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. 2023 Feb 9;245:109801. doi: 10.1016/j.drugalcdep.2023.109801

Availability of timely methadone treatment in the United States and Canada during COVID-19: A census tract-level analysis

Ofer Amram a,b,⁎, Leah Rosenkrantz c, Solmaz Amiri DDes a, Nadine Schuurman c, Victoria J Panwala a, Paul J Joudrey d
PMCID: PMC9908565  PMID: 36801707

Abstract

Objectives

We sought to compare timely access to methadone treatment in the United States (US) and Canada during the COVID-19 pandemic.

Methods

We conducted a cross-sectional study of census tracts and aggregated dissemination areas (used for rural Canada) within 14 US and 3 Canadian jurisdictions in 2020. We excluded census tracts or areas with a population density of less than one person per square km. Data from a 2020 audit of timely medication access was used to determine clinics accepting new patients within 48 h. Unadjusted and adjusted linear regressions were performed to examine the relationship between area population density and sociodemographic covariates and three outcome variables: 1) driving distance to the nearest methadone clinic accepting new patients, 2) driving distance to the nearest methadone clinic accepting new patients for medication initiation within 48 h, and 3) the difference in the driving distance between the first and second outcome.

Results

We included 17,611 census tracts and areas with a population density greater than one person per square kilometer. After adjusting for area covariates, US jurisdictions were a median of 11.6 miles (p value <0.001) further from a methadone clinic accepting new patients and 25.1 miles (p value <0.001) further from a clinic accepting new patients within 48 h than Canadian jurisdictions.

Conclusions

These results suggest that the more flexible Canadian regulatory approach to methadone treatment is associated with a greater availability of timely methadone treatment and reduced urban-rural disparity in availability, compared to the US.

Keywords: COVID-19, Methadone, OAT, Access, Treatment initiation

1. Introduction

Timely access to methadone treatment prevents overdose deaths and improves the health of people with opioid use disorder (OUD), but not all patients who may benefit from methadone treatment receive the medication (Joudrey et al., 2021a). Ensuring timely methadone treatment is available in all communities is particularly important for patients who do not respond to buprenorphine treatment. Previous research identified methadone availability as a key barrier to methadone treatment, especially in rural communities (Lister and Lister, 2021, Amiri et al., 2021). Delays in treatment initiation even as short as one day are associated with overdose death, reduced odds of methadone initiation and increased illicit opioid use (Larochelle et al., 2018, Schwartz et al., 2006, Roy et al., 2020).

In the US, methadone can only be ordered for OUD by clinicians at opioid treatment programs (OTPs) certified by the Substance Abuse and Mental Health Service Administration (SAMHSA) under the OTP’s Drug Enforcement Administration (DEA) registration. OTPs must also meet state and local regulatory requirements which together result in the segregation methadone treatment for OUD from the rest of the healthcare system. In contrast, Canada’s regulatory environment for methadone is more flexible. Regulation of methadone is controlled by provincial regulatory bodies instead of the federal government. Clinicians may prescribe methadone by undergoing additional certification regulated by provincial bodies within specialty or primary care clinics in Alberta, Ontario, and British Columbia, and the medication is often dispensed in community pharmacies similar to other chronic diseases (Calcaterra et al., 2019, Priest et al., 2019, Methadone: Centre for Addiction and Mental Health, 2022, Opioid Agonist Treatment Program Edmonton, 2022, Provincial Opioid Addiction Treatment Support Program Vancouver, 2021). Dispensation guidelines are more flexible in Canada than the US as well. In the United States, federal law prior to the onset of the COVID-19 pandemic decreed that patients on methadone maintenance therapy must present 6 days per week in person at their OTP for daily witnessed administration of methadone, until they meet stringent criteria which would allow them to “earn” additional take-home doses (Joudrey et al., 2021b). According to those regulations, a patient must be in treatment for 90 days before earning a second take-home dose per week (Joudrey et al., 2021b, Federal Guidelines for Opioid Treatment Programs, 2015). During this time, they must adhere to strict requirements including: regular clinic attendance, absence of serious behavioral problems at the clinic, absence of recent drug or alcohol abuse, no known recent criminal activity, stability of their home environment and social relationships (Federal Guidelines for Opioid Treatment Programs, 2015). Currently, new guidelines have been proposed which would allow “up to 7 days of take home doses during the first 14 days of treatment, up to 14 take home doses from 15 days of treatment and up to 28 take home doses from 31 days in treatment” (Medications for the Treatment of Opioid Use Disorder, 2022, SAMHSA, 2022). In comparison, in Canada governmental bodies issue less stringent guidelines about prescribing practices, and associations such as provincial medical regulatory bodies instead ensure that appropriate standards are observed (Priest et al., 2019). Acknowledgement that US OTPs do not meet the needs of all patients who may benefit from methadone treatment has resulted in calls for research informing the expansion of methadone treatment within the US, including research on methadone treatment within countries with alternative delivery models (Joudrey et al., 2021b). Comparing timely methadone availability within the US and Canada may inform methadone treatment expansion efforts within both countries.

