Skip to main content

Patient experiences of methadone treatment changes during the first wave of COVID-19: a national community-driven survey

Abstract

Background

During COVID-19, the Substance Abuse and Mental Health Services Administration (SAMHSA) allowed Methadone Maintenance Treatment (MMT) programs to relax in-person MMT requirements to reduce COVID-19 exposure. This study examines patient-reported changes to in-person methadone clinic attendance requirements during COVID-19.

Methods

From June 7, 2020, to July 15, 2020, a convenience sample of methadone patients (N = 392) were recruited in collaboration with National Survivors Union (NSU) in 43 states and Washington D.C. through social media (Facebook, Reddit, Twitter, and Web site pop-ups). The community-driven research (CDR) online survey collected information on how patient take-home methadone dosing and in-person drug testing, counseling, and clinic visit frequency changed prior to COVID-19 (before March 2020) to during COVID-19 (June and July 2020).

Results

During the study time period, the percentage of respondents receiving at least 14 days of take-home doses increased from 22 to 53%, while the percentage receiving one or no take-home doses decreased from 22.4% before COVID-19 to 10.2% during COVID-19. In-person counseling attendance decreased from 82.9% to 19.4%. While only 3.3% of respondents accessed counseling through telehealth before COVID-19, this percentage increased to 61.7% during COVID-19. Many respondents (41.3%) reported visiting their clinics in person once a week or more during COVID-19.

Conclusions

During the first wave of COVID-19, methadone patients report decreased in-person clinic attendance and increased take-home doses and use of telehealth for counseling services. However, respondents reported considerable variations, and many were still required to make frequent in-person clinic visits, which put patients at risk of COVID-19 exposure. Relaxations of MMT in-person requirements during COVID-19 should be consistently implemented and made permanent, and patient experiences of these changes should be explored further.

Introduction

During the COVID-19 pandemic, over 26 million people in the world who live with opioid use disorder (OUD) [16] are particularly vulnerable. They are at increased risk for negative health consequences from COVID-19 due to high rates of comorbidities such as cardiovascular and respiratory diseases [43, 59] and other negative consequences of COVID-19 including negative respiratory effects, hospitalization, and mortality from COVID-19 [4]. This population is also at a high risk of overdose, suicide, housing instability, food insecurity, and unemployment, and COVID-19 has exacerbated these issues [2, 15, 43, 59].

In the United States, 1.6 million people were living with OUD in 2019 [52]. OUD rates are increasing, as are HCV infections and fatal drug overdoses [1, 17, 27]. Clinical evidence shows that methadone is the most empirically proven treatment available in the United States for OUD [13]. Methadone maintenance treatment (MMT) improves mental and physical health, eliminates opioid withdrawal symptoms, and has few toxic side effects [37, 49]. It decreases overdose risk, HIV and HCV infections, illegal substance use, and overall morbidity and mortality [49, 61]. However, in 2019, only 408,550 people received MMT in the United States [53].

Even though MMT is a safe and effective treatment for OUD, it is heavily regulated in the United States. Unlike buprenorphine maintenance treatment (BMT), which can be prescribed by primary care providers and dispensed from pharmacies, only certified opioid treatment programs (OTPs) can dispense methadone [24, 31]. Doses are typically given to patients in-person under daily direct supervision, with regular drug testing and counseling sessions required [70]. Thus, MMT places a heavy time burden on patients, decreasing treatment retention and quality of life and making employment and rehabilitation more difficult [57, 62, 71]. Additionally, MMT can be costly, which decreases treatment retention [7, 35].

In response to COVID-19, in March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) relaxed MMT requirements to decrease COVID-19 exposure risk by reducing in-person visits for medication, drug testing, and counseling [51]. This letter aimed to address concerns that social distancing was difficult, if not impossible, to maintain given existing MMT practices, including in-person visits for medication, drug testing, and counseling. The guidance allowed 28 days of unsupervised take-home dosing for stable patients, and up to 14 days for those considered less stable. U.S. federal regulations recommend OTPs use the following criteria to determine patient stability: length of treatment, take-home dose benefits outweigh risks, treatment plan adherence, no recent positive toxicology tests or substance-use-related behaviors, no behavioral issues, stable housing and relationships, no recent diversion history, and safe storage of MMT [54]. OTPs defined patient stability with considerable variation during the first wave of COVID-19 [8, 26, 63]

On April 21, 2020, it was further recommended that OTPs increase telehealth use to further reduce potential COVID-19 exposure [2, 28].

Recent studies find that during COVID-19, MMT clinic visits and toxicology screens decreased, and take-home doses and telehealth use increased with no increase in fatal MMT-related overdose or severity of methadone poisoning exposure and little reported diversion [8, 21, 23, 25, 33, 40, 44, 69]. Increased take-home dosing during COVID-19 was associated with decreased illicit drug use and increased retention [19, 29]. Most studies have focused on clinician perspectives [30, 39, 66]. Studies on methadone patient experiences of treatment changes during COVID-19 are limited to states, counties, and individual OTPs or examine time periods after July 2020 [45, 64, 65, 68]. Little is known about MMT patient experiences of in-person treatment requirement changes across the United States during the first wave of COVID-19. In this article, we use a community-driven research (CDR) approach to examine MMT patient-reported experiences of four issues that put them at a high risk of COVID-19 exposure during the first months of COVID-19: take-home dosing limits, in-person clinic visits, drug testing, and on-site counseling requirements.

