(40) Critical Incidents in Colorado OTPs: Comparing Early COVID-19 Pandemic to Previous Years

Introduction
Opioid Treatment Programs (OTPs) dispense daily in-person and take-home doses of medication for treatment of opioid use disorder (OUD). In response to the growing COVID-19 pandemic, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued guidance to OTPs in March 2020 allowing for greater numbers of take-home doses of methadone for certain patients. Colorado OTPs received a blanket exception for all stable patients to receive 28 days of take-home doses and up to 14 days of take-home medication for patients who are less stable but can safely handle doses. This action prompted a question: would the rate of critical incidents (CIs)--safety events occurring at an OTP that are reportable to regulatory entities--increase following this regulatory change?

Methods
We obtained state-wide critical incident data for patients enrolled in OTPs from the Colorado Department of Human Services Central Registry in the Office of Behavioral Health. Only patients listed in the registry between the calendar years of 2017-2020 were included. Recorded critical incidents included arrest, assault, confidentiality breach, death, hospitalization, medical emergency, medication diversion, suicide/self-harm attempt, and other.

To calculate critical incident rate, we obtained the census of all patients enrolled in daily dosing across Colorado OTPs for each year at the calendar midpoint of March 15 – December 31, which is August 7. As March 15 was considered the start of the COVID-19 pandemic in Colorado, only critical incidents which occurred from March 15 – December 31 of each year were included. Count of CIs for a given time period was divided by the midpoint census count to calculate a critical incident rate per 100 enrolled patients.

Results
Census of OTP patient enrollment increased from 4377 in 2017 to 6472 in 2020 across 23 (2017) and 29 (2020) clinics. Medication Diversion or Error (65.6% of all critical incidents), death (12.5%), and other (9.4%) were the most frequent CIs across 2017-2020. There was a significant increase in the overall rate of critical incidents from 2017 to 2020 (1.1% to 4.0%, p< 0.001). Similarly, the overall critical incident rate in 2020 was significantly higher than the average critical incident rate for the years 2017-2019 (4.0% vs. 2.3%, p< 0.001). When compared exclusively to 2019, the year 2020 showed no difference in overall critical incident rate among Colorado OTPs (2019: 3.8%, 2020: 4.0%, p=0.511). On average, there were significantly more critical incidents per month in 2020 than in 2017-2019 (13.4±3.3 vs 26.0±5.9 p< 0.001). Notably, there was no difference in the average number of critical incidents per month between 2019 and 2020 (2019: 22.8±6.7 vs 2020: 26.0±5.9, p=0.270).

Conclusions
When compared to 2019, there was no increase in the rate of reportable critical incidents in Colorado OTPs following the SAMHSA COVID-19 guidance increasing take-home doses in 2020. The notable increase in CI incidence occurred from 2018-2019, predating the pandemic. The data indicate no increase in the occurrence of self-harm or, further underscoring the apparent safety of take-home methadone doses. As the rate of CIs following the March 2020 SAMHSA guidance did not result in an increase of critical incidents among Colorado OTPs, there should be further consideration to how a greater number of take-homes might benefit patients and OTPs.

References: 1. Khatri UG, Perrone J. Opioid Use Disorder and COVID-19: Crashing of the Crises. J Addict Med. 2020;14(4):e6-e7. doi:10.1097/ADM.0000000000000684
2. Substance Abuse and Mental Health Services Administration. Opioid Treatment Program (OTP) Guidance. https://www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf. Accessed August 15, 2020.
3. Gerra G, Saenz E, Busse A, et al. Supervised daily consumption, contingent take-home incentive and non-contingent take-home in methadone maintenance. Prog Neuropsychopharmacol Biol Psychiatry. 2011;35(2):483-489. doi:10.1016/j.pnpbp.2010.12.002