Loss, liberation, and agency: Patient experiences of methadone treatment at opioid treatment programs during the COVID-19 pandemic

Abstract

Background:

Despite its safety and effectiveness, methadone treatment for opioid use disorder (OUD) remains highly stigmatized, and stringent opioid treatment program (OTP) attendance requirements create barriers to retention for many patients. The COVID-19 pandemic prompted a shift in federal regulations governing methadone, including a blanket exemption permitting increased take-home doses of methadone. We studied the impact of these changes upon established patients’ experiences of OTP care.

Method:

We conducted semi-structured qualitative interviews with 18 OTP patients who met our criteria of having established OTP care (i.e., enrolled at the OTP for at least 12 weeks and administered methadone three to six days weekly prior to the March 2020 blanket exemption). Interviews centered on how COVID-19 had affected their experiences of receiving treatment at an OTP.

Results:

We identified three interconnected themes relevant to transformation of OTP care by the COVID-19 pandemic. Participants described mourning therapeutic OTP relationships and structure (1. loss), yet feeling more satisfaction with fewer in-person OTP visits (2. liberation), and appreciating more opportunities to self-direct their OUD care (3. agency).

Discussion:

Structural changes made to OTP care early in the COVID-19 pandemic resulted in loss of community and structure. Increasing the availability of take-home methadone also improved patient experience and sense of agency. Our findings join a diverse body of converging evidence in support of policy changes allowing for more flexible dosing and individualized OTP care.

1. Introduction

Methadone is the oldest, most widely prescribed medication for opioid use disorder (OUD). Methadone is safe and highly efficacious for reducing overdose deaths, illicit opioid use, injection risk behaviors, and transmission of Hepatitis C and Human Immunodeficiency Virus (Karki et al., 2016; Lim et al., 2022; Sordo et al., 2017). In the U.S., treatment of OUD is governed by federal regulations which dictate that ordering and administering methadone for OUD can only occur at licensed opioid treatment programs (OTPs). Since 1972, patients receiving methadone for OUD in the U.S. have been required to visit their OTPs at least six out of seven days of the week at the start of treatment and permitted no more than one “take-home” dose of methadone per week at the start of treatment. OTP daily attendance for each patient can decrease incrementally based on federal clinical criteria, including recency of drug use, availability of social support, and ability to safely store methadone (Substance Abuse and Mental Health Services Administration, 2015).

Stringent OTP attendance requirements have posed substantial barriers for OTP patients, potentially reducing adherence and retention (Joudrey et al., 2019; Pasman et al., 2022). Prior qualitative studies of people with OUD have found that they often perceived methadone treatment ambivalently, acknowledging its benefits in tension with its tolls (De Maeyer et al., 2011; M. Harris & Rhodes, 2012; Holt, 2007), which include time demands, limits on employment opportunities, and reinforcement of mistrust and stigma (Bourgois, 2000; J. Harris & McElrath, 2012). By contrast, in qualitative work of increased take-home methadone outside the U.S. analyses have noted its functional benefits for patients—less travel and cost, more convenience, and more confidentiality—as well as the destigmatizing value of social experiences such as being “trustworthy” and “normal” (Treloar et al., 2007). In work from the U.S. participants have reported an appreciation for buprenorphine’s self-administration and the concomitant experiences of “normalcy,” flexibility, and autonomy (Harris, 2015).

The COVID-19 pandemic transformed the U.S. methadone treatment system. Routine provision of services at OTPs, which included group counseling sessions and patients waiting in line for methadone administration and dispensing, increased the risk of viral transmission. As a result, on March 16, 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) allowed states to apply for blanket exemptions which would permit OTPs to dispense up to 28 days of take-home doses of methadone for stable patients and up to 14 days for patients assessed to be able to safely manage take-home methadone (Substance Abuse and Mental Health Services Administration, 2020). This flexibility in dispensing take-home doses of methadone was recently extended (Substance Abuse and Mental Health Services Administration, 2023). Substantial variability has occurred in the state- and program-level implementation of the SAMHSA guidance and a resounding call to systematically examine changes to methadone treatment delivery (Nunes et al., 2021; Frank, 2021). This nationwide “natural experiment” within OTPs has foregrounded an unanticipated opportunity to engage patients in reflecting on the benefits and challenges to OTP care and pandemic related changes.

