amount time the patient has spent in treatment: 0-90 days, 91-180 days, or 181 days or more.

Participants in this analysis examining differences in take-home dose effects before and after the pandemic were about half women (49%) and men (51%) who identified as mostly non-Hispanic White (93%). They had an average age of 40 years and the median duration of treatment was 532 days from treatment entry to the end of the study period. Sixty-five percent of patients were in treatment at the beginning of the study period and approximately half (47%) remained through the end of the study period.

Researchers also examined what would have happened in a hypothetical scenario where there was no policy change. To do this, they drew data from 216 of the 377 patients who had at least 3 months of pre-COVID data and one month of post-COVID data available. The 3 months of pre-COVID data allowed them to estimate treatment trends before the policy change. These participants had a longer time in treatment than the overall patient population, with a median treatment duration of 688 days. Prior to COVID, 42% of their methadone doses were take-home, which increased to 57% post-COVID.

Finally, the research team also sought to understand patient reactions to the policy change by interviewing 32 patients. The interviews were conducted by trained researchers who have experience administering these types of interviews in 2 waves: August-September 2020 and November- December 2020. Interviews were recorded and transcribed. A systematic process was then used to group responses into overarching themes.

Participants who were interviewed were 50% women and the majority identified as non-Hispanic White (81%). They were 42.6 years old on average.


WHAT DID THIS STUDY FIND?

Longer-term patients benefitted from relaxed take-home guidelines, though shorter-term patients had worse outcomes.

Among the patients who had been in care for longer than 180 days, there was an increase in the amount of take-home methadone doses received per month from 8 doses pre-COVID to 13 doses post-COVID. There were no changes the proportion of positive drug test results or retention rate in treatment pre- and post-COVID.

Among the patients who were in treatment for 90 to 180 days and fewer than 90 days, there were no increases in the amount of take-home methadone doses received per month pre- and post-COVID. However, those in treatment for 90 to 180 days had a higher drug test positivity rate post-COVID (33%) than pre-COVID (19%) and those in treatment for less than 90 days were more likely to discontinue treatment post-COVID (26%) than pre-COVID (13%).

In a sub-group of individuals in treatment for at least 3 months before, and 1 month after, the guidelines were relaxed, take-home dosing increased an average of 15%. This increase in take-home doses above expectation was associated with better outcomes, including lower opioid-positive drug test rates and a lower likelihood of discontinuing treatment.

Patient reactions to the relaxed guidelines were overall positive.

Patient reactions to the relaxation of take home dose restrictions were positive and grouped into 3 themes: (1) they valued feeling trusted with increased responsibility; (2) they experienced reduced travel time, allowing more time for working or recreation; and (3) they were exposed less to other patients who had less time in recovery and other potential triggers for returning to substance use.


WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

Researchers in this study examined how relaxing the methadone dose restrictions during the COVID-19 pandemic affected take-home doses, treatment retention, drug test positivity rates, and patient reactions. Results varied by time in treatment, with patients who had more than 180 days in treatment getting more take-home doses post-COVID than pre-COVID, but not showing any increases in positive drug test rates or treatment discontinuation rates. However, those in treatment for less than 180 days did not have an increase in take-home doses post-COVID compared to pre-COVID, had a higher drug test positivity rate, and were more likely to discontinue treatment. This suggests that enhancing access to take-home methadone treatment may benefit patients who have been in recovery for a longer time and builds on prior studies showing similar results.

Further, results suggest that those in recovery for less time may have been vulnerable to the stressors and isolation caused by the pandemic. This points to the need for individuals who are earlier in recovery to have greater supports in place to prevent returning to substance use when unexpected difficulties occur. Additionally, they may have faced greater systemic barriers to care that need to be addressed in order to promote greater treatment retention.

Results from the interviews assessing patients’ reactions to the relaxation of restrictions highlight the burdens and potential consequences experienced by patients attending in-person appointments to receive their dose pre-COVID.

Traveling to appointments as much as 6 times per week greatly reduces the amount of time patients have for working and recreational activities, especially for those in rural communities who have further to travel.

Frequent visits to treatment programs in areas with high proportions of people who use drugs can expose patients to others with less time in recovery and other triggers, including drug use-related cues. Patients who were interviewed reported appreciating reduced travel time and less exposure to triggers. They also reported that they valued feeling trusted with more doses.

Taken together, the study’s findings suggest the potential for modifying federal regulations on take-home methadone dosing. Specifically, changing regulations to allow patients with more than 180 days in treatment to receive 27 take-home doses instead of the 3 doses allowed prior to COVID-19 may be beneficial, particularly for those living in rural communities. However, patients with less than 180 days in recovery may face barriers to care and appear to need more support to promote their recovery long-term.


