Challenges in methadone dispensing during Covid-19: An innovative approach using videocall based services.

Since the onset of the COVID-19 pandemic, a majority of the health resources globally have been utilised towards addressing it. Introduction of measures like lockdowns and self-quarantine have made it substantially difficult for people who use drugs to access treatment or harm reduction services (Arya and Gupta, 2020). In addition, the COVID-19 pandemic presents much greater challenges to addiction services at various levels (Dunlop et al., 2020). Opioid substitution therapy, due to their default nature of daily dispensing, have faced significant disruptions (Stowe et al., 2020). While the practice recommendations (Farhoudian et al., 2020), country level guidelines (Indian Psychiatric society, 2020) and experiences from selected institutes (Basu et al., 2020) have provided some insight into prescribing buprenorphine for a longer duration, challenges with non-supervised methadone prescription persist. In some cases, the risk of overdosing can be mitigated by provision of take home naloxone. However, naloxone’s unavailability is a major limitation in several countries, including India. In situations where methadone daily dispensing is no longer feasible, there is an urgent need of adaptations in treatment models so as to facilitate social distancing. Our institute faced this challenge as well and we describe a simple, yet very useful strategy of ensuring methadone supervision using videocall through Whatsapp, a very commonly used communication application in India.

State Drug Dependence Treatment centre (SDDTC) is a tertiary care centre providing treatment services in state of Haryana in North India. The centre is one of the few hospitals in India providing Methadone Maintenance Therapy (MMT). On 23rd of March, India was put into one of the most stringent lockdown with suspension of all non-essential activities and movement. This led to the closure of routine outpatient health services at majority of the hospitals including ours. This lockdown provided a challenge to our team. Within a few days we realised that it was not feasible to continue patients on daily methadone dosing. This was primarily due to two reasons, (a) exposing the healthcare workers to possible high risk situations in the absence of adequate protection; (b) it was difficult and risky for patients to visit daily due to restrictions imposed by lockdown. Hence it was decided that take home methadone would be provided to patients, but this was complicated as there were no previous guidelines about take home methadone in Indian context, plus our centre had no experience with such provisions and there was no provision of take home naloxone available to us. Also, the guidelines issued by Indian Psychiatric Society (2020) were not applicable to many of our patients.

Choosing the patients for ‘take home’ methadone and direct observation through videoconferencing

Since the initiation of MMT services at our centre in 2016, the number of service users have steadily increased. During March 2020, the number of MMT service users was 90, which was at an all-time high for our centre. In the week following the lockdown, only 76 could access the MMT services. Having realised that these challenges were going to persist for a significant period, we improvised our services and dispensed ‘take home’ doses. We based our ‘take home’ dispensing protocol on a) distance, b) feasibility of daily visits, c) duration of treatment (>3 months on MMT), and d) family support and hence, we divided the patients into three groups:

Group 1 in which patients could come daily as they lived near the treatment centre.

Group 2 was required to have bi-weekly visits and included patients who were out of the city without any family support and had been on shorter duration of treatment. A total of 37 patients were kept on bi-weekly regimen.

Group 3 consisted of patients who came from the outskirts or nearby villages, had good family support and had been on a longer duration of treatment. Only when patients in this group confirmed having a cellular connection which allowed for video-conferencing, and an agreement to be available for calls during a particular period of the day, they were dispensed doses for 7–10 days. Finally, 33 patients were considered for supervised take home methadone dispensing. The Mean age of this group was 25 years (range 17–31 years), while the Mean duration of opioid dependence was 37 months, with all of them using heroin and 70 % using via an intravenous route. These patients were on regular MMT for a Mean duration of 6 months.

Process of methadone dispensing

A nurse (well experienced in MMT) provided the information about the whole procedure to the patient and family member. In order to ensure daily methadone intake and to prevent incorrect dosing, the family members were educated about the method of methadone administration. It was ensured that the patients took methadone in the presence of family members. They were advised to keep methadone at a safe place, out of patients’ and others’ reach. Information was also provided regarding over-dosage and to contact health services at the earliest in case of methadone overdose or it being used by someone else. After discussing with the patient, a particular time slot was provided to them during which a nurse would carry out a voice call, followed by a video call. Detailed instructions were provided to ensure that they understood well about the time of call, the daily dose, and the next follow up.

The methadone doses were dispensed in plastic/ glass containers. Family members and patients were taught to draw the exact amount in a syringe. A demonstration was carried out to teach the steps of drawing the prescribed daily dose from the bottle using a syringe to every patient.

Procedure followed during video call

We contacted patients during a pre-fixed time slot, initially through voice call (maximum of three calls in case of non-response), followed by Whatsapp video call. Phone calls at designated time ensured that the patient and family members were ready for the video call. Then the nurse would verify the patient’s identity and the presence of a family member. Then the patient would draw out the methadone using a syringe, which would be verified by the family member and nurse. Patient would fill this into a glass, drink it and confirm that he has taken the whole amount. Family members would watch out for any spillage and would report in case it happened. All of this procedure would be carried out using video conferencing and the records would be maintained in the central registers.

Outcomes after 4 weeks

A total of 33 patients were selected for daily methadone observation using video-conferencing. After 4 weeks, 26 (79 %) continued to be on treatment using this strategy. Three patients dropped out during the initial week, three more patients were shifted to a bi-weekly regimen as they failed to adhere to the protocols and one patient stopped treatment midway as he was quarantined. Among those who continued with video-conferencing protocol (26 patients), 42 % of individuals responded to video calls more than 75 % of the time, while another 38 % attended 50–75 % calls during this period. One patient could not attend video calls, but responded to audio calls 80 % of the time. Thus we had 80 % of the patients taking an observed methadone dose at least half of the treatment days using video calls.

No patient reported any incidence of overdosing or spillage. We made attempts to ensure that doses were taken in front of family members. However, on certain occasions it was not possible and hence occasional diversion or dilution of methadone is difficult to rule out. But the overall strategy significantly mitigated the chances of overdosing and diversion while ensuring the continuity of service in our sample.

However, despite our best efforts we were unable to perform routine urine screening. While video calls offered practical advantage over the usual practice of daily dispensing, the chances of a possible diversion or overdosing remained a risk. Furthermore, once the clinical services return to their normalcy, such initiatives would be difficult to continue due to lack of a dedicated manpower. Despite these limitations, our initiative provides preliminary evidence that complementing technology with family supervision can provide an alternative and a much more flexible option for an otherwise extremely rigid MMT regimen. Thus, there is an urgent need to continue these adaptations as well as to compare them with existing models so as to establish their efficacy.

Conclusion

Methadone has been the mainstay treatment for opioid dependence for many decades. Over this period, it has continued to be dispensed on a daily basis with occasional flexibility in exceptional circumstances. The challenges due to COVID-19 pandemic has forced addiction services to innovate and adapt. Our centre, using family supervision through commonly available video-conferencing tool ensured that methadone was directly observed by video calls with minimal risk of exposure to coronavirus infection. We call for more innovative approaches utilising family support and newer technologies in addiction services, particularly in OST so as to ensure patient safety and treatment continuity.

Financial disclosure

None.

Declaration of Competing Interest

The authors report no declarations of interest.