Studies are needed to understand OTP patients’ perspectives of the loosening of OTP regulations. To date, findings from samples with diverse OTP experiences, MOUD stability, and treatment duration (Levander et al., 2021; Suen et al., 2022) suggest that expanded take-home methadone has increased satisfaction with OTP services although inequities and barriers appear to persist (Abidogun et al., 2023; M. T. H. Harris et al., 2022). Specifically probing patients’ experiences of the shift from traditional methadone treatment to increased availability of take-home methadone can help answer crucial questions, such as: what are the perceived benefits and risks of expanded take-home methadone for established patients and how did the change affect their OUD treatment experiences? To this end, the current study sought to identify how established OTP patients (i.e., in care for at least three months) who were receiving supervised methadone administration at least three times weekly before the blanket exemption responded to the expansion of methadone dispensing practices. The semi-structured interviews explored patients’ perspectives regarding the COVID-19 pandemic and its impact on their OTP care relative to their prior experiences of frequent supervised methadone administration.

2. Methods

This qualitative study followed the Consolidated Criteria for Reporting Qualitative research checklist (Tong et al., 2007) and was conducted as part of a randomized controlled trial of tobacco cessation treatment among persons with OUD (NCT03365362). Our research team comprised medical doctors (AJ, MM, SN, JS, JA), a licensed clinical psychologist (TLC), a community health PhD student (AP), a medical student (SK), and a public health researcher (MP). The study was approved by the The study was approved by the Albert Einstein College of Medicine Institutional Review Board.

2.1. Setting and participants

The study recruited participants between June and October 2020 from a single community-based OTP in the Bronx, NY affiliated with an academic medical center. Participants were included in the current study if they: 1) were currently enrolled in the parent randomized trial, and 2) provided informed consent. Eligible participants for the parent trial were: 1) enrolled in an OTP for at least 12 weeks, 2) administered methadone at the OTP between three to six times weekly prior to March 2020, 3) smoking five or more cigarettes per day, and 4) interested in quitting smoking at the time of enrollment. The parent trial excluded participants with unstable medical or psychiatric illness.

2.2. Procedure

One research team member (MP) with training in qualitative research methods conducted all study interviews in English. Through her involvement in parent trial activities, the study interviewer was known to most study participants. Study staff contacted participants by phone to describe the study, obtain informed consent, and conduct the interview. Interviews were audio-recorded and lasted on average 34 (SD 4.5) minutes. The interviewer employed a semi-structured interview guide [see Supplemental Material File 1] that focused on three domains: (1) general life changes due to the COVID-19 pandemic; (2) personal experiences of receiving methadone and other OTP services before and during the pandemic, including possible methadone diversion; and (3) the impact of the pandemic and changes to OTP practices upon substance use and OUD care. Participants received a $20 debit card for completing the study interview. Interview audio-recordings were transcribed and checked for accuracy by the research team.

2.3. Analysis

We selected a mixed deductive-inductive thematic analysis approach because of its utility in identifying, systematizing, and synthesizing participants’ perspectives (Braun & Clarke, 2006) and followed best practices recommendations for thematic analysis (Nowell et al., 2017). The overarching goal of our study was to explore the perspectives of patients experiencing a historically novel transformation of their OTP care. The phenomenon being studied—the abrupt expansion of extended take-home methadone dispensing—was an entirely new experience, not only for the patients but the health care system itself. For the sake of identifying as much participant-elicited understanding as possible of their experiences, we refrained from applying an a priori theoretical framework to our interpretative work. We used the qualitative research software Dedoose to facilitate data management and interpretation. Informed by our research questions and initial review of transcripts, we developed a preliminary coding manual with definitions and examples. The study team then coded transcripts using an iterative, reflective process. Interviews were first double-coded by the research team, then reviewed by a third coder who reconciled minor discrepancies and identified any larger inconsistencies that merited group discussion. All coding pairs met weekly to resolve coding discrepancies, address codebook amendments, and discuss initial impressions. Transcripts were revisited as the coding manual was revised. Reflexive journaling facilitated the deepening of our engagement with the dataset and emergent meanings. In addition to study meeting minutes, members’ thoughts regarding coding and insights were recorded, creating an audit trail of our analytic process and related decisions. We then generated initial themes with the complementary use of thematic mapping and memoing. Through the repeated, visual representation of candidate themes and subthemes, we identified and refined theme relationships. At this stage, we used team meetings for theme discussion and vetting. To ensure coherence and referential accuracy (Lincoln & Guba, 1985), we analyzed each theme across the full data set, examined coded extracts and raw transcripts, and selected representative quotes. Quotes from participants are presented verbatim to accurately capture the patients’ experiences; because of this, some statements may use stigmatizing language.

