Extended Take-homes: More Good News in New York
The expansion of methadone take-homes was highlighted as a positive move in New York by Governor Andrew Cuomo in his State of the State message January 11. This is a huge accomplishment, and one that other states should pick up on. In addition, he focused in general on increasing the availability of medication assisted treatment, which includes buprenorphine.
“It’s rare to see OTPs mentioned” in such important state messages – or actually in any state messages – said Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates in New York. “We were pleased that this was called out,” she said of the take-homes in an interview with AT Forum. Schorr is also owner and Vice President of West Midtown Medical Group, an OTP, SUD outpatient and comprehensive primary care program in New York City.
Other proposals from the governor include:
- Increasing the number of co-located medication units and mobile addiction treatment programs
- Providing immediate help by allowing OTPs to provide interim maintenance treatment to those seeking treatment, thereby eliminating waitlists at opioid treatment programs
- Increasing peer and family services in OTP settings to make programs more patient centered, and
- Incorporating outpatient rehabilitation services into OTPs for those in need of more intensive services.
The extended take-homes began a year ago with COVID-19, when the federal government, to reduce exposure to the virus, allowed OTPs to give patients who are less than stable up to 2 weeks of take-homes (see https://atforum.com/2020/03/otp-regulations-loosened-due-to-pandemic/). In New York City, this extended to home delivery of methadone. As the cases are going back up in New York with the onset of winter, being indoors, and the holidays, it’s particularly important to have the home delivery option, said Schorr.
However, not all OTPs in the state are utilizing the extended take-homes. The state’s Office of Addiction Services and Supports (OASAS) is monitoring individual programs to discuss the appropriate use of take-homes. There may be “outliers” who may be unusually rigid about not giving take-homes during COVID, said Schorr.
From the Governor’s State of the State book
Proposal. Continue Innovation in Opioid Treatment
To combat the opioid epidemic, Governor Cuomo has expanded access to medication assisted treatment, mobile treatment, peer support services, and drug user health hubs. These initiatives have decreased the rate of opioid overdoses and opioid-related hospitalizations and emergency department visits.
Between 2016 and 2019 there was a 42 percent decrease in opioid overdose deaths in counties that participated in State Targeted Response grant activities. Those that participated in year two experienced a 64 percent decrease in opioid overdoses. More than 3,700 people obtained medication-assisted treatment and 11,870 people received opioid overdose reversal training.
Even with all of these reforms, many people who would benefit from medication-assisted treatment do not receive it, due in significant part to strict federal regulation against anti-addiction medication. Further, many providers remain entrenched in a treatment philosophy that requires patients to report to opioid treatment programs (OTPs) daily for medication administration. This outmoded requirement can restrict patients’ ability to work or attend school, and for some necessitates a difficult choice between seeking treatment or meeting other obligations. These issues have left communities across the state with significant gaps in access to addiction treatment and have resulted in some individuals not receiving the care they need.
The pandemic has pushed the system of treatment for opioid use disorder to quickly adapt and respond better to patient needs. OTP patients were able to obtain take-home medications more frequently or for longer durations, and where patients were isolated due to the pandemic the OTP provided delivery of medications so that patients would not endanger their recovery. OTPs were also able to expand services and support patients unfamiliar with take-home medication by engaging them in telehealth services, including by telephone only, which was previously not permitted.
Governor Cuomo will direct the Office of Addiction Services and Supports to build on the improvements made during the pandemic by:
- Increasing the availability of Medication Assisted
- Treatment resources across the state by increasing the number of co-located medication units and mobile addiction treatment programs;
- Expanding the use of take-home medication for opioid misuse;
- Providing immediate help by allowing OTPs to provide interim maintenance treatment to those seeking treatment, thereby eliminating waitlists at opioid treatment programs;
- Increasing peer and family services in OTP settings to make programs more patient centered; and
- Incorporating outpatient rehabilitation services into OTPs for those in need of more intensive services.
It’s still a federal requirement to use the 8-point criteria in terms of take-homes (see https://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/dear_colleague_letters/2008-colleague-letter-unsupervised-take-home-doses-opioid-treatment.pdf), said Schorr, but under the emergency waiver from last year, physicians at OTPs can also take COVID risks into account. “If we’re looking at a patient who is less than stable, a medical director might say ‘Normally I wouldn’t be giving you this much medication to take home at this time, but I’m concerned about your risk of exposure to COVID, so I’m going to give you more medication so you don’t have to go out, take the subway, and so on,” she said. In some cases the risks associated with the patient’s lack of stability exceed the risks associated with the risks of exposure to COVID-19. For example, or cognitive reasons, some patients become confused and need assistance with additional take-homes, and some patients are not ready in their recovery for additional take-homes. “If they don’t have the functional ability to make a good decision, maybe they shouldn’t have that much medication.”
Ultimately, however, what Schorr would like to do is to structure a treatment system that supports patients at all levels of functional ability and stability. “The big concern for methadone treatment is the ‘handcuffs’ thing,” she said, referring to the idea that methadone is nothing but a forced requirement for patients to show up every day, or every few days, in order to get the medication which keeps them from going into withdrawal. “When you have people who have been stable for years, why would they have to come in every day, anyplace?” she asks. These questions apply beyond the pandemic emergency.
In fact, New York is one of the most enlightened states in terms of take-homes, allowing 28 days, the maximum allowed by the federal government.
But evidence is needed before any policy change that impacts take-homes can be allowed post-pandemic, said Schorr. “Even from a clinician point of view, we do have doctors saying they don’t want patients exposed to COVID, so they will take the risk of extended take-homes for patients who are less stable in treatment,” she said. But these same clinicians feel that if they weren’t pushed to that decision by COVID, they wouldn’t take the risk. “That’s too scary” for them, she said. It’s not only scary for the physician, but for the patient. And in the end, the liability – for patient overdose, for diversion, for overdose by someone else – is the physician’s and the OTP’s.
“I am worried about the risk of diversion and having it blow back,” said Schorr. All the neighborhood groups which oppose OTPs and methadone out of NIMBY would swarm against the entire treatment model if there were bad outcomes. “We know from our history that this is a treatment that tends to be criticized,” she said. “We have to protect access. It’s a balancing act.”