Under federal law, newly enrolled methadone patients must attend a methadone program six days a week, so caregivers can watch as patients are dosed.
But here’s the problem: Because many new methadone patients don’t have an opioid treatment program (OTP) nearby, this need for daily attendance markedly affects adherence. In fact, 20% to 50% of patients report poor or partial adherence during the most critical time of treatment—the first month, when patients face the highest risk of death.
That’s the subject of a study published this month in Journal of Substance Abuse Treatment.
The study’s authors, most of whom are affiliated with Washington State University, assessed the relationship between spatial access to the only state-funded OTP in Spokane County, Washington, and adherence to treatment during the crucial first month.
Authors’ Hypothesis—Treatment adherence is lower in new patients who live farther from the OTP.
The 892 patients received their first month’s treatment sometime between February 2015 and December 2017.
Effects of Distance
In the crucial first month of treatment:
- Patients living between 5 and 10 miles from the OTP were just as likely to miss doses as those living less than 5 miles away
- Patients living more than 10 miles away were more likely to miss methadone doses than patients living within 5 miles
- Patients living more than 10 miles away were younger, on average, than those closer; these younger, farther patients were considered possibly at higher risk of not adhering to treatment—and thus at higher risk of death
Time in Therapy
In the first three months, patients were required to complete 12 sessions of cognitive or behavioral therapy. After three months, take-home doses could be considered for those with good adherence. Also, mandatory attendance for therapy dropped to once monthly.
Median age was 34 years. The older the patient, the less the likelihood of missed doses. For every year of greater patient age, missed doses dropped 2%.
The authors commented that previous studies suggest that lower income, higher medication costs, and transportation barriers may influence nonadherence, affecting Medicaid patients, such as those in this study.
Day of the Week
Patients were most likely to miss Saturday and Sunday doses. The staff provided Sunday take-home doses only until 2 PM Saturday.
The research team found that during the first month of treatment, “significant positive associations” existed between the number of doses patients missed and the distance patients traveled to the OTP.
The authors stressed the importance of regular attendance, and the need to “improve the spatial availability of OTPs” for patients scattered throughout the area.
Methadone treatment is known to reduce or eliminate drug use, risky sexual behavior, criminal behavior, and deaths. But many OTP patients lose these benefits early, because no OTP is nearby. Evidence points to the first month as being key.
COMMENT: The authors have provided valuable data showing that the legal need to observe patients’ daily dosing may affect compliance. They’ve also raised important issues for further investigation.
In the meantime, laws have been passed limiting the availability of prescription opioids, and other investigators have suggested different approaches to the opioid problem, described below.
Rosenblum et al. Writing in The Journal of Environmental and Public Health, these authors recommended flexible take-home policies, mobile methadone maintenance services, and methadone medical maintenance—methadone provided by an office-based physician, or a pharmacy. Good ideas, all awaiting implementation. But the awaiting continues: The study was published seven years ago, the opioid crisis continues to surge, and the obstacles remain.
Saitz and Daaleman. Early this year an article in The Annals of Family Medicine urged making methadone treatment part of primary care. The authors said it would be impossible for the country to adequately respond to the current epidemic “without addressing it in primary care and there is no question that the time to do it is now.”
Samet et al. An article in the July issue of New England Journal of Medicine also called for primary care availability—specifically, by asking Congress to update laws. Regulating methadone prescribing in primary care would reduce barriers, the authors said, and would “extend the benefits of a proven, effective medication to people throughout the country.”
Given the variety of approaches to the opioid crisis—restricting opioid prescriptions, constructing more OTPs, allowing primary-care prescribing—what’s the best way to proceed?
The Stanford Approach: Modeling Tools Provide Assessments
A team from Stanford University used sophisticated modeling tools to assess the benefits and harms of various responses to the opioid crisis. They found that policies that expand addiction treatment or mitigate addiction’s harmful effects, such as overdose and infection, are “immediately and uniformly beneficial.” And they lack negative consequences, such as increasing heroin-related deaths. The team published its findings this month in the online edition of The American Journal of Public Health.
As for policies that decrease the supply of prescription opioids—they can reduce prescription-related deaths, but could also increase heroin-related deaths, as some people seek heroin as a substitute for prescription opioids. It’s possible, the team believes, that eventually “some such policies may avert enough new addiction to outweigh the harms.”
What, then, is the best policy? It seems there’s no perfect answer. The Stanford team suggested “a portfolio of interventions,” but these would include reducing the prescription opioid supply, probably increasing heroin use temporarily. It would also deprive some patients with chronic pain of a medication they legitimately need.
Opening more OTPs, as the Washington State team recommends, wouldn’t have that disadvantage, and the data indicate it would optimize treatment outcomes.
Amiri S, Lutz R, Socias ME, McDonell MG, Roll JM, Amram O. Increased distance was associated with lower daily attendance to an opioid treatment program in Spokane County Washington. J Subst Abuse Treat. 2018;Oct;93:26–30. doi:10.1016/j.jsat.2018.07.006.
Rosenblum A, Cleland CM, Fong C, Kayman DJ, Tempalsky B, Parrino M. Distance traveled and cross-state commuting to opioid treatment programs in the United States. J Environ Public Health. 2011; article ID 2011;948789. Epub 2011;July 6;doi:10.1155/2011/948789.
Saitz R, Daaleman TP. Now is the time to address substance use disorders in primary care. www.annfammed.org/content/15/4/306.full. Ann Fam Med. 2017;(July);15(4):306-308. doi:10.1370/afm.2111.
Samet JH, Botticelli M, Bharel M. Perspective: Methadone in primary care — One small step for Congress, one giant leap for addiction treatment. N Engl J Med. 2018;379:7-8. doi:10.1056/NEJMp1803982.
Pitt AL, Humphreys K, Brandeau ML. Modeling health benefits and harms of public policy responses to the US opioid epidemic. Am J Public Health. Epub ahead of print August 23, 2018:e1-e7. doi:10.2105/AJPH.2018.304590.