When someone with an opioid use disorder (OUD) seeks help at a busy opioid treatment program (OTP), interim methadone services—providing up to 120 days of methadone dosing, without counseling—can make all the difference in that person’s life.
But waitlisting is sometimes an OTP’s only option. That’s because many OTPs lack interim methadone services, so all they can offer those in need is a place in line.
Clearly, there’s a need for a better solution.
A recent scoping review looked at options available to busy OTPs. Examining ways to ease access to treatment for patients with an OUD, the review found good results with interim methadone services, but drawbacks related to access. The review, “Interim Methadone—Effective but Underutilized: A Scoping Review”—was published online May 21 in Drug and Alcohol Dependence.
What Is a Scoping Review?
The relatively new research tool known as a scoping review helps clarify the scope or coverage of existing scientific papers on a specific topic. The review provides an overview of the topic’s focus and the availability of pertinent studies.
Effective but Underutilized—part of the scoping review’s title—makes a point very well: “despite the apparent benefits of interim services, use of interim services is uncommon in clinical practice.”
Requirements and Restrictions
Alternatives to methadone programs date back to the early days of the global HIV epidemic, when delays in admission to methadone programs led to requests for methadone on demand. A clinic opened in New York City to offer methadone without a counseling requirement. This “Interim Clinic” provided methadone five days a week, and take-home doses for Saturday and Sunday.
That was almost 30 years ago.
In 1993, an amendment added three requirements and two restrictions to OTP regulations.
- A letter from the state health officer authorizing interim services
- Approval from the Substance Abuse and Mental Health Services Administration (SAMHSA)
- Patient enrollment in counseling within 120 days
- Take-homes are not allowed; the OTP must be open for dosing 7 days a week
- For-profit OTPs are not allowed to deliver interim methadone
The requirements and restrictions remain in the federal regulations that today govern interim methadone services in OTPs—Chapter 42 Code of Federal Regulations Part 8 (42CFR Part 8).
It’s the last item in the bullet list—banning for-profit OTPs from providing interim methadone—that drastically limits opportunities for many people seeking help for an OUD. Because, as the authors point out, in the U.S. “more than half of the OTPs operate as for-profit entities”—disqualifying them for receiving interim methadone services. Some states have no non-profit methadone programs whatsoever.
Alternatives to Methadone Maintenance Services
Before we see the review data, here’s a quick look at the characteristics of alternative therapies.
Low-threshold facilities were developed to ease patients’ access to services and to reduce or eliminate patients’ barriers, real and perceived. Barriers can include stigma; problems associated with making appointments; travel, sometimes over long distances; cost of treatment; and so forth. Low-threshold services do not require patients to stop taking drugs to remain in the program.
Mobile engagement units and other novel services are being used increasingly to meet patients’ needs, such as traveling to the treatment location. Research on the effectiveness of these services lags the increase in their use.
Under open access, patients are enrolled in treatment immediately, whether or not they can pay. Patients also are given access to a variety of voluntary treatment options, such as medication, counseling, or psychiatric treatment.
The approach to care under open access is team-based, focusing on the patient. Counselors do not carry individual caseloads, and there’s no maximum length of treatment.
Timely access is the key in medication first. Patients receive medication as quickly as Day 1—before any time-consuming assessments or planning sessions. Patients can choose to become involved in counseling or support services, such as transportation or housing, but it’s not required. Medication is given with no arbitrary tapering or time limits, and can in fact continue indefinitely, discontinued only if it is causing the patient harm.
Project HOPE—Medication First Model, provides more information on medication-first policy.
Studies in the Scoping Review
The authors of the review looked at interim methadone and the alternatives for easing access to methadone. They gave priority to randomized trials and controlled observational studies; lower-quality evidence was included when necessary.
Six of the studies examined interim methadone services. Three looked at alternatives to interim methadone: low-threshold services, open access policy, and medication-first policy. (Details are too lengthy to include here; see the published review.)
Compared to waitlist controls, patients enrolled in interim methadone showed reduced opioid use, high rates of retention in care, and enhanced likelihood of enrolling in a full-service OTP. Retention in care and reductions in heroin use did not differ significantly when interim methadone study participants were compared with active treatment groups.
A comparison of interim methadone and a waitlist control found suppression of heroin use within the interim maintenance groups, compared to the waitlist groups, and elevated rates of admission to full OTP services.
Some additional findings:
- Reduced heroin use during interim methadone treatment
- Greater likelihood that interim methadone participants would enter OTPs, compared to waitlist participants
- Similar retention rates in interim methadone patients and those in active treatment
- The strategies to facilitate access to methadone were effective, and lacked the restrictions involved in interim methadone treatment
That last bullet suggests that providing easier access to methadone is an effective tool, a way to avoid the restrictions inherent in interim methadone treatment.
The interim methadone trials and analyses replicate and extend other studies that suggest that minimal counseling in OTPs can be as effective as the currently required standard counseling and education services. In a crisis, when demand for care exceeds program capacity, interim methadone appears to be an effective way to bring new patients into care.
Given the regulatory requirements associated with interim methadone, alternatives not subject to these regulations may warrant further review.
The concluding section in the published paper begins with this statement:
“Interim methadone appears to be generally effective at reducing heroin use and facilitating entry to standard OTP services compared to waitlist or alternative approaches, but has not been widely implemented due to regulatory barriers.”
The authors suggest additional research
- To find ways to facilitate and speed access to methadone services
- To clarify the best intensity and frequency of required psychosocial services in patients who cannot immediately access methadone treatment
- To understand how OTP regulations impact methadone access
McCarty D, Chan B, Bougatsos C, Grusing S, Chou R. Interim Methadone – Effective but Underutilized: A Scoping Review [published online ahead of print, 2021 May 21]. Drug Alcohol Depend. 2021;225: 108766. doi:10.1016/j.drugalcdep.2021.108766
For Additional Reading
Mofizul Islam M, Topp L, Conigrave KM, Day CA. Defining a service for people who use drugs as ‘low-threshold’: what should be the criteria? Int J Drug Policy. 2013;24(3):220-222. doi:10.1016/j.drugpo.2013.03.005
Stewart RE, Shen L, Kwon N, et al. Transporting to treatment: Evaluating the effectiveness of a mobile engagement unit [published online ahead of print, 2021 Mar 22]. J Subst Abuse Treat. 2021;129:108377. doi:10.1016/j.jsat.2021.108377
Goodheart B. Study report: implementing open access in OTPs; a good idea? Counselors share their thoughts and experiences. AT Forum. January 25, 2021. https://atforum.com/2021/01/study-open-access-otps/
Knopf A. With “open-access,” methadone treatment can increase patient census and eliminate waiting lists: Research. AT Forum. April 17, 2018. https://atforum.com/2018/04/with-open-access-methadone-treatment-can-increase-patient-census-and-eliminate-waiting-lists-research/
Winograd RP, Presnall N, Stringfellow E, et al. The case for a medication first approach to the treatment of opioid use disorder. Am J Drug Alcohol Abuse. 2019;45(4):333-340. doi:10.1080/00952990.2019.1605372