It is worth noting too the changes to methadone treatment policy which were made in response to the onset of the COVID-19 pandemic, in order to facilitate new requirements for social distancing. The US, being the country with the more restrictive methadone policy, experienced the most drastic change. On March 16th, 2020, the Substance Abuse and Mental Health Services Administration (SAMSHA) released guidance which permitted States to request an exemption to existing policy which would allow all stable patients to receive up to 28 days of take-home medication, and less stable to receive up to 14 days of take-home medication. Defining stable and less stable patients was up to provider or program discretion (Opioid Treatment Program OTP Guidance, 2020). In Canada, control of methadone policy rests primarily with individual provinces and territories. Thus, during the COVID-19 pandemic, provincial health bodies released guidelines with a similar aim to temporarily increase access to take-home doses of methadone to facilitate social distancing (Gomes et al., 2022, COVID-19, 2021).

Previous research within the US demonstrated OTPs are less available within rural and suburban communities relative to urban (Joudrey et al., 2019). However, these studies overestimate availability because they assume all OTPs are accommodating new patients in a timely fashion. A previous audit study comparing US and Canadian wait times for methadone treatment initiation during the first year of the COVID-19 pandemic, a period during which lockdowns in both countries impeded access to treatment, showed Canadian clinics offered shorter wait times to treatment than US OTPs (Joudrey et al., 2021a). To our knowledge, there are no existing comparisons of timely access to methadone treatment within the US and Canada despite the differences in regulatory approach. Further, previous examinations of methadone treatment availability within the US and Canada have not been informed by an audit of timely access among clinics from the patient’s perspective. Therefore, we examined timely methadone treatment availability (defined as the ability to initiate treatment within 48 h) among methadone clinics within both countries informed by a 2020 audit of methadone clinics during the COVID-19 pandemic. We hypothesized that the more restrictive US methadone regulatory system would correlate with less timely treatment availability compared to Canada.

2. Methods

We conducted a study which included 563 methadone clinics within the 14 US and 3 Canadian jurisdictions (319 in the US and 244 in Canada) audited for timeliness of medication initiation for patients utilizing Medicaid within the US and provincial insurance in Canada between May 11 and June 17, 2020. We excluded clinics serving special populations (i.e. Veterans Health Administration) and clinics without methadone treatment for OUD. In Canada, we also excluded office-based primary care providers prescribing methadone. The 14 US and 3 Canadian jurisdictions were selected because they represented the jurisdictions with the highest 2018 opioid overdose death rates within each nation. In both nations, jurisdictions are geographically diverse including both coastal and land locked jurisdictions. We did not exclude tracts based on urbanicity. Further description of the data sample and audit of the timeliness of methadone treatment was reported previously (Joudrey et al., 2021a). Next, we obtained census tracts and aggregated dissemination areas (used for rural Canada) within 14 US and 3 Canadian jurisdictions in 2020 (United States Census Bureau, 2023, Census of Population, 2023). We included all census tracts and dissemination areas within the US jurisdictions of Connecticut, District of Columbia, Kentucky, Maine, Massachusetts, Maryland, Michigan, Missouri, New Hampshire, Ohio, Rhode Island, Tennessee, Vermont, and West Virginia and within the Canadian provinces of Alberta, Ontario, and British Columbia. These jurisdictions had the highest 2018 opioid overdose death rates within each nation (Overdoses SACotEoO, 2022, Wilson et al., 2020). We excluded census tracts and areas with a population density of less than one person per square km. The Yale institutional review board determined that this study did not involve human participants.

