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]
* Methadone-Involved Overdose Deaths in the US Before and After Federal Policy Changes Expanding Take-Home Methadone Doses From Opioid Treatment Programs | Psychiatry and Behavioral Health | JAMA Psychiatry | JAMA Network
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