Methods

Consistent with the community-driven research (CDR) approach, this project was designed and led by people directly impacted by methadone treatment policies [47, 58]. The first author, in collaboration with National Survivors Union (NSU), the national union for people who use drugs in the United States, used a CDR [47] approach to the study. CDR is particularly useful for research with marginalized populations who often have negative experiences with researchers [11]. In the CDR model, members of the impacted community are considered fundamental drivers of all aspects of the research, from initiating and developing the research questions to data interpretation, analysis, and dissemination phases of the project [9]. Our use of the CDR model emphasizes leadership capacity development for community members with living experience [58]. Since the early stages of the project were unfunded, in lieu of compensating directly impacted collaborators, the first author provided NSU members with training and contributed to NSU activities unrelated to the research.

Data for these analyses come from a national online survey NSU conducted to discover if and how MMT in-person requirements were relaxed throughout the country. The cross-sectional survey, written in English, contained 28 questions including two write-in response questions (Appendix). NSU members designed the survey questions based on their MMT experiences during COVID-19 or the experiences of methadone patients in their community. Next, an academic researcher member phrased the questions, which six NSU methadone workgroup members evaluated over four two-hour sessions and further refined. Two members tested the survey prior to distribution for inclusive and accessible language, survey length, and potentially stigmatizing or traumatizing questions. As a result of testing, the survey was shortened, phrasing and word choice changed for several questions, and write-in questions were added.

The survey was conducted from June 7, 2020, to July 15, 2020. NSU members used targeted sampling methods [46] to recruit a convenience sample of methadone patients through drug use and methadone patient social media groups (Facebook, Reddit, Web site pop-ups, and Twitter). No respondents were compensated for participation because the CDR project was unfunded. All questions were optional. The anonymous survey was short (approximately 7 min) in respect of participants’ time.

In total, 455 people participated in the survey. The study inclusion criteria were self-reported current methadone treatment in the United States. Responses were checked to ensure respondents submitted only one response. We omitted respondents who did not complete the survey or reported that they were not MMT patients in the United States. The final analytic sample comprised 392 participants from 219 cities (1 to 9 participants per city) in 43 states and Washington D.C.

Data collection

The survey collected sociodemographic information including age-group, gender identity, race/ethnicity, health insurance type, monthly out-of-pocket payments for methadone, and participant MMT clinic state and city. It also collected self-reported information on take-home dose quantities, in-person clinic visits, toxicological screens, and counseling attendance.

Participant take-home dose quantities were measured categorically as: no take-home doses, 1 per week, 2 per week, 3 per week, 4 per week, 5 per week, 6 or 7 (one week), 13 or 14 (two weeks), and 27 or 28 (one month). Overall clinic attendance was measured categorically as every day, 6 times a week, 5 times a week, 4 times a week, 3 times a week, 2 times a week, once a week, twice a month, or once a month. Counseling attendance was also measured categorically as: daily, 3 times a week, 2 times a week, weekly, 6 times a month, 3 times a month, 2 times a month, once a month, once every 3 months, and none. Method of counseling attendance was also measured categorically as: not required to attend counseling services, in person, through telehealth, by telephone, and none. Information regarding how often toxicological screens were required was measured as, “never,” “1–2 times a month,” “2–5 times a month,” “5–7 times a month,” “7–10 times a month,” “10–15 times a month,” “20 +, ” and “other” as a write-in response. Items where participants indicated they did not know or if they left the question blank, that response was considered missing. Categories were established by consulting with community members and with considerations toward the balance of sample size between groups. The survey included two write-in response questions: “What has your clinic done to maintain 6-foot social distancing between people?” and “Is there anything else you would like to tell us about your clinic's practices during COVID-19?”.

Statistical analysis

Descriptive statistics were calculated for changes in required clinic visits and drug screening frequency, number of take-home doses, and counseling during COVID-19. States were grouped into four regions following the United States Census Bureau definition [67]. Insurance was grouped into three categories: private, government, and none. The private insurance category includes company healthcare plans, insurance purchased through the Affordable Care Act Health Insurance Marketplace (“Obamacare”), and self-funded insurance. The government-funded insurance category includes Medicaid, Medicare, Tricare, MassHealth, New Jersey family care, and state and county grants. People who identified two race/ethnicity categories were counted according to their minority category (for example, someone who identified as Black and white was counted as Black).

We used logistic regression models to examine factors associated with two outcomes related to in-person clinic attendance. The first outcome was whether someone received increased methadone take-home doses. Participants who did not report increased take-home doses during COVID-19 were coded as 0. Participants who reported any increase in take-home doses during COVID-19 were coded as 1. The second outcome was whether someone reported decreased in-person counseling. Participants who reported switching from in-person counseling prior to COVID-19 to telehealth or to no counseling during COVID-19 were coded as 1. Anyone who reported that they maintained in-person counseling or switched to in-person counseling during COVID-19 was coded as 0.

We looked at the associations of these two outcomes with the covariates of gender, age, region, methadone cost, and time in MMT in univariate logistic regression outcomes. We fitted a second set of logistic regressions for the same outcomes and covariates, and we accounted for time on MMT by including it as a covariate. Those who had missing data were excluded from the regression analyses.

Results

The total sample included 392 participants who reported currently receiving MMT in the United States (Table 1). A plurality came from the United States South (42.1%), with the smallest number coming from the West (8.2%) (Table 1). The majority (76.0%) identified as female, 85.9% identified as white, and 67.8% were below the age of 40. MMT treatment duration was less than 5 years for 46.4% of participants. Almost one-third (31.1%, n = 122) of participants paid $100 or more for MMT monthly (Table 1).

