Abstract
This observational study assesses whether methadone-involved overdose deaths decreased when opioid treatment programs take-home policies changed during the COVID-19 pandemic.
On March 16, 2020, to facilitate access to methadone treatment from opioid treatment programs (OTPs) during the COVID-19 pandemic, the Substance Abuse and Mental Health Services Administration allowed states to request blanket exceptions to provide up to 28 and 14 days of take-home methadone for stable and less stable patients, respectively; this signaled a shift in practice because most patients historically receive methadone daily from OTPs.1
Prior research indicates most methadone-involved overdose deaths are due to methadone used for pain rather than opioid use disorder treatment.2 It is unknown whether methadone-involved overdose deaths increased owing to expanded OTP take-home policies.
Methods
US Centers for Disease Control and Prevention National Vital Statistics System multiple cause of death 2019-2020 final and 2021 provisional data were used. Drug overdose deaths were those assigned an underlying cause of death (ICD-10 codes X40-X44, X60-X64, X85, and Y10-Y14; methadone-involved deaths had ICD-10 code T40.3). Overdose deaths could involve multiple drugs.
Monthly drug overdose deaths without involving methadone and methadone-involved and percentages of overdose deaths involving methadone during January 2019 to August 2021 were calculated. Interrupted time series analyses (ITSA) assessed changes in outcomes before/after the March 2020 methadone take-home policy. This study was exempt from institution review board review by regulation. Stata version 16 (StataCorp) ITSA program was used for analyses. P values less than .05 (2-sided) were considered statistically significant.
Results
ITSA-estimated monthly overdose deaths without involving methadone increased by 78.12 (95% CI, 53.69-102.55; P < .001) deaths per month before March 2020, by 1078.27 (95% CI, 410.08-1746.46; P = .003) deaths in March 2020, and by 69.07 (95% CI, 15.45-122.70; P = .01) deaths per month after March 2020 (Figure and Table). Trend slopes were similar before and after March 2020 (−9.05 [95% CI, −67.98 to 49.88]; P = .76).
Figure. Monthly Overdose Deaths With and Without Methadone, United States, January 2019 to August 2021.
Opioid treatment program methadone take-home policy was released by the Substance Abuse and Mental Health Services Administration on March 16, 2020. Source: National Vital Statistics System, Multiple-Cause-of-Death Final 2019-2020 Data and Provisional 2021 Data.
Table. Interrupted Time Series Analysis Estimates for Monthly Overdose Deaths With and Without Methadone, United States, January 2019 to August 2021.
| Factor | Estimate (95% CI) | P value |
|---|---|---|
| Overdose deaths without involving methadone | ||
| Monthly No. of overdose deaths in January 2019 | 5227.2 (4993.92 to 5460.48) | <.001 |
| Monthly trend (slope) prior to policy change in March 2020 | 78.12 (53.69 to 102.55) | <.001 |
| Change in No. of overdose deaths at time of policy change in March 2020 | 1078.27 (410.08 to 1746.46) | .003 |
| Monthly trend (slope) after policy change in March 2020 (compared with prior to policy change) | −9.05 (−67.98 to 49.88) | .76 |
| Monthly change in No. of overdose deaths after March 2020 | 69.07 (15.45 to 122.70) | .01 |
| Methadone-involved overdose deaths | ||
| Monthly No. of overdose deaths in January 2019 | 230.66 (216.13 to 245.18) | <.001 |
| Monthly trend (slope) prior to policy change in March 2020 | −0.12 (−2.54 to 2.29) | .92 |
| Change in No. of overdose deaths at time of policy change in March 2020 | 94.12 (45.38 to 142.86) | <.001 |
| Monthly trend (slope) after policy change in March 2020 (compared with prior to policy change) | −1.79 (−6.11 to 2.54) | .41 |
| Monthly change in No. of overdose deaths after March 2020 | −1.91 (−5.50 to 1.68) | .29 |
| Percent of overdose deaths involving methadone | ||
| Monthly percent of overdose deaths involving methadone in January 2019 | 4.23 (3.90 to 4.56) | <.001 |
| Monthly trend (slope) prior to policy change in March 2020 | −0.06 (−0.10 to −0.01) | .02 |
| Change in percent of overdose deaths involving methadone at time of policy change in March 2020 | 0.69 (0.22 to 1.15) | .006 |
| Monthly trend (slope) after policy change in March 2020 (compared with prior to policy change) | 0.01 (−0.05 to 0.06) | .82 |
| Monthly change in percent of overdose deaths involving methadone after March 2020 | −0.05 (−0.08 to −0.02) | .001 |
Before March 2020, ITSA-estimated methadone-involved overdose deaths were stable (−0.12 [95% CI, −2.54 to 2.29; P = .92) (Figure and Table). Consistent with the increase in overdose deaths without involving methadone, methadone-involved overdose deaths increased by 94.12 (95% CI, 45.38-142.86; P < .001) deaths in March 2020. Monthly methadone-involved overdose deaths remained stable after March 2020 (−1.91 [95% CI, −5.50 to 1.68]; P = .29). Trend slopes were similar before and after March 2020 (−1.79 [95% CI, −6.11 to 2.54]; P = .41).
ITSA-estimated percentages of overdose deaths involving methadone declined 0.06% (95% CI, −0.10% to 0.01%; P = .02) per month before March 2020, increased by 0.69% (95% CI, 0.22%-1.15%; P = .006) in March 2020, and declined 0.05% per month (95% CI, −0.08% to 0.02%; P = .001) after March 2020. Trend slopes were similar before and after March 2020 (0.01% [95% CI, −0.05% to 0.06%]; P = .82).
Discussion
Findings provide insights about methadone-involved overdose deaths during COVID-19. In March 2020, overdose deaths both with and without methadone increased. After March 2020, overdose deaths not involving methadone continued to increase approximately 69 deaths per month, whereas methadone-involved overdose deaths remained stable. The percentage of overdose deaths involving methadone declined at similar rates, approximately 0.05% to 0.06%, before and after the take-home policy change, with 4.5% of overdose deaths involving methadone in January 2019 and declining to 3.2% by August 2021. These findings suggest the modest increase in methadone-involved overdose deaths in March 2020 was associated with the spike in overall drug overdose deaths driven by illicitly made fentanyl in the early months of the COVID-19 pandemic3 rather than associated with OTP take-home policy changes.
This study has limitations. Approximately 5% of death certificates did not list specific drugs involved in the overdose. Provisional data for 2021 may minimally underestimate overdose deaths owing to delayed reporting. OTP take-home policy changes occurred in the context of other policy changes and secular trends that could influence treatment and harms for people with opioid use disorder.
Coupled with research demonstrating improved patient satisfaction, treatment access, and engagement from these policies,1,4,5,6 these findings can inform decisions about permanently expanding take-home methadone.
References
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