2.1. Dependent variable

We examined three different outcome variables measuring the availability of methadone treatment. First, we calculated the driving distance to the nearest methadone clinic accepting new patients from the population weighted center of each census tract or area regardless of the timeliness of access. This outcome represents the traditional assessment of methadone availability without data on wait time for medication initiation. Second, we calculated the driving distance to the nearest methadone clinic accepting new patients for medication initiation within 48 h. We chose 48 h as our definition of timeliness of access based on previous research suggesting delays longer than 1 day were associated with reduced treatment initiation (Roy et al., 2020). Finally, we calculated the difference in driving distance between our first and second outcome, representing the change in driving distance when accounting for the timeliness of access. If the closest clinic also accepted patients within 48 h, this difference was zero.

Driving distance was calculated using ArcGIS network analyst using the same methods as a previously reported (Amiri et al., 2021). To estimate the availability of treatment we audited for timeliness of medication initiation for patients utilizing Medicaid within the US and provincial insurance in Canada between May 11 and June 17, 2020. We excluded clinics serving special populations (i.e. Veterans Health Administration) and clinics without methadone treatment for OUD. Further description of the data sample and audit of the timeliness of methadone treatment was reported previously (Joudrey et al., 2021a).

2.2. Independent variable

We classified census tracts and areas by country (US versus Canada).

2.2.1. Covariates

Census tract and area covariates included percentage of population age 20–64, population density (population density was calculated by combining data from both countries together), percentage of population with high school diploma, and percentage of population who are white race, and median normalized income. In order to compare income within states and provinces, we normalized the income within each state or province. Census data covariates were selected because they were previously associated with methadone availability or community risk of opioid overdose death and comparable census reporting was available within both countries (Carrière et al., 2018, Fischer et al., 2008, Smolina et al., 2016, Pulver et al., 2014, Piske et al., 2020, Dahlhamer et al., 2021).

We obtained 2015 census demographic data for each of the fourteen US jurisdictions and also 2016 census data for the three Canadian provinces. The data was obtained from US Census Bureau American Community Survey and Statistics Canada, respectively.

2.3. Statistical analysis

Univariate analyses included the measure of central tendency and variability for continuous variables and frequency distributions, and percentages for categorical variables. We then examined all outcomes among all census tracts and areas by nation and while stratifying by quartile of census tract population density using the Kruskal-Wallis test. We then used a Wilcoxon signed-rank test to compare driving distance within each population density strata using a Bonferroni correction for multiple comparisons. Unadjusted and adjusted linear regressions were performed to further examine the relationship between country and our three dependent variables: 1) driving distance to the nearest methadone clinic, 2) driving distance to the nearest methadone clinic accepting new patients for medication initiation within 48 h, and the 3) difference between the driving distance between the first and second outcome. We adjusted models for our main independent variable (country) and all area covariates. The data were analyzed using R. The significance level was set at 0.05 (two-tailed).

3. Results

We included 17,611 of 17,664 census tracts and areas with a population density greater than one person per square km. Of those, 85.3% were in US jurisdictions. Among all census tracts and areas ( Table 1), 60% were between the ages of 20–60, 74% were white race, and 13% had no high school education or equivalent. Compared to Canada, US tracts and areas had a lower percent of working age population, lower percent of people without high school degree, lower normalized income, and lower population density. The unadjusted median driving distance to the nearest methadone clinic accepting new patients was longer in the US compared to Canada (36.9 miles vs 14.7 miles, p value < 0.001) and also longer for driving distance to the nearest methadone clinic accepting patients for medication initiation within 48 h (61.0 miles vs 19.4 miles, p value < 0.001).