Table 1 Demographic characteristics of methadone patients, United States 2020 (N = 392)

Half of the respondents reported increased take-home doses during COVID-19 (50.4% (185/367), data not shown). Patients receiving 28-day take-home doses increased 2.5-fold (n = 27 before, n = 95 during) (Table 2). The number of patients receiving one or no take-home doses decreased from 22.4 to 10.2%.

Table 2 Changes in methadone patient in-person treatment

MMT clinic attendance decreased during COVID-19. Before COVID-19, 73.7% of respondents reported weekly or more frequent attendance; during COVID-19 this percentage dropped to 41.3%. The percentage of patients attending their clinics two or less times a month increased from 21.2 to 53.3%. In total, 53.0% of respondents attended their clinic less frequently during COVID-19 than before COVID-19 (data not shown). Although clinic attendance decreased overall, some patients experienced no decrease, and some experienced an increase in clinic attendance (Fig. 1).

Fig. 1
figure 1

Alluvial plot of changes in clinic visit frequency

In-person counseling attendance decreased from 82.9% before COVID-19 to 19.4% during COVID-19. Correspondingly, while only 3.3% of respondents accessed counseling through telehealth before the pandemic, this percentage increased to 61.7% during COVID-19 (Table 2). The percentage of patients who said they were not required to attend counseling services or that services were not available increased from 8.2% before COVID-19 to 14.0% during COVID-19.

We received a write-in response from 23 respondents in 12 states (Kentucky, Indiana, Illinois, Maryland, Massachusetts, Oklahoma, Maine, Florida, Pennsylvania, Michigan, North Carolina, Ohio) that their clinics had returned to pre-COVID-19 practices and eliminated increased take-home doses.

Regression analysis of factors associated with take-home doses and in-person counseling

We found that there were no associations for increased take-home doses by age, gender, cost of treatment, or length of time in MMT (Table 3). For the counseling outcomes, those paying more than $100 out of pocket for treatment were more likely to be required to attend in-person counseling sessions than those paying less than $20 out of pocket. These associations changed minimally when controlling for the length of time in treatment (Table 3).

Table 3 Regression outcomes of associations

Discussion

This national survey utilizes a CDR approach to describe methadone patient experiences of MMT in-person requirement changes during the first wave of COVID-19 in the United States. During COVID-19, patients reported decreased in-person clinic attendance and increased take-home doses and telehealth use for counseling, similar to the findings of a multi-state survey on substance use disorder treatment experiences during COVID-19 [55]. These changes are in line with recommendations that telehealth and increased take-home doses should be implemented to decrease COVID-19 infection risk [2, 10] for patients and staff.

We found many respondents were still required to visit their clinic in person at least once a week, and many received less than two weeks of take-home doses. Some respondents reported increased in-person clinic visit requirements during COVID-19. This may be because their OTP now defined them as less stable. Some OTPs may have increased in-person attendance requirements because of liability concerns about patients’ management of expanded take-homes or lost revenues due to reduced in-person dosing [64, 65, 72]. Since studies have found that unsupervised take-home dosing does not differ from supervised in-person dosing in treatment retention, illicit opioid use, diversion, or patient deaths, direct dosing supervision may add little if any additional protection [56] and it significantly increased patients’ risk of exposure to COVID-19.

Almost 20% of the respondents were required to attend counseling sessions in person during COVID-19. However, the number of methadone patients who said they were not required to attend counseling services or that services were not available increased from 8.2 to 14% during COVID-19. Although some studies find that mandatory counseling may negatively affect patient attitudes toward treatment (WHO, 2004) other studies find that counseling may increase treatment retention and decrease opioid use and HIV risk [18, 34]. Switching counseling to telehealth would enable clinics to provide patients with its potential benefits while maintaining social distancing.

Almost one-third of respondents paid over $100 a month out of pocket for methadone. Paying high amounts for methadone treatment may decrease treatment retention, as studies have found [7, 35], especially for those experiencing financial insecurity during COVID-19. We also found that these respondents were more likely to attend in-person counseling relative to those paying less. This may be because in most states OTPs receive larger reimbursements for multiple in-person patient visits weekly [30, 63, 72].

We also found that many respondents traveled long distances via shared transport for MMT, increasing COVID-19 exposure risk. Travel time to clinics has long been shown to cause hardship for daily methadone patients [41] and decreased treatment retention [5], issues that may have worsened during COVID-19.

Patients experienced inconsistent implementation of MMT relaxations during the first months of COVID-19, as a contemporary North Carolina study also found [21]. Studies later in 2020 on OTP staff and management perspectives also showed relaxations were unevenly implemented [38, 42]. MMT relaxations varied considerably by State. Research conducted in Arizona, a state underrepresented in this study, found that most patients did not receive reduced in-person requirements or 14- or 28-day take-home doses [45]. Notably, some respondents in our study said their clinics had revoked increased take-home doses during the time of this survey (June/July 2020), just a few months after SAMHSA released its initial guidance to increase take-home dosing access. Treatment requirements may have made it difficult for people to enter or remain in treatment while protecting their health and reducing the spread of COVID-19. Stronger state and federal guidance is needed for relaxing MMT requirements, including reducing in-person group and individual counseling requirements, transitioning to telehealth for services, and increasing take-home doses consistently.

