Pandemic-Based Expanded Take Home Privileges: Risk Stratification and Relapse

Introduction: Despite modest gains made in recent years, the United States remains gripped in an opioid use disorder (OUD) epidemic that has seen as many as 70,000+ individual lose their life in a single year1. The COVID-19 pandemic that enveloped the country in late winter of 2020 resulted in Federal and State loosening of the restrictions on the dispensing of take-home privileges to those enrolled in outpatient medication assisted treatment (MAT) for an opioid use disorder2,3,4. These changes, which were enacted with the dual intent of decreasing treatment-site exposure as well as increasing social distancing in the environment of care, resulted in clinical staff development of risk stratification criteria for expanded take home privileges (ETHPs). The end result has been a sizable proportion of MAT enrolled individuals receiving between 14 and 28 consecutive take home bottles. Given the inherent controversial nature of take-home privileges for those receiving outpatient methadone treatment, this recent expansion (including to those who had not previously been granted take home bottles), has not been without significant concern about the potential for harm to be done to the clinical population. The current study, conducted in a fairly large (N=430) university sponsored, urban outpatient MAT program was designed to assess the impact of Covid-related ETHPs.

Methods: To address the primary question, three mutually exclusive categories were created based on urinalysis findings and clinical review - 1) patients with preexisting privileges whose privileges were expanded to 28 days (n=171); 2) patients who at the time had not earned privileges, but through risk stratification were considered safe to receive between 7 and 14 thbs (n=60); and 3) patients who through risk stratification were awarded no take home medications (n=176).

Results: Data were derived from 407 individuals enrolled as of March 19, 2020. Patients averaged 48.9 years (SD12.29); 56% were male. Patients had been in treatment on average 4.93 years (SD 5.36). It was observed that 84.8% of patients who had received up to 28 days of ETHPs retained those privileges at three-month follow-up (p <.001). It was interesting to note that within these 171 patients, a negative correlation between probability of bottle loss and number of previously earned thbs was observed, r = -.33, p <.01.. Additionally, 38.3% of patients whose risk stratification resulted in their being awarded reduced privileges (i.e., 7-14 days), maintained their status, despite never having previously earned thbs. Interestingly, 8.5% of those initially not awarded ETHPS due to risk stratification, earned them in the three-month follow-up period.

Conclusions: Expansion of take-home privileges did not seem to cause harm to patients who had previously established a period of sobriety as 84.8% of these individuals remained abstinent at three-month follow-up. Furthermore, these findings appear to support the risk stratification algorithm that was developed as over half of those who received ETHPs without having previously earned privileges, went on to forfeit them. Additional sub-group analysis is needed to determine potential protective mediators in those who retained THBs, including factors such as treatment history.

References: 1. Wen, L; Sadeghi, N (2020) The opioid crisis and the 2020 US election: crossroads for a national epidemic. The Lancet,
DOI:https://doi.org/10.1016/S0140-6736(20)32113-9
2. Alexander, C et al. (2020) An Epidemic in the Midst of a Pandemic: Opioid Use Disorder and COVID-19. Annals of Internal Medicine, 173, 57-58.
3. https://www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf
4. Yankun Sun, Yan Bao, Thomas Kosten, John Strang, Jie Shi, & Lin Lu (2020) Editorial: Challenges to Opioid Use Disorders During COVID‐19
Am J Addict. 29(3): 174–175