  1. The sub-group analysis of 216 participants may be individuals who were particularly committed to methadone treatment, given that they were in treatment for at least 3 months before the policy change and 1 month after the policy change. It is unclear then if these findings will apply to other patients receiving methadone who have been in treatment for less time.
  2. The results may not apply to other groups of people. Specifically, participants in the study mostly identified as non-Hispanic White, so results may not apply to other races or ethnicities. Likewise, the results may be limited to the geographic region the study was conducted in.
  3. Because data were drawn from electronic health records and were not collected initially for research purposes, some important variables are not available, such as patients’ reasons for treatment discontinuation or their treatment history.
  4. The 2 opioid treatment programs where the study took place were small. The extent to which small programs adhere to the dosage guidelines may differ in larger programs.

BOTTOM LINE

The study findings show that patients who were in treatment for more than 180 days had an increase in the amount of take-home methadone doses received with no changes in other treatment outcomes pre- and post-COVID, while those in treatment for less than 180 days did not have an increase in dosing and showed adverse treatment outcomes. This suggests that modifying federal regulations to enhance access to take-home methadone for those in treatment for this longer period of time can be beneficial with no unintended consequences, but those in treatment for less time may need additional support.


  • For individuals and families seeking recovery: The study findings show that individuals who are in treatment for a longer time may benefit from receiving additional doses of take-home methadone by feeling more trusted, reducing travel time, and reducing potential exposures to triggers during appointments, and there does not appear to be unintended consequences of receiving more doses. Accordingly, these individuals should continue to take advantage of the restriction relaxation for as long as possible. However, individuals earlier in their recovery may still be vulnerable and are encouraged to seek out additional support and strategize ways to reduce barriers to receiving care. 
  • For treatment professionals and treatment systems: There were no unintended consequences and some benefits of providing additional take-home methadone doses to individuals further along in recovery. Accordingly, by following the relaxed guidelines for individuals with more time in methadone treatment (e.g., 180 days or more), treatment providers and programs may improve patient outcomes and experiences without unintended consequences. For those newer to treatment, the relaxed guidelines could have unintended negative effects, though programs may be able to provide additional supports to buffer against those negative outcomes.
  • For scientists: More research on the effects of enhancing access to take-home methadone doses among different populations and in different geographic regions would help shed light on the extent to which the current study’s results apply to other populations. Similarly, research on these effects in larger clinics would help to uncover whether the size of the clinic is associated with adherence to federal guidelines and if it has an impact on treatment outcomes. Finally, examining some of the variables that were not able to be investigated in the present study would provide a greater understanding of the restriction relaxation’s effects on treatment outcomes. 
  • For policy makers: By making the relaxed restrictions a permanent policy change, access to take-home methadone doses will be enhanced, which can benefit individuals who have been stable in recovery for a longer time. However, funding for additional research on these effects with different populations, in different regions, and with different clinics would provide a greater understanding of what the impacts may be. Further, funding for research to better understand the needs of individuals earlier in recovery could help promote their treatment retention, reduce mortality, and improve lives. Finally, by being aware of the numerous barriers to care that individuals with opioid use disorders face, policymakers can work to implement policies that address them.

CITATIONS

Hoffman, K. A., Foot, C., Levander, X. A., Cook, R., Terashima, J. P., McIlveen, J. W., . . . & McCarty, D. (2022). 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. Journal of Substance Abuse Treatment, 108801. doi: 10.1016/j.jsat.2022.108801


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WHAT PROBLEM DOES THIS STUDY ADDRESS?

The opioid use disorder medication methadone keeps people in treatment longer and reduces mortality risk. Before the COVID-19 pandemic, federal regulations required patients to receive their doses in-person at a treatment facility. While take-home doses were available, there were limitations on the amount of take-home methadone doses patients could receive at one time.

These limitations were based on the number of days the patient was in treatment, with those in treatment for a longer time being eligible to receive more doses. For instance, patients in treatment for 1-90 days could receive up to 1 take-home dose per week, while those in treatment for more than 2 years could receive up to 27 every month. Patients could receive more take-homes based on the following considerations: absence of recent alcohol or drug use, clinic attendance pattern, behavioral problems occurring simultaneously, recent criminal activity, stability of the home environment, treatment duration, safe storage of the take-home dosages, and the benefit to the patient outweighs the risk.

When the COVID-19 pandemic began in March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) relaxed these restrictions with the goal of improving treatment access and reducing the risk of COVID-19 transmission that can occur at crowded opioid treatment facilities. This allowed patients who were considered “clinically stable” as defined by the considerations above to receive up to 27 take-home doses and those who were less stable to receive to receive up to 13 take-home doses, regardless of their time in treatment.