During COVID-19, it is critical to remember that we are still in the midst of an overdose crisis, and overdose rates are increasing across the USA [14, 60]. One treatment that has consistently proven to greatly reduce the risk of overdose is methadone. While the new federal SAMHSA guidelines are a step forward, we have not yet seen consistent relaxation of barriers to treatment for methadone patients across the United States. Researchers have long called for expanding access to methadone treatment, reducing supervised in-person dosing, and decreasing regulations and the burden of compliance and attendance [50]. Given that methadone-related fatal overdose rates have not increased since the MMT relaxations were implemented [8, 32], the COVID-19 relaxations in MMT requirements should be further relaxed and made permanent, as experts have also recommended [14]. National Institute on Drug Abuse Director Nora Volkow recently made a statement supporting office-based prescription and pharmacy dispensing of methadone [20]. Allowing methadone treatment in community pharmacies would also help expand access to methadone treatment, reduce travel times, and help address the opioid epidemic and issues arising from COVID-19 [12]. Given COVID-19 and the overdose crisis, increasing methadone access, and reducing barriers to treatment is all the more urgent.

Limitations

Our study has limitations. Since this CDR study was initially unfunded, full participation in the research process was less accessible to NSU members who could not afford to donate their time. Our current projects prioritize compensation for all participants. The questionnaire relied on self-reported information, which raises reliability and validity questions about the findings; however, we have no reason to believe that participants were not truthful. Furthermore, this cross-sectional study represents patient experiences of MMT changes during the survey time period. Program changes continue to evolve over time. Additionally, this convenience sample of methadone patients recruited through social media who self-selected into the survey and were not compensated for participation may not be representative. Although our sample is not clustered by state or city (no more than 9 people participated from any city), the sample may not be representative by race/ethnicity, gender identity, time in treatment, or other variables. We did not disseminate a Spanish language survey, which may have led to portions of the United States being underrepresented. Moreover, we do not have enough data on non-white participants to describe any racial disparities, which is another limitation of the sample. Also, many factors likely to influence take-home regimens, including stability measures, were not collected. Finally, MMT restriction relaxations may depend on clinic protocols rather than patient characteristics.

Conclusion

Methadone patients report considerable variation in how relaxations in methadone treatment have been implemented during COVID-19. Although some patients received increased take-home doses and decreased in-person clinic attendance requirements, many reported frequent in-person clinic visits. Further research should explore the reasons for the variation in MMT relaxation implementation during COVID-19. OTPs should be encouraged to permanently and consistently reduce MMT barriers, particularly in-person attendance requirements.

Availability of data and materials

The data and code to reproduce this analysis can be found at https://osf.io/f6zw2/.

References

  1. Ahmad F, Rossen L, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Reviewed November 12, 2020.

  2. Alexander GC, Stoller KB, Haffajee RL, Saloner B. An epidemic in the midst of a pandemic: opioid use disorder and COVID-19. Annals Int Med. 2020;173(1):57–8. https://0-doi-org.brum.beds.ac.uk/10.7326/M20-1141.

    Article  Google Scholar 

  3. Alter A, & Yeager C (2020) COVID-19 Impact on US national overdose crisis. University of Baltimore. Baltimore: ODMAP. Retrieved July 12, 2020.

  4. Baillargeon J, Polychronopoulou E, Kuo YF, Raji MA. The impact of substance use disorder on COVID-19 outcomes. Psychiatr Serv. 2021;72(5):578–81.

    Article  PubMed  Google Scholar 

  5. Beardsley K, Wish ED, Fitzelle DB, O’Grady K, Arria AM. Distance traveled to outpatient drug treatment and client retention. J Subst Abuse Treat. 2003;25(4):279–85.

    Article  PubMed  Google Scholar 

  6. Becker WC, Fiellin DA. When epidemics collide: Coronavirus disease 2019 (COVID-19) and the opioid crisis. Publ Online. 2020. https://0-doi-org.brum.beds.ac.uk/10.7326/M20-1210.

    Article  Google Scholar 

  7. Booth RE, Corsi KF, Mikulich-Gilbertson SK. Factors associated with methadone maintenance treatment retention among street-recruited injection drug users. Drug Alcohol Depend. 2004;74(2):177–85.

    Article  PubMed  Google Scholar 

  8. Brothers S, Viera A, Heimer R. Changes in methadone program practices and fatal methadone overdose rates in Connecticut during COVID-19. J Substan Abuse Treat. 2021;131:108449

    Article  CAS  Google Scholar 

  9. Carrera JS, Key K, Bailey S, Hamm JA, Cuthbertson CA, Lewis EY, et al. Community science as a pathway for resilience in response to a public health crisis in Flint, Michigan. Soc Sci. 2019;8(3), 94.

    Article  Google Scholar 

  10. Chen K L, Brozen M, Rollman J E, Ward T, Norris K, Gregory K D, & Zimmerman F J (2020) Transportation access to health care during the COVID-19 pandemic: trends and implications for significant patient populations and health care needs. Los Angeles, CA: UCLA Institute of transportation studies. Report No.: UC-ITS-2021–11 | https://0-doi-org.brum.beds.ac.uk/10.17610/T6RK5N. Accessed Oct 30, 2020.

  11. Christopher S, Watts V, McCormick AKHG, Young S. Building and maintaining trust in a community-based participatory research partnership. Am J Public Health. 2008;98(8):1398–406.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Cochran G, Bruneau J, Cox N, Gordon AJ. Medication treatment for opioid use disorder and community pharmacy: expanding care during a national epidemic and global pandemic. Substance Abuse. 2020;41(3):269–74.

