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      Medication treatment for opioid use disorder in the age of COVID-19: Can new regulations modify the opioid cascade?

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          Abstract

          The temporary loosening of regulations governing methadone and buprenorphine treatment for opioid use disorder (OUD) in the U.S., instituted to prevent the spread of COVID-19, has created an opportunity to explore the effectiveness of new models of care for people with OUD. The opioid cascade describes the current status of the treatment system, where only a fraction of people with OUD initiate effective medication treatment for OUD (MOUD), and of those only a fraction is retained in treatment. Regulatory changes—such as availability of larger take-home supplies of methadone and buprenorphine initiated via telemedicine (e.g., no initial in person visit; telemedicine buprenorphine permitted across state lines)—could modify the cascade, by reducing the burden and increasing the attractiveness, availability, and feasibility of MOUD both for people with OUD and for providers. We review examples of more liberal MOUD regimens, including the implementation of buprenorphine in France in the 1990s, primary care–based methadone in Canada, and low-threshold buprenorphine models. Research is needed to document whether new models implemented in the U.S. in the wake of COVID-19 are successful, and whether safety concerns, such as diversion and misuse, emerge. We discuss barriers to implementation, including racial and ethnic health disparities, and lack of knowledge and reluctance among potential providers of MOUD. We suggest that the urgency and public spiritedness of the response to COVID-19 be harnessed to make gains on the opioid cascade, inspiring prescribers, health systems, and communities to embrace the delivery of MOUD to meet the needs of an increasingly vulnerable population.

          Highlights

          • The COVID-19 epidemic has prompted regulatory changes to support medication treatments for opioid use disorder.

          • Loosened regulations governing methadone and buprenorphine present an opportunity to expand treatment.

          • Models of lower threshold availability of buprenorphine and methadone have succeeded in other countries and settings.

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          Most cited references27

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          Collision of the COVID-19 and Addiction Epidemics

          People with substance use disorder may be especially susceptible to COVID-19, and compromised lung function from COVID-19 could also put at risk those who have opioid use disorder and methamphetamine use disorder. This commentary describes the risks of the collision of the COVID-19 and addiction epidemics.
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            Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.

            Opioid-dependent patients often use the emergency department (ED) for medical care.
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              COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States

              The global pandemic of COVID-19 is colliding with the epidemic of opioid use disorders (OUD) and other substance use disorders (SUD) in the United States (US). Currently, there is limited data on risks, disparity, and outcomes for COVID-19 in individuals suffering from SUD. This is a retrospective case-control study of electronic health records (EHRs) data of 73,099,850 unique patients, of whom 12,030 had a diagnosis of COVID-19. Patients with a recent diagnosis of SUD (within past year) were at significantly increased risk for COVID-19 (adjusted odds ratio or AOR = 8.699 [8.411–8.997], P < 10−30), an effect that was strongest for individuals with OUD (AOR = 10.244 [9.107–11.524], P < 10−30), followed by individuals with tobacco use disorder (TUD) (AOR = 8.222 ([7.925–8.530], P < 10−30). Compared to patients without SUD, patients with SUD had significantly higher prevalence of chronic kidney, liver, lung diseases, cardiovascular diseases, type 2 diabetes, obesity and cancer. Among patients with recent diagnosis of SUD, African Americans had significantly higher risk of COVID-19 than Caucasians (AOR = 2.173 [2.01–2.349], P < 10−30), with strongest effect for OUD (AOR = 4.162 [3.13–5.533], P < 10−25). COVID-19 patients with SUD had significantly worse outcomes (death: 9.6%, hospitalization: 41.0%) than general COVID-19 patients (death: 6.6%, hospitalization: 30.1%) and African Americans with COVID-19 and SUD had worse outcomes (death: 13.0%, hospitalization: 50.7%) than Caucasians (death: 8.6%, hospitalization: 35.2%). These findings identify individuals with SUD, especially individuals with OUD and African Americans, as having increased risk for COVID-19 and its adverse outcomes, highlighting the need to screen and treat individuals with SUD as part of the strategy to control the pandemic while ensuring no disparities in access to healthcare support.
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                Author and article information

                Journal
                J Subst Abuse Treat
                J Subst Abuse Treat
                Journal of Substance Abuse Treatment
                Published by Elsevier Inc.
                0740-5472
                1873-6483
                14 November 2020
                14 November 2020
                : 108196
                Affiliations
                [a ]New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States of America
                [b ]Columbia Center for Healing of Opioid and Other Substance Use Disorders – Enhancing Intervention Development and Implementation (CHOSEN), Riverside Drive, New York, NY 10032, United States of America
                [c ]Columbia University Irving Medical Center, West 168th Street, New York, NY 10032, United States of America
                [d ]Irving Institute for Clinical and Translational Research, West 168th Street, New York, NY 10032, United States of America
                [e ]Columbia School of Social Work, 1255 Amsterdam Ave, New York, NY 10027, United States of America
                Author notes
                [* ]Corresponding author at: New York State Psychiatric Institute, 1051 Riverside Dr., Suite 120, New York, NY 10032, United States of America.
                Article
                S0740-5472(20)30453-0 108196
                10.1016/j.jsat.2020.108196
                7666540
                33221125
                c84b8f8e-5df2-4dbb-b13e-94560d0c2563
                © 2020 Published by Elsevier Inc.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 15 June 2020
                : 15 September 2020
                : 10 November 2020
                Categories
                Article

                covid-19,opioid cascade,methadone,buprenorphine,opioid use disorder,medication treatment for opioid use disorder,regulations,telemedicine,low-threshold buprenorphine,barriers to implementation,disparities

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