Table 1.

Characteristics of census tracts and areas within fourteen US and three Canadian jurisdictions.

Census tract and area characteristic All tracts
Mean (SD)		 United States
Mean (SD)		 Canada
Mean (SD)		 p value
n 17,611 14,993 2618
%Population age 20–64 60 (6.2) 60 (6.2) 61 (5.9) < 0.001
% white race 74(27.9) 74 (28.1) 73 (26.1) 0.84
% with no high school equivalent 13 (8.8) 12 (8.2) 19 (10.0) < 0.001
Income (Normalized by state/province) 0.3 (0.1) 0.25 (0.1) 0.33 (0.1) < 0.001
Population density(Per SqKm) 1436.2 (2475.9) 1225.4 (2052.3) 2642.5 (3924.3) < 0.001
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a Data sources came from the Canadian 2016 census and the US 2015 census data. In order to compare income within states and provinces, we normalized the income within each state (Connecticut, District of Columbia, Kentucky, Maine, Massachusetts, Maryland, Michigan, Missouri, New Hampshire, Ohio, Rhode Island, Tennessee, Vermont, and West Virginia) or province (Alberta, Ontario, and British Columbia.

In analyses of outcomes stratified by population density ( Table 2), the Canadian population was shown to have a lower median travel distance to both clinics prescribing methadone accepting new patients, and to clinics accepting patients within 48 h. This trend was borne out across all quartiles of population density. In addition, the median change in distance when accounting for timely access was greater within the US compared to Canada.

Table 2.

Driving distance to methadone treatment among census tracts and areas fourteen US and three Canadian jurisdictions in 2020.

Median miles (IQR)
Classification United States Canada p value
All clinics accepting new patients
n 14,993 2618 < 0.001
All census tracts 15.9 (5.7–41.5) 4.3 (2.1 – 10.2) < 0.0001
1st quartile population density 38.1 (22.3–67.9) 17.6 (8.8–38.9) < 0.0001
2nd quartile population density 17.2 (8.2–41.9) 4.7 (2.7–9.4) < 0.0001
3rd quartile population density 11.1 (5.2–32.8) 3.0 (1.9–5.0) < 0.0001
4th quartile population density 4.7 (2.2–12.6) 2.1 (1.2 −3.9) < 0.0001
Clinics with medication initiation within 48 h
n 14,993 2618 < 0.001
All census tracts 30.5 (11.0–77.3) 5.4 (2.5–15.1) < 0.0001
1st quartile population density 63.4 (34.3–138) 21.6 (10.2–49.7) < 0.0001
2nd quartile population density 34.8 (13.9–84) 6.4 (3.32–14.9) < 0.0001
3rd quartile population density 21.6 (9.9–70.8) 3.7 (2.2–6.6) < 0.0001
4th quartile population density 11.3 (3.9–31.6) 2.4 (1.3–4.4) < 0.0001
Change in distance when limited to access within 48 h
n 14,993 2618 < 0.001
All census tracts 2.8 (0–32.1) 0 (0–0.1) < 0.0001
1st quartile population density 3.9 (0–54.5) 0 (0–0.3) < 0.0001
2nd quartile population density 4 (0–34.5) 0 (0–0.6) < 0.0001
3rd quartile population density 2.6 (0–31.4) 0 (0–0) < 0.0001
4th quartile population density 1.9 (0–13.2) 0 (0–0) < 0.0001
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a We then examined all outcomes among all census tracts and areas by nation and while stratifying by quartile of census tract population density using the Kruskal-Wallis test. We then used a Wilcoxon signed-rank test to compare drive distance within each population density strata using a Bonferroni correction for multiple comparisons.

When adjusting for tract and area covariates, US jurisdictions were associated with longer driving distance to the nearest methadone clinic accepting new patients and the nearest methadone clinic providing medication initiation within 48 h. In an adjusted model, US jurisdictions were associated with a greater increase in driving difference when accounting for medication access within 48 h ( Table 3).

Table 3.