    Article  PubMed  Google Scholar 

  13. Connery HS. Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harv Rev Psychiatry. 2015;23(2):63–75.

    Article  PubMed  Google Scholar 

  14. Davis CS, Samuels EA. Opioid policy changes during the COVID-19 pandemic-and beyond. J Addict Med. 2020. https://0-doi-org.brum.beds.ac.uk/10.1097/ADM.0000000000000679.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Degenhardt L, Bucello C, Mathers B, Briegleb C, Ali H, Hickman M, McLaren J. Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies. Addiction. 2011;106(1):32–51.

    Article  PubMed  Google Scholar 

  16. Degenhardt L, Charlson F, Ferrari A, Santomauro D, Erskine H, Mantilla-Herrara A, Whiteford H, Leung J, Naghavi M, Griswold M, Rehm J. The global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990–2016: a systematic analysis for the global burden of disease study 2016. Lancet Psychiatr. 2018;5(12):987–1012.

    Article  Google Scholar 

  17. Drew L. Opioids by the numbers. Nature. 2019;573(7773):S2-s3.

    Article  CAS  Google Scholar 

  18. Dugosh K, Abraham A, Seymour B, McLoyd K, Chalk M, Festinger D. A systematic review on the use of psychosocial interventions in conjunction with medications for the treatment of opioid addiction. J Addict Med. 2016;10(2):91.

    Article  CAS  PubMed Central  Google Scholar 

  19. Ezie C, Badolato R, Rockas M, Nafiz R, Sands B, Wolkin A, Farahmand P. COVID 19 and the opioid epidemic: an analysis of clinical outcomes during COVID 19. Substance Abuse Res Treat. 2022;16:11782218221085590. https://0-doi-org.brum.beds.ac.uk/10.1177/11782218221085590.

    Article  Google Scholar 

  20. Facher L (2022) Top US addiction researcher calls for broad deregulation of methadone. STAT. https://www.statnews.com/2022/11/16/nora-volkow-nida-broad-deregulation-methadone/

  21. Figgatt MC, Salazar Z, Day E, Vincent L, Dasgupta N. Take-home dosing experiences among persons receiving methadone maintenance treatment during COVID-19. J Subst Abuse Treat. 2021;123: 108276.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Glober N, Mohler G, Huynh P, Arkins T, O’Donnell D, Carter J, Ray B. Impact of COVID-19 pandemic on drug overdoses in Indianapolis. J Urban Health. 2020;97:802–7.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Goldsamt LA, Rosenblum A, Appel P,Paris P, Nazia N. The impact of COVID-19 on opioid treatment programs in the United States. Drug Alcohol Depend. 2021;228:109049.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Hansen H, Roberts SK. Two tiers of biomedicalization: Methadone, buprenorphine, and the racial politics of addiction treatment. In: Critical perspectives on addiction, vol. 14. Emerald Group Publishing Limited; 2012. p. 79–102.

  25. Harris MT, Lambert AM, Maschke AD, Bagley SM, Walley AY, Gunn CM. “No home to take methadone to”: experiences with addiction services during the COVID-19 pandemic among survivors of opioid overdose in Boston. J Substance Abuse Treatment. 2022;1(135):108655. https://0-doi-org.brum.beds.ac.uk/10.1016/j.jsat.2021.108655.

    Article  CAS  Google Scholar 

  26. Hatch-Maillette MA, Peavy KM, Tsui JI, Banta-Green CJ, Woolworth S, Grekin P. Re-thinking patient stability for methadone in opioid treatment programs during a global pandemic: provider perspectives. J Subst Abuse Treat. 2021;124: 108223.

    Article  CAS  PubMed  Google Scholar 

  27. Hedegaard H, Miniño A M, & Warner M (2020) Drug overdose deaths in the United States, 1999-2018. Atlanta, GA: National center for health statistics. NCHS Data Brief No. 356. https://www.cdc.gov/nchs/data/databriefs/db356-h.pdf. Last accessed Oct 30, 2020.

  28. Heimer R, McNeil R, Vlahov D. A community responds to the COVID-19 pandemic: a case study in protecting the health and human rights of people who use drugs. J Urban Health. 2020;97(4):448–56.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Hoffman KA, Foot C, Levander XA, Cook R, Terashima JP, McIlveen JW, Korthuis PT, McCarty D. Treatment retention, return to use, and recovery support following COVID-19 relaxation of methadone take-home dosing in two rural opioid treatment programs: a mixed methods analysis. J Substance Abuse Treatment. 2022;1(141):108801. https://0-doi-org.brum.beds.ac.uk/10.1016/j.jsat.2022.108801.

    Article  CAS  Google Scholar 

  30. 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Jaffe JH, O’Keeffe C. From morphine clinics to buprenorphine: regulating opioid agonist treatment of addiction in the United States. Drug Alcohol Depend. 2003;70(2):S3–11.

    Article  PubMed  Google Scholar 

  32. Jones CM, Compton WM, Han B, Baldwin G, Volkow ND. Methadone-involved overdose deaths in the us before and after federal policy changes expanding take-home methadone doses from opioid treatment programs. JAMA Psychiat. 2022;79(9):932–4.

    Article  Google Scholar 

  33. 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.