3. Results

We attempted contact with 41 of the 56 participants in the parent trial. Of the 41, 15 did not respond, 5 had inactive phone service, and 2 did not keep scheduled appointments. A total of 19 interviews were completed; due to issues with audio recording, we included 18 interviews in the final sample. Participants were predominantly women (56%), Latinx (56%), and middle aged (mean = 55 years), and had been in the OTP for a mean of eight years. Prior to the COVID-19 pandemic, most (66%) were administered methadone at the OTP five or six days weekly. At the time of interview, all participants had experienced a reduction in their OTP methadone administration schedule, none were attending more than three-times weekly, and 42% were visiting the OTP once weekly or twice monthly for methadone administration (Table 1).

Table 1.

Sample Demographic and Clinical Characteristics (n = 18)

Characteristic	N (%) or Mean (SD)
Age, years	55 (8)
Gender
Woman	10 (56%)
Race/Ethnicity
Black	6 (33%)
Latinx	10 (56% )
White	2 (11%)
Insurance coverage
Medicaid	17 (94%)
Uninsured	1 (6%)
Education, high school equivalent or higher	9 (50%)
Current housing status
Private residence	11 (61%)
Temporary housing (e.g., with family or friends)	3 (17%)
Shelter	2 (11%)
Living on the street	1 (6%)
Other	1 (6%)
Employment status
Disability	7 (39%)
Employed	6 (33%)
Unemployed	5 (28%)
Time in methadone treatment, years	8 (6)
Methadone dose, mg/day	100 (57)
Methadone administration schedule at OTP
Prior to COVID-19
6-days weekly	7 (39%)
5-days weekly	5 (28%)
4-days weekly	4 (22%)
3-days weekly	2 (11%)
At time of interview
3-days weekly	3 (17%)
2-days weekly	2 (11%)
1-day weekly	7 (39%)
Every two weeks	6 (3%)

Qualitative analyses identified three interconnected themes relevant to transformation of OTP care by the COVID-19 pandemic (see Table 2 for representative quotes from each theme and sub-theme). Participants described mourning therapeutic OTP relationships and structure (1. loss) yet feeling more satisfaction with fewer in-person OTP visits (2. liberation) and appreciating more opportunities to self-direct their OUD care (3. agency).

Table 2.

Themes and subthemes derived from thematic analysis of in-depth interviews with OTP patients (n=18) about their experiences of increased take-home methadone during COVID-19 pandemic.

Theme	Subtheme	Representative Quote(s)
Loss
	Loss of relational support	“By going there we develop some good relationships, you know, with people that you know when they we’re able to relate. We help one another, whether we realize it or not. And it really helps, you know?” (P14)
		“I come every two weeks, and some of the people that I interacted with, I don’t know when they’re coming now. I don’t bump into the people that I normally used to say hello to and I got to chat with. I miss that.” (P11)
	Loss of therapeutic structure	“I’d rather go every day. Give me something to do. At first I said look, man, this is good! Then I started missing it because of what you’re doing every day.” (P10)
		“I just miss just going, period. It was something to do.” (P17)
Liberation		“It is such a weight off my shoulders...It’s much, much better.” (P6)
		“It made it a lot easier.” (P3)
	Reduction in time burden	“If I want to go visit my mother, now I can. But before I couldn’t because I had to go every day… I think it’s wonderful.” (P6)
	Reduction in risk burden	“Because the, the less I could go, the less I go there are less opportunity I have to get you know sick, that’s the way I see it.” (P3)
		“It’s a hassle. It’s just a hassle. It’s not the program, it’s not the people.
		It’s the people around the program because they’re all drug addicts.” (P5)
	Reduction in stigma burden	“...there’s times we have to wait outside at the methadone clinic, in line, and stuff like that. And that kind of bothered me, ‘cause, you know, it’s, I don’t want somebody to know I’m going to a methadone clinic if somebody sees me.” (P12)
	Persistence of burden	“I tried explaining my fears... and my circumstances and stuff [to my counselor], and he was, like, ‘Well, I’m not gonna condone you anymore take-homes. I don’t even want you having these. I don’t know if you’re gonna sell ‘em on the street or not.’ And that... discouraged me ... my own counselor doesn’t have faith in me....” (P12)
Agency		“She [counselor] had asked if I wanted to come in once a week or once every two weeks. I chose to go once every week.” (P10)
		“Since I do take-home[s], I don’t have to wake up and take my meds. If I’m asleep, I’m asleep. And when I wake up I drink it if I feel like drinking it. Sometimes I don’t drink it until the afternoon.” (P18)

