SAMHSA and the DEA have relaxed regulations on Opioid Treatment Programs (OTPs) to enable increased tele- health and take-home doses during this public health emergency. However, clinicians need to weigh the risks for each individual patient associated with both OUD and COVID-19. Many aspects of this crisis may increase the risk for relapse. Patients are experiencing high levels of stress and anxiety related to the pandemic, many have or will lose their jobs, and social isolation is exacerbating mental health and addiction related symptoms. Treatment with methadone continues to be an effective and safe option for patients with moderate to severe opioid use disorder. Clinicians need to balance multiple risks in determining the number of take-home doses of methadone for any given patient. All patients with opioid use disorder treated with methadone should also receive at least a prescription for the overdose reversal medication naloxone, if not the actual naloxone medication.
Considerations for the selection of methadone
- The physician needs to determine the number of in-person visits expected during the initial dose titration period and the number of take-home medication doses the patient can safely manage during induction and stabilization.
- The number of take-home doses should be based upon individual patient risk and need.
- Strategies to minimize the risk associated with take-home doses:
- lock boxes designed to release a single dose of methadone at a pre-set time.
- increased frequency of phone or audio-visual check-ins with the patient may be helpful.
- Identify a chain-of-custody for take-home doses with a responsible family member or other adult.
- The patient can engage in phone or audio-visual telehealth visits for follow-up as required.
Considerations for Methadone Formulation
If dispensing larger numbers of take-home doses, consider 40mg dispersible tablets instead of the liquid formula- tion. This formulation can only be dispensed in an OTP setting. It can be easier to secure and store, and safer with which to travel.
Considerations for Methadone Dosing
Opioid Treatment Programs (OTPs) should consider promoting physical distancing through the use of telehealth and increased take-home doses, when safe and appropriate (See Ensuring Access to Care in Opioid Treatment Programs Guidance). Programs should also make changes to how patients flow through their facility to ensure patients and staff can maintain 6+ feet of distance.
The stress, anxiety, and social isolation associated with the COVID-19 pandemic may exacerbate a patient’s addiction and mental health symptoms. Clinicians should check in with patients more regularly through telehealth (including telephone-based check-ins) to assess the patient’s response to medication and any signs that the patient’s medication or treatment plan may need to be modified.
OTPs should be aware of the safety risks associated with increased take-home doses of methadone, and the need for increased patient monitoring. Clinicians should be alert to signs that patients may be misusing or diverting their medications, such as patients returning early for additional medication. Programs and clinicians should consider how to manage these situations in the context of the COVID-19 crisis. For example,
- When to require an in-person appointment with the patient
- How to address suspected diversion (including to friends or family who lost access to their medication during this crisis)
- Moving to smaller number of take-home doses
- Enhanced urine drug testing (see Adjusting Drug Testing Protocols Guidance)
Programs should also explore methods for minimizing patient risks related to take-home methadone. For example:
- Consider enhanced methods for monitoring medication adherence
- Specially designed lock boxes with controlled release, enabling one dose to be released once per day at a specific time.
- If these tools are too expensive for the program to cover, the program could consider exploring funding options with the State Opioid Treatment Authority as there may be opportunities for using SOR or CARES funding for this purpose.
- For select, extremely complex patients, consider using telehealth to monitor their daily dosing, including ensuring that remaining doses are all accounted for.
- Engaging the patient’s family or support system to manage and monitor dosing, if the patient has a reliable support system that could play this role
- Increased telephonic check-ins
The COVID-19 crisis will force clinicians to make some very challenging clinical decisions as they try to balance the risks associated with OUD versus those associated with the COVID-19 Pandemic. Programs and clinicians should also consider data you have access to that can help you assess the impact of the changes you or your program is implementing. While you may have limited access to local and state level data during the crisis, consider data you can collect in your own practice or program. For example:
- • Early returns/early refills
- • Suspected misuse or diversion (among patients considered to be stable vs. less stable)
- • Patient hospitalizations such as for overdose or withdrawal
- • Unexpected drug screen results (if these are being done)