Early studies that have investigated the impact of relaxing the take-home dosing restrictions showed a 50% decrease in the number of monthly clinic visits and a 100% increase in the amount of take-home doses dispensed monthly. There were also early concerns about how the pandemic may negatively affect mental health and substance use, particularly in rural communities where patients likely live further away from treatment facilities and are accordingly more burdened by travel time and distance. While the relaxation of restrictions may reduce some of these burdens and improve treatment access, there may also be unintended consequences such as lower treatment retention and an increased number of positive drug tests, though such concerns require more investigation.

This study examined how relaxing methadone dose restrictions affects take-home doses, treatment retention, and drug test positivity rates in 2 opioid treatment programs, as well as how patients responded to them. Studies such as these can help us understand how enhancing access to take-home methadone doses impacts important treatment outcomes.


HOW WAS THIS STUDY CONDUCTED?

The research team used mixed methods (i.e., both quantitative and qualitative approaches) to examine how relaxing methadone dose restrictions affects take-home doses, treatment retention, drug test positivity rates, and patient reactions in 2 opioid treatment programs that serve 5 rural counties in Oregon. These programs followed the federal guidelines and distributed up to 27 take-home doses for patients who met the criteria for being clinically stable and 13 take-home doses for those who were considered to be less stable.

The study first examined differences in take-home doses before and after the COVID-19 policy changes and the associations with treatment discontinuation and urine drug test positivity. The pre-COVID period was defined September 1, 2019 to February 28, 2020 and the post-COVID period was defined as April 1, 2020 to September 30, 2020. March 2020 was excluded from the study because the restriction relaxation was made effective in the middle of the month. Data for the analysis was drawn from the electronic health records of 377 patients and was grouped into 3 categories depending on the amount time the patient has spent in treatment: 0-90 days, 91-180 days, or 181 days or more.

Participants in this analysis examining differences in take-home dose effects before and after the pandemic were about half women (49%) and men (51%) who identified as mostly non-Hispanic White (93%). They had an average age of 40 years and the median duration of treatment was 532 days from treatment entry to the end of the study period. Sixty-five percent of patients were in treatment at the beginning of the study period and approximately half (47%) remained through the end of the study period.

Researchers also examined what would have happened in a hypothetical scenario where there was no policy change. To do this, they drew data from 216 of the 377 patients who had at least 3 months of pre-COVID data and one month of post-COVID data available. The 3 months of pre-COVID data allowed them to estimate treatment trends before the policy change. These participants had a longer time in treatment than the overall patient population, with a median treatment duration of 688 days. Prior to COVID, 42% of their methadone doses were take-home, which increased to 57% post-COVID.

Finally, the research team also sought to understand patient reactions to the policy change by interviewing 32 patients. The interviews were conducted by trained researchers who have experience administering these types of interviews in 2 waves: August-September 2020 and November- December 2020. Interviews were recorded and transcribed. A systematic process was then used to group responses into overarching themes.

Participants who were interviewed were 50% women and the majority identified as non-Hispanic White (81%). They were 42.6 years old on average.


WHAT DID THIS STUDY FIND?

Longer-term patients benefitted from relaxed take-home guidelines, though shorter-term patients had worse outcomes.

Among the patients who had been in care for longer than 180 days, there was an increase in the amount of take-home methadone doses received per month from 8 doses pre-COVID to 13 doses post-COVID. There were no changes the proportion of positive drug test results or retention rate in treatment pre- and post-COVID.

Among the patients who were in treatment for 90 to 180 days and fewer than 90 days, there were no increases in the amount of take-home methadone doses received per month pre- and post-COVID. However, those in treatment for 90 to 180 days had a higher drug test positivity rate post-COVID (33%) than pre-COVID (19%) and those in treatment for less than 90 days were more likely to discontinue treatment post-COVID (26%) than pre-COVID (13%).

In a sub-group of individuals in treatment for at least 3 months before, and 1 month after, the guidelines were relaxed, take-home dosing increased an average of 15%. This increase in take-home doses above expectation was associated with better outcomes, including lower opioid-positive drug test rates and a lower likelihood of discontinuing treatment.

Patient reactions to the relaxed guidelines were overall positive.

Patient reactions to the relaxation of take home dose restrictions were positive and grouped into 3 themes: (1) they valued feeling trusted with increased responsibility; (2) they experienced reduced travel time, allowing more time for working or recreation; and (3) they were exposed less to other patients who had less time in recovery and other potential triggers for returning to substance use.


WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

Researchers in this study examined how relaxing the methadone dose restrictions during the COVID-19 pandemic affected take-home doses, treatment retention, drug test positivity rates, and patient reactions. Results varied by time in treatment, with patients who had more than 180 days in treatment getting more take-home doses post-COVID than pre-COVID, but not showing any increases in positive drug test rates or treatment discontinuation rates. However, those in treatment for less than 180 days did not have an increase in take-home doses post-COVID compared to pre-COVID, had a higher drug test positivity rate, and were more likely to discontinue treatment. This suggests that enhancing access to take-home methadone treatment may benefit patients who have been in recovery for a longer time and builds on prior studies showing similar results.

