When COVID-19 forced Bronx opioid treatment programs (OTPs) to change the way they operated, the OTPs made dramatic changes and saw better outcomes in just ten weeks. In an article published in March in the Journal of Substance Abuse Treatment, the authors summarize their experiences and share what they learned.
Background
The Bronx has been the epicenter of the overdose and COVID-19 pandemics. Its OTPs have provided treatment and access to medications for opioid use disorder (MOUD) since the 1970s, and currently care for 3,600 patients.
On March 16, 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a guidance allowing states to request exceptions to the existing criteria for take-home doses of MOUD: up to 28 days for stable patients and up to 14 days for less-stable patients who could safely manage their medication. That was “a stark contrast to the usual rigid guidelines,” the study’s authors point out.
Acting quickly to balance the risks of MOUD misuse and SARS-COV2 exposure, Bronx OTPs
- Halted toxicology testing for established patients
- Dramatically increased the number of unsupervised take-home doses of MOUD
- Reduced OTP visits for patients facing the highest risk for COVID-19-related complications and death (see chart below)
In a key decision, the OTP group also shifted focus to patient-centered care, such as patient goals and engagement in care.
The authors note: “We were also able to adjust in real-time in response to incidents of potential misuse or diversion (e.g., patients not returning take-home bottles, or presenting for MOUD earlier than would be expected).” When these incidents occurred, the team adjusted schedules, allowing as many take-home doses as they could while sustaining patient safety.
| Clinical Situation | OTP Attendance Requirements |
| No special concerns about patient’s ability to manage medication at home | Once every week or two |
| Diagnosis of OUD in early or sustained remission | Up to once monthly |
| Diagnosis of active OUD | As few as 3 per week |
Decisions about the number of take-home doses were based on a clinician’s assessment of the patients’ ability to store and self-administer the medication.
Results of the OTPs’ Actions
- No fatal overdoses
- First two weeks: a drop in the number of patients visiting the OTP 5 to 6 times a week from 47% down to 9%
- First ten weeks: 6 nonfatal overdoses, no fatal overdoses (in contrast, the previous 10 weeks saw 2 nonfatal overdoses and 1 fatal overdose)
- March 16 to May 31, 2020: 20 deaths, all attributable to COVID-19
The OTPs’ Advice to Other OTPs
- Shift the focus away from rigid clinical guidelines and regulations; concentrate instead on patient-centered measures—engagement in care, and patient goals
- In deciding how to distribute take-home doses of MOUD, rely less on toxicology testing and more on patient-centered measures
- Reassess OTP reimbursement models
The Future of OUD Care in OTPs
In addition to continuing to mitigate COVID-19 risks to OTP patients, the authors recommend:
Formally evaluating the results of dosing changes on the following categories: quality of life, substance use, diversion, overdose, and engagement in treatment, during and outside surges | → | Using the evaluation data to guide clinical practice and government policies | → | As situations return to normal, using lessons learned during COVID-19 as “a catalyst for permanent change to OTP practice and policy” |
The authors close with three summary recommendations:
1. We advocate for flexible, patient-centered care in opioid treatment programs
While granting that the structure and services OTPs offer help many patients, the authors point out that some patients may not need those services, or may find regular OTP visits burdensome.
They acknowledge that active drug use imposes challenges on medication adherence, and that directly observed therapy can improve medication adherence and clinical outcomes.
They conclude that “OTPs must balance structure and flexibility in ways that are aligned with patients’ treatment goals and needs.”
2. Clinical decision-making should focus on a range of meaningful patient-centered measures
The authors recommend against using abstinence to guide take-home dosing schedules. Instead, they say, clinicians should weigh participation in patient-centered care, specifically:
- medical and mental health care
- family engagement
- peer work
- vocational training
- employment
In addition, “toxicology testing can serve as an objective measure of drug use and as a clinical tool to guide discussions of patients’ substance use disorder treatment.” But the authors believe that toxicology testing should not be overweighted as a criterion for unsupervised dosing.
When they ended toxicology screening on their established patients during COVID-19, the authors were able to individualize treatment while maintaining the safety of their patients and keeping patients engaged in their treatment.
3. Payment to OTPs should be re-imagined to allow programs to provide patient-centered care
Before COVID-19, OTPs in New York State were not reimbursed by Medicaid for unsupervised take-home doses. That created an economic incentive for clinics to require patients to visit for their medication doses, rather than giving clinically stable patients multiple take-home doses.
During the pandemic there has been a temporary shift to a more patient-centered, bundled payment approach. (In bundled payment, programs typically provide a single, comprehensive payment to cover the various services involved in one episode of care.) The authors recommend reassessing state Medicaid OTP reimbursement models so that, post-COVID, OTPs continue to be adequately reimbursed for services requiring fewer OTP visits.
Adequate reimbursement could be arranged in either of two ways, the authors explain: by reimbursing for take-home doses, or by continuing the modified bundled payment after the COVID-19 pandemic ends.
In closing, the authors make it clear that the changes brought about during COVID-19 mean better care for patients, and they would like to see the changes become permanent:
By sustaining these changes in a post-COVID-19 era, we imagine the future of OUD care in OTPs as less burdensome and more flexible for our patients. We submit that this new treatment paradigm will be better suited to foster patient engagement through patient-centered approaches.
Reference
Joseph G, Torres-Lockhart K, Stein MR, Mund PA, Nahvi S. Reimagining patient-centered care in opioid treatment programs: Lessons from the Bronx during COVID-19. J Subst Abuse Treat. 2021(Mar);122:108219. doi:10.1016/j.jsat.2020.108219