A study published yesterday in JAMA Network Open details US utilization of the two most effective medications used to treat opioid use disorder (OUD) in the first year of the COVID-19 pandemic, finding that quantities of methadone dwindled as buprenorphine doses expanded. The increases in buprenorphine dispensed didn't offset the proportional declines in the methadone distributed.
RAND Corp. scientists analyzed US Census Bureau information and quarterly state data from the Automated Reports and Consolidated Ordering System (ARCOS) on per-capita quantities (in milligrams [mg]) of the controlled medications methadone and buprenorphine from Jan 1, 2012, to Jun 30, 2021. Both medications alleviate opioid withdrawal symptoms and cravings while not inducing the high that keeps users going back to opioids.
ARCOS, which tracks the flow of controlled substances in the United States, includes data from drug manufacturers and point-of-sale and retail dispensing at hospitals, clinics, and pharmacies.
The authors noted that the COVID-19 pandemic worsened the already-severe opioid crisis in the United States owing to lockdown-related social isolation and stress, with the number of overdose deaths in 2020 the highest ever recorded.
A unique decline in distribution of methadone
From the first to the second quarter of 2020, per-person quantities of buprenorphine rose slightly, from 3.6 mg to 3.7 mg. But methadone quantities fell 20%, from 13.2 mg per person to 10.5 mg.
"Compared with the mean methadone supply per capita in 2019 (11.4 mg), the decline in quarter 2 of 2020 was still substantial (−8%)," the researchers wrote. "Part of this large decline might be attributable to an increase in methadone supply in quarter 1 of 2020, but that increase did not appear to explain the full decline that persisted for 1 year. The persistence of this decline is unique relative to historical methadone supply trends [measured as the quantity dispensed]."
In 2020 and 2021, some states saw greater methadone distribution declines than others, with reduced supplies in 35 states and Washington, DC, reductions as high as 50% in Florida and New Hampshire, and increases of up to 26% in 15 states. These decreases weren't offset by proportional increases in the per-person availability of buprenorphine.
Possible reasons behind changes in quantity distributed
Only opioid treatment programs (OTPs) can dispense methadone, while any clinician with a waiver can prescribe buprenorphine for pick-up at retail pharmacies, which the researchers said could have caused greater disruption in the supply of methadone, particularly for patients just beginning treatment.
"Furthermore, clinicians with waivers may prescribe buprenorphine to new patients for treatment without first conducting an in-person evaluation, whereas OTPs can only admit new patients and initiate treatment with methadone if an initial in-person physical evaluation is performed," they wrote.
In March 2020, in response to possible pandemic-related disruptions in access to these medications amid the US opioid crisis, the US Substance Abuse and Mental Health Service Administration and states enabled OTPs to use audio-only (as opposed to audiovisual) telemedical visits to prescribe buprenorphine and provide greater access to take-home methadone doses.
"Past research has shown that even short delays in access may adversely affect MOUD [medication for OUD] initiation, illicit opioid use, and overdose death," they wrote. "As the dual crisis proceeds with substantial growth in fatal and nonfatal overdoses, access to effective treatment for OUD is critical."
They called for research into why some states but not others experienced pronounced declines in methadone use. "Although more work is certainly needed to understand the implications of this reduced methadone supply, this timely evidence suggests a need for urgent attention to help state and local capabilities treat patients with OUD," they wrote.