Should take-home medication for opioid use disorder become the norm?

 

The impact of COVID-19 on people with pre-existing health problems has been devastating. To speak of any benefit of the COVID crisis for them is perhaps heretical.  But an important COVID-induced change in the treatment of opioid use disorder (OUD) is a crisis response with demonstrated benefits.  In many countries, people living with OUD who wish to receive the gold-standard treatment of methadone maintenance therapy are required to present themselves daily to be observed consuming this opioid agonist medicine.  As reported by Harm Reduction International, a non-profit organization because of COVID-19, there was some form of easing of the daily attendance requirement in 47 countries. Of these, some 23 countries improved access by providing methadone through home delivery or other outreach services.

These changes represent a breakthrough.  In many countries, policy-makers have long resisted provision of take-home doses of methadone based on perceptions of high risk of diversion of methadone to illicit uses.  Take-home doses are often allowed as a privilege only to patients who have been followed for a long time and then only in doses covering a few days.  With COVID-related restrictions on movement, many countries allowed week-long or even month-long take-home doses, greatly reducing the risk of treatment interruption among people locked down or otherwise unable or unwilling to attend daily sessions.  In addition, random urinalysis, a requirement of methadone programs in some countries, was in some cases dropped in favor of other kinds of monitoring, including telehealth check-ins.

Buprenorphine, a partial opioid agonist, is also a widely used medication for OUD (MOUD).  The potential for diversion of buprenorphine to illicit use is seen by policy-makers to be lower than that of methadone, especially when a buprenorphine/naloxone combination formulation is used, as is the case in many countries.  In some countries, such as France, buprenorphine administration has long been well integrated in primary care and into the training of general-practice physicians.  In others, such as the United States of America, physicians are required to have special training, and there are other restrictions, such as a limit on the number of buprenorphine patients per physician and a requirement that patients be seen in person before beginning treatment. Federal drug authorities in the USA dropped the in-person examination requirement during  COVID-19-s.  In some services in India, the rule for daily or weekly presentation for newer buprenorphine patients was waived in favor of two-week take-home doses for all patients.

A number of peer-reviewed evaluations of COVID-related loosening of MOUD restrictions, particularly in the United States, indicate that both patients and providers are finding these changes to be largely positive, though with some cautions. Patients unsurprisingly expressed relief from daily queues at methadone clinics, which would pose COVID risks.  Telehealth consultations assisted providers in keeping track of patients who might have problems with the changed protocol.  In some jurisdictions, at-home administration was assisted by medicine containers that could be monitored electronically to prevent diversion.  Some experience indicated that home administration has not been associated with an increase in overdose episodes, which some had feared.  In some places, protocols combined distribution of naloxone, an overdose-reversing medicine, with at-home MOUD to prevent overdose mortality and injury, or authorities gave guidance on improving naloxone access for those with take-home doses.

Unfortunately, some jurisdictions now have returned or are planning to return to the pre-COVID methods of administration of methadone.  In Ohio, a state in USA,  for example, reinstituted pre-COVID restrictions in spite of opposition from methadone providers.  State health officials cited the wide available of COVID vaccines as a reason for abandoning the emergency-related take-home doses, though vaccination rates in Ohio are relatively low.  Providers in countries as diverse as Ukraine and Argentina have urged that COVID-related changes in MOUD administration be made permanent.

Less restrictive policy, particularly regarding take-home methadone, should continue to be studied, but health officials should not rush to abandon changes that benefit people living with OUD, who have long faced many barriers to care.  Rapid assessments of the emergency MOUD experiences that document the perspectives of both patients and providers, as well as means of reducing diversion risks, would be useful.  While opioid overdose and opioid use disorders as well as COVID remain important public health problems, it would be unfortunate to miss the opportunity to enhance access to proven OUD treatment.

About the author

Joanne Csete is adjunct associate professor of public health at Columbia University Mailman School of Public health and was founding director of the HIV and Human Rights Program at Human Rights Watch.  She has worked for years on policy change related to health services for criminalized persons.

Competing Interests 

None

Handling Editor

Soumyadeep Bhaumik

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