Further, results suggest that those in recovery for less time may have been vulnerable to the stressors and isolation caused by the pandemic. This points to the need for individuals who are earlier in recovery to have greater supports in place to prevent returning to substance use when unexpected difficulties occur. Additionally, they may have faced greater systemic barriers to care that need to be addressed in order to promote greater treatment retention.

Results from the interviews assessing patients’ reactions to the relaxation of restrictions highlight the burdens and potential consequences experienced by patients attending in-person appointments to receive their dose pre-COVID.

Traveling to appointments as much as 6 times per week greatly reduces the amount of time patients have for working and recreational activities, especially for those in rural communities who have further to travel.

Frequent visits to treatment programs in areas with high proportions of people who use drugs can expose patients to others with less time in recovery and other triggers, including drug use-related cues. Patients who were interviewed reported appreciating reduced travel time and less exposure to triggers. They also reported that they valued feeling trusted with more doses.

Taken together, the study’s findings suggest the potential for modifying federal regulations on take-home methadone dosing. Specifically, changing regulations to allow patients with more than 180 days in treatment to receive 27 take-home doses instead of the 3 doses allowed prior to COVID-19 may be beneficial, particularly for those living in rural communities. However, patients with less than 180 days in recovery may face barriers to care and appear to need more support to promote their recovery long-term.


  1. The sub-group analysis of 216 participants may be individuals who were particularly committed to methadone treatment, given that they were in treatment for at least 3 months before the policy change and 1 month after the policy change. It is unclear then if these findings will apply to other patients receiving methadone who have been in treatment for less time.
  2. The results may not apply to other groups of people. Specifically, participants in the study mostly identified as non-Hispanic White, so results may not apply to other races or ethnicities. Likewise, the results may be limited to the geographic region the study was conducted in.
  3. Because data were drawn from electronic health records and were not collected initially for research purposes, some important variables are not available, such as patients’ reasons for treatment discontinuation or their treatment history.
  4. The 2 opioid treatment programs where the study took place were small. The extent to which small programs adhere to the dosage guidelines may differ in larger programs.

BOTTOM LINE

The study findings show that patients who were in treatment for more than 180 days had an increase in the amount of take-home methadone doses received with no changes in other treatment outcomes pre- and post-COVID, while those in treatment for less than 180 days did not have an increase in dosing and showed adverse treatment outcomes. This suggests that modifying federal regulations to enhance access to take-home methadone for those in treatment for this longer period of time can be beneficial with no unintended consequences, but those in treatment for less time may need additional support.


  • For individuals and families seeking recovery: The study findings show that individuals who are in treatment for a longer time may benefit from receiving additional doses of take-home methadone by feeling more trusted, reducing travel time, and reducing potential exposures to triggers during appointments, and there does not appear to be unintended consequences of receiving more doses. Accordingly, these individuals should continue to take advantage of the restriction relaxation for as long as possible. However, individuals earlier in their recovery may still be vulnerable and are encouraged to seek out additional support and strategize ways to reduce barriers to receiving care. 
  • For treatment professionals and treatment systems: There were no unintended consequences and some benefits of providing additional take-home methadone doses to individuals further along in recovery. Accordingly, by following the relaxed guidelines for individuals with more time in methadone treatment (e.g., 180 days or more), treatment providers and programs may improve patient outcomes and experiences without unintended consequences. For those newer to treatment, the relaxed guidelines could have unintended negative effects, though programs may be able to provide additional supports to buffer against those negative outcomes.
  • For scientists: More research on the effects of enhancing access to take-home methadone doses among different populations and in different geographic regions would help shed light on the extent to which the current study’s results apply to other populations. Similarly, research on these effects in larger clinics would help to uncover whether the size of the clinic is associated with adherence to federal guidelines and if it has an impact on treatment outcomes. Finally, examining some of the variables that were not able to be investigated in the present study would provide a greater understanding of the restriction relaxation’s effects on treatment outcomes. 
  • For policy makers: By making the relaxed restrictions a permanent policy change, access to take-home methadone doses will be enhanced, which can benefit individuals who have been stable in recovery for a longer time. However, funding for additional research on these effects with different populations, in different regions, and with different clinics would provide a greater understanding of what the impacts may be. Further, funding for research to better understand the needs of individuals earlier in recovery could help promote their treatment retention, reduce mortality, and improve lives. Finally, by being aware of the numerous barriers to care that individuals with opioid use disorders face, policymakers can work to implement policies that address them.

CITATIONS

Hoffman, K. A., Foot, C., Levander, X. A., Cook, R., Terashima, J. P., McIlveen, J. W., . . . & McCarty, D. (2022). 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. Journal of Substance Abuse Treatment, 108801. doi: 10.1016/j.jsat.2022.108801


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