3.1. Loss of OTP supports

Loss was prominent in participant narratives. Within this theme, we encountered losses that were interpersonal in nature (subtheme of relational loss of support) as well as structural (subtheme of loss of therapeutic structure).

3.1.1. Loss of relational support.

Established OTP relationships and feelings of community were disrupted by the sudden end of face-to-face interaction. Participants spoke of missing the support of fellow OTP patients, the power of in-person groups, and the close relationships developed with OTP counselors and staff. One participant (P18) reflected upon the interpersonal bonds formed in OTP counseling groups, stating, “You know, we’re a family.”

While some OTP relationships could be maintained through telehealth and less frequent OTP visits, participants noted that the pillars of face-to-face OTP interactions—mutual recognition and connection—were drastically altered by the COVID-19 pandemic. One participant (P14) noted that they missed the therapeutic benefits of group dynamics and peer insight. They described the loss of connection with the termination of in-person counseling groups:

“You think you’re the only one that’s going through certain things and you find out there’s somebody else that’s going through it… [That] made you feel good because you know you wasn’t alone… Like 15 people that end up [sharing] some really serious thoughts that ordinarily you wouldn’t share. It really makes you a different person.”

With the transition to telehealth, participants confronted the loss of community aspects of the OTP. One participant (P6) related how they missed OTP staff bearing witness to their challenges and successes:

“They all know me and have been seeing me for so long. If I fall and relapse, they can look at me one time and tell. And they all talk to me about it. We have a good rapport.”

Many noted that teletherapy helped them maintain contact with their counselors. But, for some, the loss of in-person contact was palpable. One participant (P15) described:

“It’s not like face-to-face, so sometimes you can feel the difference. I enjoy talking with someone face-to-face as opposed to speaking with them over the phone.”

3.1.2. Loss of therapeutic structure.

Alongside missing in-person relational support, participants described their loss as a falling away of predictability and routine that OTP care offered before the pandemic. For some, the rhythm and regularity of OTP visits for methadone administration were anchoring daily experiences that disappeared with the transition to expanded take-home methadone. One participant (P14) shared:

“You go five days a week and you take two groups a day. That’s two hours a day that you’re doing every day, like routine, you know? Now we don’t do it at all. It’s a hell of a change. Nothing to do. Me and some other people in the groups, we used to look forward to it.”

As a whole, the losses recounted by participants coalesced around OTP relational attachments and structural elements that participants identified as offering them experiences of being cared for, comradery, and community.

3.2. Liberation from OTP burdens

Alongside loss, participant narratives about pandemic-related changes fell under the theme of liberation. These liberations consisted of perceived reductions in three distinct categories of burden: time, risk, and stigma, which we present as distinct subthemes. The liberation theme united a series of affective moments (like relief, joy, and surprise) that participants experienced when they recognized that the terms of their OTP care had changed dramatically. Despite speaking about losing valued facets of OTP care, a majority simultaneously voiced appreciation for the ways in which former burdens of traditional OTP structure were lifted during the COVID-19 pandemic. While some participants did not share this sense of liberation (captured by the subtheme, persistence of burden), expanded take-home methadone was overwhelmingly met with higher satisfaction than prior, more frequent OTP visits.

3.2.1. Time.

More time and travel flexibility were often contrasted against burdensome experiences at the OTP pre-pandemic. Participants related how difficult it had been to negotiate competing responsibilities such as employment or other health conditions with the OTP’s observed dosing requirements. They noted that previously, the time-consuming nature of OTP visits compounded the burden of their frequency. A participant (P11) reflected on the conflict between work and methadone treatment before the pandemic:

“It took long to get medicated. I have to be medicated by a certain time so I can get to work on time. And a lot of times, it didn’t go well. The line was much too long.”

When in-person visit obligations were reduced, patients shared feeling more agentic and having—suddenly—more control of their daily schedules. This meant more time for self-guided goals, interests, and social connection.

