In these pages of Addiction Treatment Forum we feature two studies describing experiences at opioid treatment programs (OTPs) during COVID-19. The first study, from Bronx/Montefiore OTPs, reports favorable outcomes and more-flexible patient care, compared to pre-COVID. The second study, from RAND Drug Policy Research Center, is based on telephone surveys of caregivers at 20 OTPs in 13 U.S. states, and reports on responses to service delivery changes early in the pandemic.
Seeking comments about what we can learn from these studies, we reached out by email to an author of each study and to a leading expert on opioid addiction disorders who was not involved in either study:
- Sarah Hunter, PhD, lead author of the RAND study, is a senior behavioral scientist, professor at the Pardee RAND Graduate School, and a member of the editorial board of the Journal of Substance Abuse Treatment
- Kristine Torres-Lockhart, MD, second author of the Bronx/Montefiore study, is an assistant professor of medicine, Division of General Internal Medicine, Montefiore Medical Center & Albert Einstein College of Medicine
- Keith Humphreys, PhD, is the Esther Ting Memorial Professor in the Department of Psychiatry and Behavioral Sciences at Stanford University, and a trailblazer in preventing and treating addiction disorders
Dr. Torres-Lockhart (Bronx/Montefiore Study)
Kristine Torres-Lockhart, MD, commented that “the loosening of federal regulations around methadone dispensing and clinical practice during the COVID-19 pandemic has led to heterogenous adoption of new practice patterns across the country. These new practice patterns,” she said, “appear to be specific to OTPs.
“OTPs are rooted in a prison system that can be highly punitive and steeped in structural racism, concentrated in urban areas with higher populations of Black residents,” she noted, while access to buprenorphine is segregated to areas with higher White populations.
“The RAND study highlights how variable the adoption of clinical practice changes was across OTP providers, and their experiences providing methadone treatment during the pandemic. This study,” she said, referring to the Bronx/Montefiore study, “underscores the importance of studying the counterpart, the patient experience and meaningful patient outcomes, given practice pattern changes, in a rigorous way. This can provide information to help shape policy changes going forward.
“Current methadone regulations are archaic,” Dr. Torres-Lockhart said, “and this is an opportunity to study how drastic changes to clinical practice—increased patient flexibility, increased take-home doses, decreased toxicology testing—can affect meaningful patient outcomes (outside of toxicology testing results). It is an opportunity to better understand how overdose rates, treatment engagement, family engagement, quality of life, etc., changed with increased flexibility, telemedicine, and increased access to take-home doses.
“Before the public health emergency created by COVID,” she noted, “methadone regulations were too rigid and were misaligned with many patient goals for treatment. We now have an opportunity to inform future policy based on rigorous research and evidence.”
Dr. Hunter (RAND Study)
Dr. Hunter sees the Bronx/Montefiore paper as “a ‘deep dive’ into one system’s approach to delivering methadone during the COVID pandemic.” Her study, the RAND Study, surveyed prescribers at 20 OTPs “early in the pandemic—last May-June 2020—when a lot of OTPs were just figuring out how to adapt to the new flexibilities in prescribing, while delivering socially distant care.”
Dr. Hunter noted that the Bronx/Montefiore study reported making changes in care-delivery that were similar to those of some of the OTPs that RAND surveyed,” such as less frequent toxicology screens, but that the Bronx/Montefiore study also examined patient outcomes, “which is extremely helpful and beyond the scope of our study.”
Although the recommendations in the two studies are similar in terms of considering different reimbursement strategies, such as allowing more telecare visits and take-home doses, Dr. Hunter pointed out the key difference: the Bronx/Montefiore study goes further. The researchers were able also to examine outcomes related to changes in monitoring strategies. “That is a great advancement in thinking, and to the field,” she said.
She added: “Some OTP providers we spoke with were somewhat resistant to any changes in service provision (due to the flexibilities allowable during the pandemic), which speaks a bit about the variation in perspectives among OTP providers across the country.
“Bronx/Montefiore is probably a bit ahead of the curve in this regard!” she said.
Dr. Humphreys’ comments reflect his broad perspective, developed during many years in the addiction treatment field.
Dr. Humphreys observed that “decades of international experience with opioid agonist therapy shows that both overly rigid and overly lax regulation can damage patients and communities. It’s not surprising,” he said, “that clinicians disagree about the effects of the relaxing of regulations COVID caused, because some clinics and some patients benefitted, and others did not. The best way to resolve the dispute is to conduct careful evaluations without prejudgment, so that we can learn what subset of changes we want to maintain after COVID is behind us.”
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;122:108219. doi:10.1016/j.jsat.2020.108219
Hunter SB, Dopp AR, Ober AJ, Uscher-Pines L. Clinician perspectives on methadone service delivery and the use of telemedicine during the COVID-19 pandemic: A qualitative study. J Subst Abuse Treat. 2021;124:108288. doi:10.1016/j.jsat.2021.108288
Articles in Addiction Treatment Forum
Reimagining Patient Care: Bronx OTPs Share Lessons Learned During COVID-19. Addiction Treatment Forum, April 27, 2021. By Barbara Goodheart, ELS.
OTP Clinicians’ Responses to Telemedicine and Changes in Methadone Service Delivery During COVID-19: A Qualitative Study. Addiction Treatment Forum, May 26, 2021. By Barbara Goodheart, ELS.