by Andrew Byrne, MD of suburban Sydney, Australia
1. Changes to opiate treatment programs during Covid – benefits for some, harms for others.
2. Buprenorphine alone or with naloxone: Which is safer? (Kelty et al.)
3. Harm reduction and diazepam prescribing in opiate programs.
4. Microdose transfers from methadone to buprenorphine – the ‘Bernese’ method measures up.
5. Are we seeing the end of the ‘methadone clinic’?
6. The role of opiate maintenance clinics in Covid prevention, diagnosis, vaccination, quarantine, home dosing, etc.
Part the First: Covid changes.
Covid has taught us many things about many things, including opiate maintenance treatments. From early in the Covid pandemic most patients were given extra take-home or dispensed doses. For about a month due to the delta crisis in New South Wales our practice gave no supervised doses but just doses for home consumption from the practice window. Although substantial numbers of our patients benefited greatly from increased liberties with take-away or dispensed doses of methadone and buprenorphine, a minority have got into trouble, some in a small way, others seriously.
In our practice we detected about ten percent of our patients, mostly ‘doubling up’ on doses and thus running out before normal return dates. Others were injecting the medication, selling it or just saving amounts ‘for a rainy day’ (in case the clinic were closed down). One patient developed serious septic thrombosis from regular inguinal injecting, requiring in-patient treatment for an extended period. Yet another was reported to be selling doses to others in the practice.
Daily supervised dosing has been the usual practice in nearly all opiate maintenance research and practice, at least initially. However, the place of continued supervised dosing has never been systematically investigated to my knowledge. We found no distinguishing factors in those who ‘stumbled’ when given extra dispensed doses during Covid lock-down periods. Some were stable, employed, long term patients while others were known to use other drugs including alcohol and had less stable lives generally.
Detection of irregularities with adherence was made by self-report, venipunctures, requests for supplements or hospitalisations. Such patients often dictated their own safety measures such as more regular attendance, increased dose supervision and for some, dose adjustments. Transfer from methadone to buprenorphine was also considered in some cases.
During the period of zero supervision, several of our patients started taking split doses, finding the benefit of less sedation and longer duration of action. They were disappointed when dose supervision resumed once the clinic re-opened for regular operation. The most obvious solution for this is transfer to buprenorphine which is longer acting and usually non-sedating. This can now be accomplished, even in those on high doses of methadone, using the ‘Bernese’ microdosing technique without the need to reduce methadone doses at all (more about that in a future posting).
Several groups have tried to measure changes from the Covid provisions in opiate maintenance yet there is still no systematic examination of the outcomes of dose supervision and regular attendance for medication. See Bart from Minneapolis; Lintzeris from Sydney. A Yale University group headed by addiction psychiatrist Ayana Jordan was working on the subject during the early months of Covid in mid-2020. A press release waxes about the benefits of increased dispensed doses in American methadone programs (see first reference below). However, I have read little about the ‘down side’ which we have noted above. Evidence based treatment will always be safest even though it may be inconvenient.
Best wishes to all my faithful and patient readers, keep safe and enjoy the holiday period.