3.2.2. Risk.

Reduction of health risks was also featured within the theme of liberation. Many participants, particularly those living with HIV and other chronic diseases, spoke of relief that fewer OTP visits would reduce potential exposure to COVID-19 infection (“The less I go, the less opportunity I have to get sick,” P4). Several participants noted that fewer visits to the OTP reduced their exposure to high-risk situations for substance use. One (P7) remarked:

“You can hardly get in the door without somebody trying to push something in your face. Pills, some type of illegal, illicit drug. And that’s hard...I’m only human, you know?”

3.2.3. Stigma.

A third aspect of liberation involved the transformation of participants’ experiences of methadone-related stigma during the pandemic. With fewer in-person OTP visits, participants recounted more easily dodging the stigma associated with methadone treatment. This stigma was noted by many participants as a familiar aspect of OTP care. One participant (P2) shared they feared being negatively evaluated by others in the community and would not publicly disclose receiving OTP services:

“It’s hard to say exactly how they’ll treat you. But they might look at you funny... Like, ‘Oh. This is an old drug addict.’ You know, ‘Watch your purse. He’ll steal from you.’”

Another participant (P11) described the presumption of methadone misuse they had experienced and that belied the lived reality of many receiving methadone:

“I don’t want the stigma of people going to the methadone clinic and selling their bottles or getting high off the methadone. There’s a stereotype but there’s a lot of good, hardworking, honest people that are in the clinic.”

To mitigate stigma before the pandemic, some spoke of having adopted an “in and out” approach to OTP engagement:

“I got to the point where I just go and turn those bottles in, get mine and get out of there as quickly as I possibly can.” (P6)

The COVID-19 reduction in OTP visits complemented this participant strategy of minimizing contact—and association—with the physical OTP environment as a means of buffering feelings of shame and stigma. Extended take-home doses of methadone meant less frequent OTP visits, and thus, fewer opportunities to experience stigma.

3.2.4. Persistence of burden.

Moments of liberation were widespread but not felt by all. Several participants expressed frustration at the continued time, risk, and stigma burdens that appeared newly exacerbated by their unmet requests for a specific take-home dosing duration. These individuals noted inconsistencies in the quantity of take-home doses patients received and perceived these differences to be motivated by provider mistrust and prioritization of risk of diversion over patient preference.

Despite this articulated staff concern, participants reported that they neither engaged nor witnessed methadone diversion. Some had anecdotal accounts about other OTP patients, and several participants described it as an act of self-sabotage. One remarked (P12):

“I wouldn’t be stupid enough to sell my methadone. I need it to function, every day.”

One apparent cost of these chronic experiences of burden and dissatisfaction was the reported risk of disengagement from methadone treatment. A participant (P4) was frustrated to be administered methadone at the OTP twice weekly; in response, they described stretching their methadone doses to reduce their OTP visits to their desired schedule. Consequently, they experienced withdrawal symptoms and urges to return to heroin use, and contemplated discontinuing methadone altogether:

“The only thing that I think—and it might happen—is that I might end up relapsing. Because I’ve been thinking about that myself, about just stopping and maybe just start using and going eventually for two or three months or four months and then going to a detox.”

Overall, the liberation theme reflected primarily positive affective, and behavioral responses to COVID pandemic-related OTP changes, as well as ongoing dissatisfactions in OTP care.

3.3. Agency.

A third theme, agency, intersected the themes of loss and liberation. Agency reflected the patients’ pre-existing, active stances toward their health that were bolstered by COVID-19-related policy changes. Agency operated to keep participants safe, healthy, and as engaged with the OTP as they desired to be during the COVID-19 pandemic. This agency and greater control of their OTP care was closely tied to participants’ appreciation for the reduction in OTP visit frequency, stood in contrast to earlier OTP experiences, and was an active ingredient in participants’ feeling of satisfaction and liberation after COVID-19 changes to OTP care. Agency was also conspicuous in participants’ overarching narratives of self-care and strategies to effectively self-manage their one- or two-week methadone supply. Participants described a novel experience of taking their medication daily on their desired schedule. Participants expressed the nature of agency—having control of their care—as self-evident, obvious, and fundamental. One participant likened it to how they were capable of self-administering medications for the management of other health issues. Put simply:

“I have other medications in my house.” (P13)

Of note, agency was not a new experience for participants. Prior to regulation changes, participants had an ongoing sense of responsibility for and ownership over aspects of OTP treatment that further evolved with extended take-home doses of methadone. The agency exercised during the COVID-19 pandemic was rooted in participants’ experience in navigating imperfect health care systems that were often ill-fitted to their needs. Participants adapted to the demands of a strictly regimented OTP system while also achieving their own priorities. As one participant (P5) described it:

“I deal with whatever I have to deal with in order to get what I need.”

