{"id":39834,"date":"2021-08-11T11:02:47","date_gmt":"2021-08-11T11:02:47","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmjgh\/?p=39834"},"modified":"2021-08-11T11:04:24","modified_gmt":"2021-08-11T11:04:24","slug":"should-take-home-medication-for-opioid-use-disorder-become-the-norm","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmjgh\/2021\/08\/11\/should-take-home-medication-for-opioid-use-disorder-become-the-norm\/","title":{"rendered":"Should take-home medication for opioid use disorder become the norm?"},"content":{"rendered":"<p>&nbsp;<\/p>\n<p>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.\u00a0 But an important COVID-induced change in the treatment of opioid use disorder (OUD) is a crisis response with demonstrated benefits.\u00a0 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. \u00a0As reported by <a href=\"https:\/\/www.hri.global\/files\/2021\/03\/04\/Global_State_HRI_2020_BOOK_FA_Web.pdf\">Harm Reduction International<\/a>, 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.<\/p>\n<p>These changes represent a breakthrough.\u00a0 In many countries, policy-makers have long <a href=\"https:\/\/www.healthaffairs.org\/do\/10.1377\/hblog20190920.981503\/full\/\">resisted provision of take-home doses<\/a> of methadone based on perceptions of high risk of diversion of methadone to illicit uses.\u00a0 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. \u00a0With 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.\u00a0 In addition, random <a href=\"https:\/\/www.healthaffairs.org\/do\/10.1377\/hblog20190920.981503\/full\/\">urinalysis<\/a>, a requirement of methadone programs in some countries, was in some cases dropped in favor of other kinds of monitoring, including telehealth check-ins.<\/p>\n<p>Buprenorphine, a partial opioid agonist, is also a widely used medication for OUD (MOUD).\u00a0 The potential for diversion of buprenorphine to illicit use is seen by policy-makers to be lower than that of methadone, especially when a <a href=\"https:\/\/europepmc.org\/backend\/ptpmcrender.fcgi?accid=PMC3154701&amp;blobtype=pdf\">buprenorphine\/naloxone combination<\/a> formulation is used, as is the case in many countries.\u00a0 In some countries, such as France, buprenorphine administration has long been well integrated in primary care and into the training of general-practice physicians.\u00a0 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 <a href=\"https:\/\/www.samhsa.gov\/sites\/default\/files\/faqs-for-oud-prescribing-and-dispensing.pdf\">in-person examination requirement<\/a> during \u00a0COVID-19-s.\u00a0 In some services in <a href=\"https:\/\/www.indianjpsychiatry.org\/article.asp?issn=0019-5545;year=2020;volume=62;issue=3;spage=322;epage=326;aulast=Basu\">India<\/a>, the rule for daily or weekly presentation for newer buprenorphine patients was waived in favor of two-week take-home doses for all patients.<\/p>\n<p>A number of peer-reviewed evaluations of COVID-related loosening of MOUD restrictions, particularly in the United States, indicate that both patients and <a href=\"https:\/\/www.journalofsubstanceabusetreatment.com\/article\/S0740-5472(21)00014-3\/fulltext\">providers<\/a> are finding these changes to be largely positive, though with some cautions. <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC8032399\/pdf\/main.pdf\">Patients<\/a> unsurprisingly expressed relief from daily queues at methadone clinics, which would pose COVID risks.\u00a0 Telehealth consultations assisted providers in keeping track of patients who might have problems with the changed protocol.\u00a0 In some jurisdictions, at-home administration was assisted by medicine containers that could be <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7834258\/\">monitored electronically<\/a> to prevent diversion. \u00a0Some experience indicated that home administration has not been associated with an <a href=\"https:\/\/www.journalofsubstanceabusetreatment.com\/article\/S0740-5472(21)00175-6\/fulltext\">increase in overdose<\/a> episodes, which some had feared. \u00a0In some places, protocols combined <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7666540\/\">distribution of naloxone<\/a>, an overdose-reversing medicine, with at-home MOUD to prevent overdose mortality and injury, or authorities gave <a href=\"https:\/\/www.hca.wa.gov\/assets\/program\/opioid-treatment-program-faq.pdf\">guidance<\/a> on improving naloxone access for those with take-home doses.<\/p>\n<p>Unfortunately, some jurisdictions now have returned or are planning to return to the pre-COVID methods of administration of methadone.\u00a0 In Ohio, a state in USA, \u00a0for example, <a href=\"https:\/\/www.cincinnati.com\/story\/news\/2021\/05\/04\/experts-say-methadone-treatment-rules-relaxed-pandemic-should-stay-flexible-with-opioid-crisis\/4859273001\/\">reinstituted pre-COVID restrictions<\/a> in spite of opposition from methadone providers.\u00a0 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 <a href=\"https:\/\/www.mayoclinic.org\/coronavirus-covid-19\/vaccine-tracker\/\">relatively low<\/a>.\u00a0 Providers in countries as diverse as <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7769928\/\">Ukraine<\/a> and <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7568517\/\">Argentina<\/a> have urged that COVID-related changes in MOUD administration be made permanent.<\/p>\n<p>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.\u00a0 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.\u00a0 While opioid overdose and opioid use disorders as well as COVID remain important <a href=\"https:\/\/www.cdc.gov\/nchs\/nvss\/vsrr\/drug-overdose-data.htm\">public health problems<\/a>, it would be unfortunate to miss the opportunity to enhance access to proven OUD treatment.<\/p>\n<p><strong>About the author<\/strong><\/p>\n<p><em>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.\u00a0 She has worked for years on policy change related to health services for criminalized persons.<\/em><\/p>\n<p><strong>Competing Interests\u00a0<\/strong><\/p>\n<p>None<\/p>\n<p><strong>Handling Editor<\/strong><\/p>\n<p>Soumyadeep Bhaumik<\/p>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; 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.\u00a0 But an important COVID-induced change in the treatment of opioid use disorder (OUD) is a crisis response with demonstrated benefits.\u00a0 In many countries, people living with OUD [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmjgh\/2021\/08\/11\/should-take-home-medication-for-opioid-use-disorder-become-the-norm\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":350,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[172,297,32],"tags":[164,337,335,329,336],"class_list":["post-39834","post","type-post","status-publish","format-standard","hentry","category-covid-19","category-public-health-research","category-universal-health-coverage","tag-covid-19","tag-methadone","tag-opioid-use-disorder","tag-policy","tag-take-home-medication"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Should take-home medication for opioid use disorder become the norm? - BMJ Global Health blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmjgh\/2021\/08\/11\/should-take-home-medication-for-opioid-use-disorder-become-the-norm\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Should take-home medication for opioid use disorder become the norm? - BMJ Global Health blog\" \/>\n<meta property=\"og:description\" content=\"&nbsp; The impact of COVID-19 on people with pre-existing health problems has been devastating. 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