    Article  CAS  PubMed  Google Scholar 

  34. Kelly SM, O’Grady KE, Mitchell SG, Brown BS, Schwartz RP. Predictors of methadone treatment retention from a multi-site study: a survival analysis. Drug Alcohol Depend. 2011;117(2–3):170–5.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Kourounis G, Richards BDW, Kyprianou E, Symeonidou E, Malliori MM, Samartzis L. Opioid substitution therapy: lowering the treatment thresholds. Drug Alcohol Depend. 2016;161:1–8.

    Article  PubMed  Google Scholar 

  36. Krawczyk N, Bunting AM, Frank D, Arshonsky J, Gu Y, Friedman SR, Bragg MA. “How will I get my next week’s script?” Reactions of reddit opioid forum users to changes in treatment access in the early months of the coronavirus pandemic. Int J Drug Policy. 2021;1(92):103140.

    Article  Google Scholar 

  37. Kreek MJ. Methadone-related opioid agonist pharmacotherapy for heroin addiction: history, recent molecular and neurochemical research, and future in mainstream medicine. In: Glick SD, Maisonneuve IM, editors. Annals of the New York Academy of Sciences, vol. 909. New Medications for Drug Abuse. New York, NY: New York Academy of Sciences; 2000. p. 186–216.

    Google Scholar 

  38. Levander XA, Pytell JD, Stoller KB, Korthuis PT, Chander G. COVID-19-related policy changes for methadone take-home dosing: A multistate survey of opioid treatment program leadership. Substance abuse. 2022;43(1):633–9. https://0-doi-org.brum.beds.ac.uk/10.1080/08897077.2021.1986768.

    Article  CAS  PubMed  Google Scholar 

  39. Lin C, Clingan SE, Cousins SJ, Valdez J, Mooney LJ, Hser YI. The impact of COVID-19 on substance use disorder treatment in California: service providers’ perspectives. J Substance Abuse Treatment. 2022;133:108544. https://0-doi-org.brum.beds.ac.uk/10.1016/j.jsat.2021.108544.

    Article  CAS  Google Scholar 

  40. Livingston NA, Davenport M, Head M, Henke R, LeBeau LS, Gibson TB, Banducci AN, Sarpong A, Jayanthi S, Roth C, Camacho-Cook J. The impact of COVID-19 and rapid policy exemptions expanding on access to medication for opioid use disorder (MOUD): a nationwide veterans health administration cohort study. Drug Alcohol Dependence. 2022;1(241):109678.

    Article  Google Scholar 

  41. Luger L, Bathia N, Alcorn R, Power R. Involvement of community pharmacists in the care of drug misusers: pharmacy-based supervision of methadone consumption. I J Drug Policy. 2000;11(3):227–34.

    Article  CAS  Google Scholar 

  42. Madden EF, Christian BT, Lagisetty PA, Ray BR, Sulzer SH. Treatment provider perceptions of take-home methadone regulation before and during COVID-19. Drug Alcohol Depend. 2021;228:109100.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Mallet J, Dubertret C, Le Strat Y. Addictions in the COVID-19 era: current evidence, future perspectives a comprehensive review. Progress Neuro-Psychopharmacol Biol Psychiatry. 2020;106:110070.

    Article  Google Scholar 

  44. McIlveen JW, Hoffman K, Priest KC, Choi D, Korthuis PT, McCarty D. Reduction in oregon's medication dosing visits After the SARS-CoV-2 relaxation of restrictions on take-home medication. J Addict Med. 2021;15(6):516.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Meyerson BE, Bentele KG, Russell DM, Brady BR, Downer M, Garcia RC, Garnett I, Lutz R, Mahoney A, Samorano S, Arredondo C, Andres HJ, Coles H, Granillo B. Nothing really changed: arizona patient experience of methadone and buprenorphine access during COVID. PLoS ONE. 2022;17(10):e0274094.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Miller PG, Sønderlund AL. Using the internet to research hidden populations of illicit drug users: a review. Addiction. 2010;105(9):1557–67.

    Article  PubMed  Google Scholar 

  47. Montoya MJ, Kent EE. Dialogical action: moving from community-based to community-driven participatory research. Qual Health Res. 2011;21(7):1000–11.

    Article  PubMed  Google Scholar 

  48. NIDA. (2019). Overdose death rates. https://www.drugabuse.gov/relatedtopics/trends-statistics/overdose-death-rates. Updated January 2019. Accessed Oct 29, 2020.

  49. O’Connor AM, Cousins G, Durand L, Barry J, Boland F. Retention of patients in opioid substitution treatment: a systematic review. PLoS ONE. 2020;15(5): e0232086.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Pitt AL, Humphreys K, Brandeau ML. Modeling health benefits and harms of public policy responses to the US opioid epidemic. Am J Public Health. 2018;108(10):1394–400.

    Article  PubMed  PubMed Central  Google Scholar 

  51. SAMHSA. (2020a). FAQs: Provision of methadone and buprenorphine for the treatment of opioid use disorder in the COVID-19 emergency. Rockville, MD: Substance Abuse and mental health services administration. https://www.samhsa.gov/sites/default/files/faqs-for-oud-prescribing-and-dispensing.pdf. Last accessed Oct 28, 2020.

  52. SAMHSA (2020b) Key substance use and mental health indicators in the United States: Results from the 2019 National survey on drug use and health (HHS Publication No. PEP20-07-01-001, NSDUH Series H-55). Rockville, MD: Center for behavioral health statistics and quality, substance abuse and mental health services administration. Retrieved from https://www.samhsa.gov/data/

  53. SAMHSA (2020c). National survey of substance abuse treatment services (N-SSATS): 2019. Data on substance abuse treatment facilities. Rockville, Substance abuse and mental health services administration.