Specifically, participants recounted maneuvering through and around traditional OTP rules to arrive at what felt like the most beneficial “dose” of care. For some, prior to the pandemic, this constituted lowering their amount of contact with care by adopting the “in and out” approach (described in 3.2.3.) to reduce burdens of time, stigma, and/or risk. Agency was also apparent in participants’ choices to increase the frequency of their OTP visits. Another participant (P16) explained that before the pandemic they had requested more frequent observed dosing to access more support, and thus lessen their perceived risk of problematic use:

“I was on twice-a-week and I switched, put myself on three-times-a-week. Because I felt like going to the clinic would keep me cleaner at times.”

An important application of agency was in engagement with care and the re-establishment of OTP relationships. Agency was central in participant-motivated efforts to rebuild a sense of the OTP community fractured by the COVID-19 pandemic. These efforts resembled mutual aid gestures—providing support direct from OTP patients to other OTP patients. For example, a participant (P18) who had shared their loss of OTP “family” explained it as:

“I do my part. I call my peers. And as soon as they answer the phone I say, ‘I’m just checking in. I’m checking in, make sure you’re safe, you’re all right and letting you know that I’m good.’ So that’s been working for us.”

She related how her OTP group formed a peer-initiated telephone chain. When a group member was hospitalized, this network alerted OTP staff who could help to ensure continuation of the hospitalized OTP patient’s methadone.

Agency existed within reports of clinical stability: most participants described themselves as feeling in control of their opioid use and related urges. For many, the reduction of OTP visits provided newfound convenience with a foregrounded sense of self-direction and agency over their OTP care:

“As long as I maintain contact with the staff, the doctors and the counselor and you guys [research staff], whereas I have that connection no matter if I’m going every day or not, it just makes it easy, so there’s less to worry about. ‘Cause, you guys are there, you know?” (P1)

In sum, agency, operating prior to the pandemic, was heightened by changes to methadone treatment delivery and fostered participants’ self-management of medication-taking and engagement with OTP care.

4. Discussion

Methadone treatment regulations and clinical protocols have been predicated on the need to protect patients and communities from the potential harms of methadone (Jaffe & O’Keeffe, 2003). Yet participants in our study—established OTP patients with an average 8 years of methadone treatment— experienced the traditional OTP regimen as often burdensome, and then substantially improved with the increased flexibility offered by more take-home methadone. The absence of positive aspects of the OTP—community and consistency—were notably sensed as a loss during the pandemic. Crucially, increased take-home methadone afforded participants newfound opportunities to exercise agency and skills for self-management developed across their long tenures of OTP care.

Familiarity of routine and social connection are fundamental components of effective OUD care that are valued by patients and staff (Barnett et al., 2021; Treitler et al., 2022). Study participants articulated grieving the interpersonal and structural supports once offered by more frequent, in-person services and recognized these as healing aspects of their pre-COVID OTP experiences. Similarly, qualitative investigations of long-acting injectable depot buprenorphine, which can reduce contact with OUD care setting to monthly, have revealed patient concerns over the diminishment of social support and structure with the reduction of in-person visits (Neale et al., 2018; Barnett et al., 2021). Our study aligns with other qualitative findings of COVID-19 ruptures to community support, increased social isolation, and disintegration of daily structure with people who use drugs in and out of OUD care (Abidogun et al., 2023; M. T. H. Harris et al., 2022; Watson et al., 2022). In contrast, other recent studies of patient experiences of COVID-related changes to OTP care in the rural US (Levander et al., 2021) and urban West Coast (Suen et al., 2022) have reported increased satisfaction without a sense of loss. Our study also found pronounced increases in satisfaction with reduced OTP visits, as described by the theme of liberation. Of note, our study sampled participants who were also actively trying to quit smoking: a group motivated to improve their current health state. Across all studies, participants receiving OTP services during COVID-19 have voiced a strong preference for increased take-home methadone, a validation of their capacities for self-care and stability with more take-home doses, and a desire for the continuation of these practices.

