Early in the COVID-19 pandemic, experts at Mount Sinai Beth Israel (MSBI)—one of the largest systems in the U.S. for delivering medications for opioid use disorder (MOUD)—quickly realized the need for streamlining methadone delivery in their 10 opioid treatment programs (OTPs).
They reasoned that a new age—and the COVID-19 era certainly qualifies—calls for out-of-the-box thinking, to satisfy mandates from the state and to promote safety for staff and patients. So they came up with ways to streamline four key procedural areas, discussed below: reduction of pick-up doses, toxicology screens, treatment interactions (contacts with patients), and discharges. They published their findings in December in the Journal of Substance Abuse Treatment.
1) Reduction of In-Person Pick-up Doses
Before COVID-19, MSBI patients new to treatment and those with an active substance use disorder were required to pick up medication six days a week. Requirements were quickly lowered during COVID-19, to 14-day and 28-day take-homes for patients who qualified, to help mitigate the impact of the pandemic. As patients were given more medication to take home, verification of their identity was of the utmost importance. Largely because of these changes, visits for medication dropped 44% from the same time the year before.
Medication was delivered by courier to quarantined OTP patients who had COVID-19 symptoms, tested positive, were at high risk for developing COVID-19, or had been exposed to someone with the disease. The medication was distributed by the New York City Department of Health and Mental Hygiene, in coordination with the New York State Office of Addiction Services and Supports (OASAS).
2) Drug Urine Toxicology Screens
Frequent drug screens were already in place at MSBI OTPs, so the frequency of testing didn’t change. But random assessments were replaced by additional monthly urine toxicology screens for patients with increased take-home medication.
3) Treatment Interactions
At the start of COVID-19, MSBI quickly shifted its required treatment interactions, using phone contact and virtual contact whenever appropriate.
Many employees worked remotely; those working in clinics wore protective equipment. In-person contacts were limited to necessary encounters, such as physical exams and biological tests. Often these were scheduled for times when patients would be picking up medication.
When staff were on site, they accommodated patients who wanted to come in person, providing them with a safe space to sit and to have confidential conversations during their counseling sessions. Often, patient and counselor were in separate rooms and communicated by telephone to help mitigate COVID-19 transmission.
Because of limitations on mobility, the OTPs took a relatively lenient view of discharges in order to help reduce the spread of COVID-19. Every effort was made to retain patients, and extensive outreach was conducted for patients who did not show up as scheduled. If a safety risk was involved, discharge was avoided by moving patients to a different OTP within the MSBI system.
Results of the MSBI Streamlining Efforts
All MSBI OTPs are part of the same system, so the new procedures consistently rolled out across all clinics. At the end of March 2020, the team adjusted pick-up schedules for all patients, a process that took two weeks. Schedules were revised for about 85% of the OTPs’ approximately 5,400 patients. Less than 1% of patients received home delivery via courier services.
- Visits for medication decreased 21% from March to April
- Patient engagement fell, then increased again in July
- The percentage of positive toxicology results for opioid use remained close to its level pre-COVID-19
Many staff easily adjusted to the changes, but some missed being able to gain clues through observation—such as detecting the odor of alcohol on the breath, or the aroma of marijuana on clothing. And some missed the interpersonal connection of being in the same room as a patient.
Support for Staff and Patients
The OTPs provided support groups to help staff and patients deal with stress and adjust to the changes.
Most patients benefited from the ability to have more take home doses and frequent the clinic less; however, some patients wanted more frequent visits. The staff maintained flexibility to accommodate patients who came to the clinic for the social aspects and the clinical support from staff and their peers. The authors noted that patients as a group “tend to be disenfranchised and socially isolated, leading [some] to continue daily pick-ups.” Because many patients benefited from the proposed changes discussed, this has prompted MSBI “to explore this approach as a sustainable model.”
MSBI is considering relying more heavily on technology, such as using smartphones and iPads for treatment interactions across OTP clinics. Public-use devices could be stationed where patients could access them, such as in homeless shelters, safe havens, and residential facilities. The OTPs have recently enhanced their internet connectivity to allow the use of iPads in delivering services, and they continually seek funding to support additional efforts in using technology to advance care.
Medicaid and the Office of Addiction Services and Supports set up a bundled rate for take-home medications during COVID-19. The bundled rate has been extended, and the parameters for billing under the bundled rate have been loosened. This will be reviewed periodically.
Accommodating Patients’ Needs
COVID-19 increased patients’ feelings of isolation, stress, and insecurity—in many cases making patients feel more vulnerable, and having an influence on relapse. MSBI OTPs realized the need to be flexible and to adapt to the new reality, streamlining procedures and minimizing contact.
The authors closed with a view toward the future:
“We have reached a new era, one requiring out-of-the-box thinking to ensure the safety of those we treat, our providers, and surrounding community. We must continue to find ways to build upon our initial adaptations and pave the way for a future vision, one that might look very different from what we once knew but that is marked by creativity and hope.”
Tracy K, Wachtel L, Friedman T. The impact of COVID-19 on opioid treatment program (OTP) services: Where do we go from here? J Subst Abuse Treat. 2021;131:108394. doi:10.1016/j.jsat.2021.108394