This article is part of a series exploring state efforts to ensure that people with OUD continue to receive treatment safely during the pandemic.
As states contend with an opioid crisis that may be worsening because of the COVID-19 pandemic, policymakers are introducing innovative approaches to ensure that treatment for those with opioid use disorder (OUD) can be provided safely. For example, some states are taking steps to help patients get access to such FDA-approved medications despite physical distancing requirements that have forced changes to treatment regimens and people’s interactions with the health care system.
For example, Indiana announced in March that it will provide lockboxes to the increased number of people now taking home longer-term doses of OUD medication so they no longer have to risk coronavirus exposure by picking up their treatment daily. The boxes, meant to ensure that this larger amount of medication does not get into the hands of anyone other than the patient, are supplied with the overdose reversal drug naloxone as another safety measure.
Colorado, meanwhile, plans to use federal grant funds to pay for lockboxes and take-home medicine bottles to provide similar safeguards while encouraging distribution of naloxone as well. And Massachusetts has pledged to support opioid treatment programs (OTPs)—the state and federally regulated facilities that offer certain OUD medications—in supplying lockboxes.
With the coronavirus continuing its spread nationwide, OUD patients need to minimize the amount of time spent traveling to and inside their OTPs. Before the public health emergency, federal regulations required many to take their daily dose of medication while supervised at these clinics. Still, as determined by OTP medical directors and in compliance with federal guidelines, patients could take home several days’ or a week’s supply, known as take-home doses, under specific circumstances.
In response to the pandemic, the federal government has granted states more flexibility with OTP rules to make sure people with OUD can still get treatment. In essence, the pool of patients eligible for take-home doses grew. OTP practitioners now can give patients in the early stages of their recovery as much as two weeks' worth of medication. Patients who are stable on their medications can receive up to a 28-day supply of take-home doses.
The new rules reflect the dangers posed by COVID-19. When determining the amount of take-home doses, clinicians also must consider whether patients have been diagnosed with the disease, have been exposed to it, or have co-morbidities that put them at high risk if they get sick. Patients must make frequent phone check-ins and attend some in-person meetings, depending on how often they met with their practitioners before the pandemic.
Generally, take-home dosing allows providers to individualize treatment according to a patient’s needs. Expanding these policies during the pandemic means greater flexibility to protect the health and safety of patients. However, it also means they must accept more risk by storing medications at home, a risk comparable to having prescription painkillers in a residence. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) requirements for home dosing weigh the risk of the medication’s diversion and recommend that patients take steps to avoid accidental ingestion, including by children.
Lockboxes should help reduce these risks. In Indiana, the state is providing OTPs with specially designed medicine boxes with four-digit combination locks to be set by each patient. In other states, lockboxes can be any container that the patient locks with a key or combination code. Either way, the boxes can keep prescriptions—including OUD medications—safe from people other than the patient, whether at home or while traveling to and from the OTP.
Before the government boosted flexibility in response to the COVID-19 public health emergency, OTP medical directors would weigh factors such as the length of time in treatment, regular clinic attendance, lack of criminal activity, the ability to safely store medication, and stability of the home environment in deciding whether to allow take-home doses. Providers now have more options to tailor treatment in addition to those factors.
The process and reduced visits to the OTP can require extra reassurances for patients. For example, Dr. Robert Sherrick, chief medical officer of Community Medical Services (CMS) in Kalispell, Montana, said his office takes “a highly individualized approach” with each OUD patient to decide the best dosing regimen and to make sure that person does not feel abandoned during the pandemic. CMS requires lockboxes for doses of a week or longer, consistent with SAMHSA guidelines.
The goal is continuing and consistent care. “We aren’t going anywhere,” Sherrick said.
Jennifer Mason, vice president of CMS in Peoria, Arizona, said that lockboxes could help people feel more comfortable bringing medication home with them. “Our priority,” she said, “is keeping people safe.”
The ability of states such as Indiana, Colorado, and Massachusetts to provide lockboxes and other security measures may depend on federal guidance during and beyond the pandemic—but these are important strategies for supporting patients in their recovery as the nation continues the dual fights against opioid misuse and COVID-19.
Beth Connolly is the project director and Alaina McBournie is an officer with Pew’s substance use prevention and treatment initiative.