Abstract
Methadone access may be uniquely vulnerable to disruption during COVID-19, and even short delays in access are associated with decreased medication initiation and increased illicit opioid use and overdose death. Relative to Canada, US methadone provision is more restricted and limited to specialized opioid treatment programs. To compare timely access to methadone initiation in the US and Canada during COVID-19. This cross-sectional study was conducted from May to June 2020. Participating clinics provided methadone for opioid use disorder in 14 US states and territories and 3 Canadian provinces with the highest opioid overdose death rates. Statistical analysis was performed from July 2020 to January 2021. Nation and type of health insurance (US Medicaid and US self-pay vs Canadian provincial). Proportion of clinics accepting new patients and days to first appointment. Among 268 of 298 US clinics contacted as a patient with Medicaid (90%), 271 of 301 US clinics contacted as a self-pay patient (90%), and 237 of 288 Canadian clinics contacted as a patient with provincial insurance (82%), new patients were accepted for methadone at 231 clinics (86%) during US Medicaid contacts, 230 clinics (85%) during US self-pay contacts, and at 210 clinics (89%) during Canadian contacts. Among clinics not accepting new patients, at least 44% of 27 clinics reported that the COVID-19 pandemic was the reason. The mean wait for first appointment was greater among US Medicaid contacts (3.5 days [95% CI, 2.9-4.2 days]) and US self-pay contacts (4.1 days [95% CI, 3.4-4.8 days]) than Canadian contacts (1.9 days [95% CI, 1.7-2.1 days]) (P < .001). Open-access model (walk-in hours for new patients without an appointment) utilization was reported by 57 Medicaid (30%), 57 self-pay (30%), and 115 Canadian (59%) contacts offering an appointment. In this cross-sectional study of 2 nations, more than 1 in 10 methadone clinics were not accepting new patients. Canadian clinics offered more timely methadone access than US opioid treatment programs. These results suggest that the methadone access shortage was exacerbated by COVID-19 and that changes to the US opioid treatment program model are needed to improve the timeliness of access. Increased open-access model adoption may increase timely access.
Highlights
Opioid overdose deaths are rising in the context of the COVID-19 pandemic.[1,2,3] Timely access to medications for opioid use disorder (OUD) is critical to preventing overdose deaths,[4] but COVID-19 may have disrupted the treatment delivery system
Among 268 of 298 US clinics contacted as a patient with Medicaid (90%), 271 of 301 US clinics contacted as a self-pay patient (90%), and 237 of 288 Canadian clinics contacted as a patient with provincial insurance (82%), new patients were accepted for methadone at 231 clinics (86%) during US Medicaid contacts, 230 clinics (85%) during US self-pay contacts, and at 210 clinics (89%) during Canadian contacts
Canadian clinics offered more timely methadone access than US opioid treatment programs. These results suggest that the methadone access shortage was exacerbated by COVID-19 and that changes to the US opioid treatment program model are needed to improve the timeliness of access
Summary
Opioid overdose deaths are rising in the context of the COVID-19 pandemic.[1,2,3] Timely access to medications for opioid use disorder (OUD) is critical to preventing overdose deaths,[4] but COVID-19 may have disrupted the treatment delivery system. OTPs must meet multiple federal, state, and local requirements designed to minimize diversion and mandate the frequency of administration, toxicology screening, and behavioral treatment.[10] Beginning in March 2020, SAMHSA allowed increased take-home medication and utilization of telemedicine for established patients.[11,12,13] Canadian professional organizations recommended increased take-home medication in March,[14] but methadone provision was already less restricted prior to COVID-19 facilitating integration into other health care services.[15] Specialty and primary care clinicians may prescribe methadone in-person or through telemedicine,[16] and both administration and dispensing may occur within pharmacies.[10,17] The flexibility of the Canadian regulatory environment allows for greater variation in the structure of methadone clinics (ie, a clinic providing a methadone order or prescription for OUD) relative to US OTPs
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