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Substance Use and Addiction Medicine

Methadone Access for Opioid Use Disorder During the COVID-19 Pandemic Within the United States and Canada

Educational Objective
To identify the key insights or developments described in this article

1 Credit CME

JAMA Network Open

Published Online: July 23, 2021

Original Investigation

Article Information and Disclosures

Paul J. Joudrey, MD, MPH¹;

Zoe M. Adams, BA¹;

Paxton Bach, MD, MSc²;

Sarah Van Buren, CNM³;

Jessica A. Chaiton, BSc²;

Lucy Ehrenfeld, RN³;

Mary Elizabeth Guerra, BS¹;

Brynna Gleeson, BA⁴;

Simeon D. Kimmel, MD, MA⁵;

Ashley Medley, MPP, RN³;

Wassim Mekideche⁶;

Maxime Paquet⁶;

Minhee Sung, MD^1,7;

Melinda Wang, BA¹;

R. O. Olivier You Kheang, BSc⁶;

Jingxian Zhang, BS¹;

Emily A. Wang, MD, MAS¹;

E. Jennifer Edelman, MD, MHS^1,8

Author Affiliations

¹Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
²British Columbia Center on Substance Use, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
³Yale School of Nursing, Orange, Connecticut
⁴Vassar College, Poughkeepsie, New York
⁵Sections of General Internal Medicine and Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
⁶Faculty of Pharmacy, Université de Montréal, Montréal, Canada
⁷VA Connecticut Healthcare System, West Haven
⁸Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut

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Key Points

Question How does timely methadone access for opioid use disorder compare between the US and Canada during COVID-19?

Findings In this cross-sectional study of methadone clinics during COVID-19 in 13 US states and the District of Columbia and 3 Canadian provinces with the highest rates of opioid overdose deaths, more than 1 in 10 clinics were not accepting patients, one-third of which reported this was due to COVID-19. Canadian clinics offered appointments faster than US clinics.

Meaning These findings suggest that methadone access may be worse than previously estimated and exacerbated by COVID-19 and that Canadian clinics may provide timelier access than US opioid treatment programs.

Abstract

Importance 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.

Objective To compare timely access to methadone initiation in the US and Canada during COVID-19.

Design, Setting, and Participants 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.

Exposures Nation and type of health insurance (US Medicaid and US self-pay vs Canadian provincial).

Main Outcomes and Measures Proportion of clinics accepting new patients and days to first appointment.

Results 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.

Conclusions and Relevance 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.

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Article Information

Accepted for Publication: May 12, 2021.

Published: July 23, 2021. doi:10.1001/jamanetworkopen.2021.18223

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Joudrey PJ et al. JAMA Network Open.

Corresponding Author: Paul J. Joudrey, MD, MPH, Department of Internal Medicine, Yale School of Medicine, 367 Cedar St, Harkness Hall A, New Haven, CT 06520 (paul.joudrey@yale.edu).

Author Contributions: Dr Joudrey had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Edelman and Wang are co–senior authors.

Concept and design: Joudrey, Bach, Kimmel, Sung, You Kheang, E. Wang, Edelman.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Joudrey, Guerra, Medley, Sung, You Kheang, E. Wang.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Joudrey, Chaiton, Kimmel, Medley, Zhang.

Obtained funding: Joudrey.

Administrative, technical, or material support: Adams, Van Buren, Chaiton, Ehrenfeld, Guerra, Medley, You Kheang, Zhang.

Supervision: Bach, E. Wang, Edelman.

Conflict of Interest Disclosures: Dr Bach reported grants from the Michael Smith Foundation for Health Research and grants from the Canadian Institutes of Health Research outside the submitted work. Dr Kimmel reported personal fees from Abt Associates for work as a consultant on access to medications for opioid use disorder in nursing facilities and personal fees from the American Academy of Addiction Psychiatry Fees for lecturing about medications for opioid use disorder and harm reduction as part of the opioid response network outside the submitted work. No other disclosures were reported.

Funding/Support: Funding for this publication was provided by grant number 5K12DA033312 (Dr Joudrey), L30 DA052056 (Dr Joudrey), and 1UM1DA049412-01 (Dr Kimmel) from the National Institute on Drug Abuse, a component of the National Institutes of Health.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: Data from this work was presented during the College on the Problems of Drug Dependence COVID-19 Impacts on SUD Research Webinar; October 29, 2020.

Additional Contributions: We thank Kim Jiang for her completion of standardized patient calls for this project. She was not compensated.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.