Dear Colleagues,
Finally we are seeing some
useful publications regarding the major changes in provision of opiate
maintenance during the Covid pandemic (see links below). Yet the jury is still out regarding the value
of supervised consumption of methadone (and buprenorphine) in long-term opiate
maintenance.
Jones, Volkow and colleagues
report American opiate overdose death rates with and without methadone
involvement before and after March 2020 when new guidelines were being
implemented. Clinics were permitted to
give 28 or 14 take-home doses for ‘stable’ and ‘less stable’ patients
respectively. They examined coroner
records for overdoses, noting that historically most methadone overdoses were
in pain patients (unsupervised) rather than in those in dependence programs (with
supervised dosing).
Starting from January 2019
the group extracted monthly data on overdose deaths to August 2021 from
official and preliminary (2021) the CDCP.
They found a brief spike in all overdoses at the commencement of the
Covid pandemic around April 2020 but no significant increases in the months
following despite supervision of methadone doses being reduced dramatically. They also found that overdoses not involving
methadone continued to increase progressively through August 2021 and correspondingly,
the proportion of overdose deaths involving methadone declined. Other authors report May 2020 as the peak in
the US with overdoses 50% higher than a year earlier.
Overdose is the most serious
complication of unsupervised methadone but there are others such as treatment
drop-outs, relapse to the use of alternative drugs and alcohol, sometimes with
concomitant mental illness. Fentanyl is a
major risk factor in America but is seen less in Australia to date. A search on Google Scholar found a small
number of papers which looked at these matters, none finding significant or
lasting changes after the change in methadone guidelines (see below).
Old research shows that most
diverted or ‘black market’ methadone is taken by people who would normally
qualify for methadone treatment. Worryingly however, such recipients are also at
highest risk of overdose from unknown quantities of diverted, street or
prescribed opioids.
In our Sydney clinic from
March 2020 we increased our provision of dispensed (non-supervised) doses as
well as introducing a raft of preventive measures including social distancing, ‘telehealth’
consultations, mask mandate, perspex shield at dispensing counter, hand
sanitizer, gloves for staff, home visits for Covid infected patients, encouraging
vaccination, etc. We also suspended routine
urine toxicology tests.
While there were no reports
of overdose in our patient group, in the early weeks of the new guidelines we
noted that a proportion (~5%) of patients were running out of methadone
early. We provided occasional
supplementary doses and if these were requested more than once more frequent
attendance was recommended. One patient
stated: “Look Doc, when it comes to opiates I am a pig. If I have four bottles for four days they are
always gone in three or less. That
leaves me in withdrawals”. He sought return
to Monday, Wednesday and Friday attendance and did well thereafter through the
pandemic.
Regarding the lack of control
in some given extended ‘take-homes’, higher doses may be needed by some, others
more frequent attendance, others still may need more psychosocial supports. Anxiety, panic disorder, insomnia and
depression are common in this population group: American treatment guidelines state
that patients should not be denied appropriate treatment just because they are
on OTP. Long acting benzodiazepines
should only be prescribed in modest doses, limited quantities and with close
monitoring when appropriate. Antidepressants are effective in a significant
minority of cases in our experience. Since
the introduction of real-time prescription monitoring in Australian states patients
are no longer so easily able to attend multiple doctors and pharmacies without
detection. Prescribed medications will
always be safer than unknown quantities of short acting, high-potency black
market drugs.
Back to the point of the
article by Jones, Volkow and colleagues: what is the purpose of dose
supervision? Regular attendance gives some
daily discipline for new, unstable and unhappy patients. But how long is it needed? This has never been studied systematically to
my knowledge so the current naturalistic experiment should be used to determine
how far one can go. But now some experienced
researchers need to collect appropriate longitudinal clinical data to give
further guidance on best practice. Most
would agree that after the initial period of daily attendance more flexible
arrangements should be available for those who can show that they have moved
away from illicit drugs and become more socially integrated with work, study,
family life, etc. But then?
See references below for
other aspects of the current loosening of take-home provisions for methadone
maintenance patients. I hope this is
useful for clinicians who practise in the field.
Written by Andrew Byrne .. Now
semi-retired – Mobile: 0490408477
[with thanks to J James, C.
Jones and R Hallinan for editing assistance]
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