Multivariable models of driving distance to methadone treatment within fourteen US and three Canadian jurisdictions in 2020.

All clinics accepting new patients
 Clinics with medication access within 48 h
 Change in distance
Predictors Estimates CI p Estimates CI p Estimates CI p
(Intercept) 28 19.74 – 36.64 < 0.001 51 39.54 – 61.60 < 0.001 22 15.90 – 28.89 < 0.001
White 36 32.33 – 38.65 < 0.001 49 44.75 – 53.00 < 0.001 13 10.96 – 15.82 0.001
Country [US] 14 11.78 – 16.40 < 0.001 27 24.12 – 30.15 < 0.001 13 11.30 – 14.86 < 0.001
% with no HighSchool 39 29.97 – 47.36 < 0.001 27 16.08 – 38.78 < 0.001 -11 -17.97 – − 4.60 < 0.001
Population Density(Per sqKM) -2573 -2937.19 – − 2208.47 < 0.001 -4129 -4604.87 – − 3653.61 < 0.001 -1556 -1835.70 – − 1275.55 < 0.001
% Pop 20–64 -39 -49.88 – − 27.63 < 0.001 -52 -66.77 – − 37.73 < 0.001 -14 -22.07 – − 4.97 0.002
Income -49 -55.88 – − 42.85 < 0.001 -88 -96.24 – − 79.23 < 0.001 -38 -43.35 – − 33.34 < 0.001
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a Data sources came from the Canadian 2016 census and the US 2015 census data. In order to compare income within states and provinces, we normalized the income within each state or province. Unadjusted and adjusted linear regressions were performed to examine the relationship between covariates and our three dependent variables: 1) driving distance to the nearest methadone clinic, 2) driving distance to the nearest methadone clinic accepting new patients for medication initiation within 48 h, and the 3) difference between the driving distance between the first and second outcome.

Fig. 1 shows access to timely methadone treatment in both the US and Canada. Within the US, a clear pattern is seen in which rural areas in TN, KY, and MO have long travel distances to timely methadone treatments. However, a more detailed spatial analysis to explore areas of poor access in a granular manner is planned for the future.

Fig. 1.

Fig. 1

Open in a new tab

Driving distance to methadone clinic accepting new patients within 48 h among census tracts and areas fourteen US and three Canadian jurisdictions 2020. NOTES [In order to compare income within states and provinces, we normalized the income within each state (Connecticut, District of Columbia, Kentucky, Maine, Massachusetts, Maryland, Michigan, Missouri, New Hampshire, Ohio, Rhode Island, Tennessee, Vermont, and West Virginia) or province (Alberta, Ontario, and British Columbia).

Source/Notes: Authors’ analysis of data from the methadone clinic survey and from the Canadian 2016 census and the US 2015 census data

4. Discussion

In this cross-sectional spatial analysis of jurisdictions within the US and Canada, median driving distance to methadone treatment was over three times greater within the US compared to Canada, and this disparity in driving distance increased to over five times greater when limited to methadone clinics providing timely medication access within 48 h. These longer driving distances within the US were not accounted for by tract or area differences in population density, age, race, education, or income. Long travel distances to timely methadone treatment remain a barrier to care in both nations, but these results suggest Canada’s more flexible regulatory approach to methadone treatment is associated with markedly greater availability of methadone treatment relative to the US. These results support the integration of methadone treatment into the rest of the US healthcare system via strategies like office-based methadone prescribing similar to how buprenorphine prescription is regulated currently (Breaking, 2021).

Our results showing greater availability of methadone treatment with increasing population density within both the US and Canada is consistent with previous research showing availability decreases with greater rurality (Amiri et al., 2021, Joudrey et al., 2019, Joudrey et al., 2020). Our results demonstrate this rural disparity in methadone availability is worse in the US relative to Canada, especially after accounting for the timeliness of medication initiation. This rural disparity in availability within the US could be reduced by opening more OTPs but this has been difficult to achieve historically due to regulations, staffing, community resistance, and cost. Alternatively, incorporation of methadone treatment into other outpatient settings, such as federally qualified health centers could reduce the rural disparity in availability without the opening of new health care facilities (Joudrey et al., 2021a).

