Study finds no link between take-home opioid agonist therapy, overdose risk
An increase in take-home doses of opioid agonist therapy early in the COVID-19 pandemic was associated with lower rates of treatment interruption and did not increase the risk for opioid-related overdoses, according to a recent study.
“Changes in clinical practice related to provision of take-home doses of opioid agonist therapy (OAT) that were implemented early in the pandemic were not associated with increased risk of harm,” Tara Gomes, PhD, an epidemiologist and principal investigator of the Ontario Drug Policy Research Network in Canada, told Healio. “Instead, we found that providing more flexible access to OAT can help people stay in treatment without increased risk of overdose.”
The retrospective propensity-weighted cohort study, published in JAMA, assessed how the increase in dispensing of take-home OAT doses impacted treatment retention and opioid-related harm among 21,297 patients in Ontario, Canada.
At baseline, before more flexible OAT access was implemented on March 22, 2020, Gomes and colleagues reported that 5,852 patients received daily dispensed methadone and 662 received daily dispensed buprenorphine/naloxone. The remaining patients were receiving five to six take-home doses of OAT at baseline, including 11,010 patients receiving take-home methadone and 3,773 receiving take-home buprenorphine/naloxone. The researchers evaluated changes in the frequency of OAT take-home doses between March 22, 2020, and April 21, 2020, and observed patients for up to 180 days.
Among the daily dispensed methadone cohort, Gomes and colleagues reported that initiation of take-home doses was associated with a significantly lower risk for opioid overdose (6.9% vs. 9.5% per person-year; weighted HR = 0.73; 95% CI, 0.56-0.96), treatment discontinuation (51% vs. 63.6% per person-year; wHR = 0.8; 95% CI, 0.72-0.9), and treatment interruption (19% vs 23.9% per person-year; wHR = 0.8; 95% CI, 0.67-0.95) compared with no change in take-home doses. However, there was no significant difference in outcomes among patients receiving daily dispensed buprenorphine/naloxone who initiated take-home doses vs. those who did not.
Among those who were already receiving take-home doses of methadone at baseline, an increase to at least 13 take-home doses was significantly associated with lower risks for OAT discontinuation (14.1% vs. 19.6% per person-year; wHR = 0.72; 95% CI, 0.62-0.84) and interruption in therapy (5.1% vs. 7.4% per person-year; wHR = 0.69; 95% CI, 0.53-0.9) compared with no change in take-home doses. Additionally, extended take-home doses of buprenorphine/naloxone were also significantly associated with a lower risk for interruption in therapy (9.5% vs 12.9% per person-year; wHR = 0.74; 95% CI, 0.56-0.99) compared with no change.
According to the researchers, prescribing flexibilities during the pandemic allowed some patients who would not have historically been eligible for take-home OAT doses to receive them. Prior to the pandemic, eligibility predicated on perceived social stability and sustained abstinence from all substance use. The revised guidance recommends de-emphasizing abstinence and contingency management, Gomes and colleagues wrote. The current findings, they added, have implications for policymakers “as they consider extending or permanently implementing more flexible provision of OAT.”
“Future work is needed to explore specific populations of people receiving OAT who benefited most from these changes to help continue to guide prescribers in clinical decision-making surrounding provision of more flexible access to OAT,” Gomes said.