  54. SAMHSA (2023) Methadone take-home flexibilities extension guidance. Retrieved from https://www.samhsa.gov/medications-substance-use-disorders/statutes-regulations-guidelines/methadone-guidance. Last accessed Feb 2, 2023.

  55. Saloner B, Krawczyk N, Solomon K, Allen ST, Morris M, Haney K, Sherman SG. Experiences with substance use disorder treatment during the COVID-19 pandemic: findings from a multistate survey. Int J Drug Policy. 2022;101: 103537.

    Article  PubMed  Google Scholar 

  56. Saulle R, Vecchi S, Gowing L. Supervised dosing with a long-acting opioid medication in the management of opioid dependence. Cochrane Database Syst Rev. 2017;4(4):CD011983.

    PubMed  Google Scholar 

  57. Shakira RH, W., Sarimah, A., & Norsa’adah, B. Factor predictive of 1-year retention on methadone maintenance therapy program: a survival analysis study. Addict Disord Treat. 2017;16(2):64–9.

    Article  Google Scholar 

  58. Simon C, Brothers S, Strichartz K, Coulter A, Voyles N, Herdlein A, Vincent L. We are the researched, the researchers, and the discounted: the experiences of drug user activists as researchers. Int J Drug Policy. 2021;98:103364.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Slaunwhite AK, Gan WQ, Xavier C, Zhao B, Buxton JA, Desai R. Overdose and risk factors for severe acute respiratory syndrome. Drug and Alcohol Dependence, Publ Online. 2020. https://0-doi-org.brum.beds.ac.uk/10.1016/j.drugalcdep.2020.108047.

    Article  Google Scholar 

  60. Slavova S, Rock P, Bush HM, Quesinberry D, Walsh SL. Signal of increased opioid overdose during COVID-19 from emergency medical services data. Drug Alcohol Dependence Publ Online. 2020. https://0-doi-org.brum.beds.ac.uk/10.1016/j.drugalcdep.2020.108176.

    Article  Google Scholar 

  61. Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, Pastor-Barriuso R. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:1550.

    Article  Google Scholar 

  62. Stover H. Barriers to opioid substitution treatment access, entry and retention: a survey of opioid users, patients in treatment, and treating and non-treating physicians. Eur Addict Res. 2011;17:44–54.

    Article  PubMed  Google Scholar 

  63. Suen LW, Castellanos S, Joshi N, Satterwhite S, Knight KR. “The idea is to help people achieve greater success and liberty”: a qualitative study of expanded methadone take-home access in opioid use disorder treatment. Substance abuse. 2021;43(1):1143.

    Google Scholar 

  64. Suen LW, Castellanos S, Joshi N, Satterwhite S, Knight KR. “The idea is to help people achieve greater success and liberty”: a qualitative study of expanded methadone take-home access in opioid use disorder treatment. Substance Abuse. 2022;43(1):1143–50.

    Article  PubMed  Google Scholar 

  65. Suen LW, Coe WH, Wyatt JP, Adams ZM, Gandhi M, Batchelor HM, Castellanos S, Joshi N, Satterwhite S, Pérez-Rodríguez R, Rodríguez-Guerra E, Albizu-Garcia CE, Knight KR, Jordan A. Structural adaptations to methadone maintenance treatment and take-home dosing for opioid use disorder in the era of COVID-19. Am J Public Health. 2022;112(S2):S112–6. https://0-doi-org.brum.beds.ac.uk/10.2105/AJPH.2021.306654.

    Article  PubMed  Google Scholar 

  66. Treitler PC, Bowden CF, Lloyd J, Enich M, Nyaku AN, Crystal S. Perspectives of opioid use disorder treatment providers during COVID-19: adapting to flexibilities and sustaining reforms. J Substance Abuse Treat. 2022;132:108514.

    Article  CAS  Google Scholar 

  67. US Census Bureau. (2010). Census regions and divisions of the United States. US Census Bureau website.

  68. Walters SM, Perlman DC, Guarino H, Mateu-Gelabert P, Frank D. Lessons from the first wave of COVID-19 for improved medications for opioid use disorder (MOUD) treatment: benefits of easier access, extended take homes, and new delivery modalities. Subst Use Misuse. 2022;57(7):1144–53. https://0-doi-org.brum.beds.ac.uk/10.1080/10826084.2022.2064509.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Welsh C, Doyon S, Hart K. Methadone exposures reported to poison control centers in the United States following the COVID-19-related loosening of federal methadone regulations. Int J Drug Policy. 2022;102:103591.

    Article  PubMed  PubMed Central  Google Scholar 

  70. World health organization (WHO). Department of mental health, substance abuse, world health organization, international narcotics control board, united nations office on drugs, & crime. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva, Switzerland: World Health Organization; 2009. https://www.who.int/substance_abuse/publications/Opioid_dependence_guidelines.pdf. Accessed 30 Oct 2020.