In our study, loss and liberation formed a striking contrapuntal. Many participants were saddened and relieved by fewer in-person OTP visits. This ambivalence may stem from what recent qualitative work (Jakobsen et al., 2022) termed “trade-offs” that are regularly negotiated to access the resources tied to OTP. Akin to our participants’ descriptions, (Jakobsen et al., 2022) noted that OTPs can be simultaneously experienced as support-providing and risk-producing for patients. For example, in our sample the social networks embedded in the OTP spanned the continuum from health promotion to risk: the OTP context housed both the missed peer and OTP staff support (loss) and perceived traces of the illegal drug market that patients wished to avoid (liberation from risk). Overall, participants were more satisfied with their OTP care following COVID-19-related changes to OTP practices, despite the loss of OTP social supports. This finding may indicate that participants valued liberation and agency more than the social support received from the OTP. What our participants experienced as the loss of valued facets of OTP care—interpersonal connection and consistency—may contribute to the design of policy interventions aiming to increase acceptability, engagement, and retention in methadone treatment.

Our findings articulate how, with the COVID-19 pandemic-related policy changes, participants’ feelings of agency were newly validated, respected, and more aligned with OTP care. Having a diminished sense of control over OUD treatment presents a significant barrier to engagement and retention (Deering et al., 2011). For methadone in particular, patients’ perceptions of dose adequacy and participation in dose changes have been associated with higher levels of treatment satisfaction (Trujols et al., 2020). In the context of prior research, our findings suggest the utility of actively promoting and enhancing agency to better engage and retain patients in methadone treatment.

Participants described the ability and desire to self-manage and safeguard their methadone, highlighting their need to continue an essential medication, and expressed surprise at the prospect of diversion. No participants explicitly disclosed diverting their methadone supply. Other studies of OTP patients report similar findings (Amram et al., 2021; Figgatt et al., 2021; Levander et al., 2021; Suen et al., 2022) that suggest that for at least a portion of the sampled population, increased flexibility in dosing practices does not increase perceptions of methadone misuse, harm, or risk. Emergent, state-level data on minimal change in the rates of methadone poisonings support these patient accounts (Brothers et al., 2021; Figgatt et al., 2021; Gomes et al., 2022; Treitler et al., 2022). Historically, narratives about diversion have been used to support social control of poor and minoritized people with OUD and have served to justify daily observed methadone dosing. This focus on policing diversion likely maintains and re-energizes stigma towards patients taking methadone. The relief participants in this study expressed about fewer opportunities to be surveilled highlights the need to create an OTP system that is more accessible, more engaging, and less restrictive.

4.1. Study implications

Our study findings align with a growing body of evidence that suggests that expanding access to take-home methadone could considerably enhance the patient experience of and the satisfaction with methadone treatment (Corace et al., 2022; Suen et al., 2022; Walters et al., 2022). In our study, participants, all of whom were administered methadone at the OTP three to six times weekly prior to the COVID-19 regulatory changes, largely described themselves as stable with a more flexible dosing schedule. In tandem, for some participants, the interpersonal bonds and structure of OTP were highly valued aspects of care; others distinctly cherished their new experience of infrequent, streamlined OTP services. As such, the current study highlights a range of OTP patients’ needs, preferences, and experiences and suggests the importance of moving OTP care towards a patient-centered model: care that is available, accessible, and acceptable to patients (Fox et al., 2019).

Of import, some study participants reported dissatisfaction with what was perceived as arbitrary or unfair decisions regarding the duration of extended take-home methadone. Flexible take-home methadone dispensing may continue to operate akin to traditional policies which unilaterally deem some patients “trustworthy” and others not. This issue has been elsewhere noted as “unjust” by interviewees (Harris et al., 2022) and carries stigmatizing implications (Levander et al., 2021; Neale, 1999; Suen et al., 2022; Treloar et al., 2007). This concern about eligibility and fairness will not be resolved by solely lowering take-home thresholds. Our findings contribute to the pressing call for a more equitable system that establishes clear, communicated guidelines and engages patients in the policy-making process.