Our results show that previous examinations of methadone treatment availability within both the US and Canada overestimate methadone availability because the timeliness of methadone initiation is not acknowledged. Our approach of linking availability data to an audit of clinic services, allows our examination to more closely represent real patients experience of methadone initiation during the first year of the COVID-19 pandemic. Moreover, given the lockdowns during the first year of the pandemic, which likely further limited treatment initiation, the results of this study provide insight into the resilience of the health systems and the ability to provide access to methadone treatment during such unusual circumstances. Other dimensions of access, such as cost and the acceptability of services, were not examined and they may also differ between the two countries.

Despite the magnitude of the differences in methadone availability observed between the two nations, our results may underestimate the difference between the two nations. In Canada, office-based primary care providers can prescribe methadone for OUD, and our study did not include these primary care providers. Additionally, our study examined availability of sites for methadone initiation but did not examine sites for methadone administration and dispensing. In the US, methadone administration and dispensing is limited to OTPs while it is integrated into community pharmacies in Canada, which may further enlarge differences in availability once patients are engaged in treatment (Joudrey et al., 2020). Thus, while our figures represent the average distance to both methadone initiation and daily dispensation in the US, they only reflect the average distance to methadone initiation in Canada.

Recent legal scholarship demonstrates US regulatory agencies (e.g. SAMHSA and the DEA) have greater discretion to modify methadone regulations in accordance with scientific evidence and patient needs (Dooling and Stanley, 2022). Our results support actions by US SAMHSA and the DEA to allow integration of methadone prescribing for OUD into office-based settings to expand available treatment locations for timely methadone initiation. In addition to federal action, state agencies will also need to take steps to allow methadone treatment within new settings (Doyle and Baaklini, 2022). Finally, the Centers for Medicare & Medicaid Services will need to develop new payment models for methadone prescribing for OUD outside of traditional OTPs (Hawryluk, 2022).

Our study has several limitations. Our driving distance represents area population estimates and should not be used to predict individual driving distances. Our cross-sectional study represents a comparison of driving distances during the first year of the pandemic and cannot not assess changes in availability over time. There are multiple methadone regulatory differences between the US and Canada and this study did not examine the independent effect of each policy difference. Which specific regulatory actions may lead to the greatest increase in availability should be the focus of further research. While we controlled for key covariates which may impact service availability within both nations and selected factors with similar census measures in both nations, differences in each nations approach to census collection may impact our results. Our results represent the availability of timely methadone for patients utilizing Medicaid within the US, and does not include availability for patient paying out of pocket or with private insurance. However, our previous research demonstrated there was no difference in the timeliness of access for patients utilizing Medicaid or paying out of pocket and these two groups represent the majority of patients receiving methadone for OUD within the US (Joudrey et al., 2021a). Finally, the census data used in the study (2015/16 for Canada and 2020 for the US), did not much the year that data was collected from clinics.

5. Conclusion

In this cross-sectional study of census tracts and areas within the US and Canada, driving distance to methadone treatment was over three times greater within the US compared to Canada, and this disparity in driving distance increased to over five times greater when limited to methadone clinics providing timely medication access. Census tract or area demographic and population differences did not account for these differences. These results suggest the more flexible Canadian regulatory approach to methadone treatment is associated with greater availability of timely methadone treatment relative to the US and reduced urban-rural disparity in availability. These results support the integration of methadone treatment into additional outpatient settings within both nations, and regulatory changes within the US to enable such integration and expansion.

CRediT authorship contribution statement

Ofer Amram: Conceptualization, Methodology, Writing – original draft, Data curation. Leah Rosenkrantz: Data collection Canada, Reviewing and preparation Solmaz Amiri: Data curation, Analysis United States. Nadine Schuurman: Writing – review & editing. Paul J. Joudrey: Writing – review & editing, Conceptualization.

Funding

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

Role of Funding Source

Nothing declared.

Conflict of Interest

No conflict declared.

Acknowledgements

None.

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