  71. Wu LT, Zhu H, Swartz MS. Treatment utilization among persons with opioid use disorder in the United States. Drug Alcohol Depend. 2016;169:117–27.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Wyatt JP, Suen LW, Coe WH, Adams ZM, Gandhi M, Batchelor HM, Castellanos S, Joshi N, Satterwhite S, Pérez-Rodríguez R, Rodríguez-Guerra E, Albizu-Garcia CE, Knight KR, Jordan A. Federal and state regulatory changes to methadone take-home doses: impact of sociostructural factors. Am J Public Health. 2022;112(S2):S143–6. https://0-doi-org.brum.beds.ac.uk/10.2105/AJPH.2022.306806.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank the NSU methadone advocacy team, Anna Herdlein, Lindsay Roberts, Elizabeth Day, Zach Salazar, David Frank, Adam Viera, Dan Bromberg, J.P. Miller, and everyone who volunteered their time on this project. We are grateful for help and support from MATSA, National Survivors Union (NSU), and North Carolina Survivors Union. We also thank all the grassroots organizations who have created community-driven research before us, and especially, all the participants in our study.

Funding

We thank the Urgent Action Fund and the Criminal Justice Research Center (CJRC) for funding the last phase of the project.

Author information

Authors and Affiliations

Authors

Contributions

SB analyzed the data and wrote the manuscript. AP conducted a statistical analysis of data, drafted the methods section, created the tables and figure, and edited the manuscript. CS contributed to the interpretation of the data and provided substantial edits to the text. KS and LV designed the study. AC and NV contributed to the study design and interpretation of the data. All authors approved the final article.

Corresponding author

Correspondence to Sarah Brothers.

Ethics declarations

Ethics approval and consent to participate

Yale University Institutional Review Board reviewed this study, which was determined to fall under the category of not human subjects research because it was not individually identifiable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendix

Appendix

Methadone patient online survey

1. How old are you?

18–25

25–30

30–35

35–40

40–45

45–50

50 + 

2. What is your current gender identity?

Cis Man

Cis Woman

Agender

Nonbinary

Trans Man

Trans Woman

Other (write-in response)

3. Which of the following best describes your race? Please check all that apply

Native American

African American

Asian/Asian American

Caucasian

Hispanic

Pacific Islander

Prefer not to answer

Other (write-in response)

4. What best describes your health insurance?

Medicaid/Medicare

Government Healthcare (Obama Care)

Self-Pay Private Insurance

Company Healthcare Plan

I don't have health insurance

Other (write-in response)

5. How much do you pay out of pocket per month for methadone?

$0-$20

$20-$40

$60-$80

$100-$120

$140-$160

$160-$180

$180-$200

6. What state is your clinic located in?

 

7. What city is your clinic located in?

 

8. How many miles away is the clinic from your home?

 

9. How many minutes is the travel time each way?

0–20 min

20–30 min

30–45 min

45–60 min

60–75 min

75–90 min

over 90 min

10. How do you get to your clinic? Please check all which apply

Public transportation bus

Public transportation train

Walk

Bike

Carpooling with others

Driving by self

11. How long have you been prescribed methadone?

1–3 months

3–6 months

6–9 months

9 months-1 year

1–3 years

3–5 years

5–7 years

7–10 years

10 + years

12. How often did you go to the clinic before the pandemic?

Every day

3 times a week

2 times a week

Once a week

Twice a month

Once a month

Other (write-in response)

13. How often do you go to the clinic NOW?

Every day

3 times a week

2 times a week

Once a week

Twice a month

Once a month

Other (write-in response)

14. How many take-home doses did you receive BEFORE the pandemic?

I did not receive take-homes

2 weekends

3 on Thursdays

7 (one week)

14 (two weeks)

28 (one month)

Other (write-in response)

15. How many take-home doses do you receive NOW?

I do not receive take-homes

3 weekends

4 on Thursdays

8 (one week)

15 (two weeks)

29 (one month)

Other (write-in response)

16. Were you required to attend any of the following at your clinic BEFORE the pandemic? Please check all which apply

Individual counseling

Group counseling

Family counseling

Court ordered drug counseling

I was not required to attend any type of counseling

Other (write-in response)

17. How did you attend required counseling services BEFORE the pandemic?

I wasn't required to attend counseling services

In person

Through Telehealth

Other (write-in response)

18. How often during a month did you attend these counseling services BEFORE the pandemic?

 

19. How do you attend counseling services NOW?

I wasn't required to attend counseling services

In person

Through Telehealth

Other (write-in response)

20. How often during the month do you attend counseling services NOW?

 

21. Were you required by your clinic to participate in mandatory drug screens BEFORE the pandemic?

Yes

No

22. How often were you required to take a drug screen BEFORE the pandemic?

Never

1–2 times a month

2–5 times a month

5–7 times a month

7–10 times a month

10–15 times a month

20 + 

Other (write-in response)

23. How often are you required to take a drug screen NOW?

Never

1–2 times a month

2–5 times a month

5–7 times a month

7–10 times a month

10–15 times a month

20 + 

Other (write-in response)

24. Is your clinic trying to maintain the social distancing at a space of 6 feet?

Yes

No

Sometimes

Other (write-in response)

25. What has your clinic done to maintain 6-foot social distancing between people?

 

26. Is there anything else you would like to tell us about your clinics’ practices during COVID-19?

 

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Brothers, S., Palayew, A., Simon, C. et al. Patient experiences of methadone treatment changes during the first wave of COVID-19: a national community-driven survey. Harm Reduct J 20, 31 (2023). https://0-doi-org.brum.beds.ac.uk/10.1186/s12954-023-00756-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://0-doi-org.brum.beds.ac.uk/10.1186/s12954-023-00756-3

Keywords