Another important study implication is the perpetuation of stigma through policy. Stigma toward OUD and OTPs is a major barrier to both engagement and retention in treatment (Woo et al., 2017; Yarborough et al., 2016). Traditional regulations around methadone delivery increase stigma by prioritizing diversion prevention over patient-centeredness, despite the harms this can cause directly (to patients enrolled in OTPs) and indirectly (deterring potential treatment seekers). In our study, participants found methadone treatment to be more acceptable with reductions in stigma burden associated with COVID-19 related changes. However, these perceived stigma reductions were the result of reduced contact with the OTP, rather than alterations in the experience of OTP care; stigma persisted, yet participants were exposed to it less by their fewer OTP visits. Our study findings highlight how structural factors maintain stigma. Prioritizing patient-centeredness would reduce stigma by improving the experience of those receiving OTP services and changing the perception of OTP care as helpful and desirable, instead of a last resort (Gryczynski et al., 2013). To effectively address stigma, macro-level policy interventions will be imperative (Cheetham et al., 2022). Though SAMHSA has extended flexibilities in dispensing of take-home methadone beyond the COVID public health emergency (Substance Abuse and Mental Health Services Administration, 2023), and is in the process of finalizing revisions to existing regulations, state and OTP institutional policy changes will also be necessary to reduce the burdens and stigma of methadone treatment.

4.2. Limitations

The study recruited participants (n=18) from a single urban, non-profit clinical site with an academic affiliation and the findings may not generalize to other settings. Similar findings from OTPs in rural Oregon suggest that patient perspectives on pandemic-related changes to OTP care remain similar across settings (Levander et al., 2021). Nevertheless, our study carries different implications for OTP care in different geographic regions. For instance, urban communities may have differing social support-enhancing resources accessible to its OTP patients than rural communities (Swann et al., 2021), such that effective strategies to counter the theme of loss identified in our sample will vary across settings. Our sample was recruited from participants in a tobacco cessation clinical trial with specific inclusion criteria (e.g. current smokers interested in quitting) and exclusion criteria (e.g. no current major depressive disorder, manic episode or psychotic disorder), and thus may reflect a motivated subgroup with potentially fewer psychiatric burdens than is typical for the OTP setting (Zhu et al., 2021). Furthermore, our interviews were conducted between March and August 2020 and captured relatively early pandemic experiences of individuals receiving OTP services. Longitudinal data will be necessary to understand whether and how participants’ initial perspectives on loss, liberation, and agency evolve over time as well as charting the long-term consequences of the diminishment of in-person OTP supports and expansion of take-home methadone. We focused on what changed for OTP patients familiar with supervised methadone administration; we exclusively interviewed established OTP patients who were receiving supervised methadone administration at least three times weekly prior to the pandemic. To identify the full spectrum of experiences with expanded take-home methadone, more research is necessary with populations whose existing healthcare disparities may be exacerbated by an increase in take-home methadone, such as the unstably housed (Abidogun et al., 2023; M. T. H. Harris et al., 2022; Watson et al., 2022). In our study, underreporting of substance use and diversion may have occurred. Emergent findings, however, suggest that diversion has been a rare occurrence among OTP samples during the COVID-19 pandemic (Amram et al., 2021; Wyatt et al., 2022)

5. Conclusion

The COVID-19 pandemic provided a historically singular opportunity to consider OTP patients’ experiences during a radical shift in methadone delivery in the U.S. Understanding how patients familiar with frequent supervised methadone administration experienced expanded take-home methadone can inform efforts to effectively reduce the known burdens of OTP care to patients. Our analyses of participant accounts identified three interactive elements: 1. loss, 2. liberation, and 3. agency. Participants mourned the loss of healing social bonds and structures while simultaneously applauding the liberation from such impositions as time demands, exposure to drug-related risks, and experiences of stigma. Increases in take-home methadone centered participants’ sense of agency and ownership over their OUD care. Taken together, these three elements—loss, liberation, and agency—may collectively signal the possibilities and challenges of structurally innovating contemporary OTP practices in the United States. Continuing to expand and individualize take-home methadone for established OTP patients may be a first step.

Highlights.

• The COVID-19 pandemic increased take-home methadone dispensing in the U.S..

• Interviews (n=18) explored how patients responded to expanded take-home methadone.

• Less visits to the opioid treatment program (OTP) meant loss of support and structure.

• Very often expanded take-home methadone reduced time, risk, and stigma burdens.

• OTP patients appreciated more opportunities to self-manage their care.

• Clinical and policy innovations are warranted to further individualize OTP care.