BMC Bridge Clinic Charts a Needed Path to Methadone for Opioid Withdrawal
At Faster Paths, a bridge clinic for substance use disorder at Boston Medical Center, the demand for methadone treatment last year came quickly and entirely through word of mouth.
"Once we started, demand skyrocketed," says Jessica Taylor, MD, medical director of Faster Paths. "I remember coming in the second week after the official launch, and there was a queue at the door in the morning."
Last spring, the low-barrier clinic, which offers urgent, transitional care for substance use disorders, launched a new clinical pathway. According to a case study published in Addiction Science & Clinical Practice, Faster Paths may be the first bridge clinic to offer methadone for emergency opioid withdrawal management while referring patients to ongoing care.
Methadone, an opioid agonist, is a first-line treatment for opioid use disorder. Taylor calls it a life-saving treatment for a life-threatening illness. The National Academies of Sciences, Engineering, and Medicine agrees. In the U.S., however, methadone is highly stigmatized, and federal regulations restrict its use for outpatient treatment to licensed opioid treatment programs. At these methadone clinics, as they're commonly called, patients can often face long wait times and logistical hurdles to starting treatment.
There are cases, though, when methadone can be used as an emergency treatment for outpatients. These cases use what's known in federal regulations as the 72-hour rule, or three-day rule. It allows providers who do not work at a methadone clinic to administer methadone in person to relieve acute withdrawal symptoms for up to three days while linking the patient to ongoing care, (such as at a methadone clinic).
Bridge clinics offer on-demand opioid treatment
Bridge clinics are relatively new as a service model for substance use disorders. They offer a safe space for patients to work toward their goals, prioritizing patient input and harm reduction. Formed in response to the opioid overdose crisis, bridge clinics make it easier for patients to be treated without delay, providing walk-in, on-demand access to medication treatment. They are often set-up within or in coordination with emergency departments or existing programs that provide medication for opioid use disorder.
Typically, that medication is buprenorphine or naltrexone, two of three FDA-approved drugs for opioid use disorder. The third, methadone, cannot be prescribed and is, by and large, limited to licensed treatment facilities.
“Unfortunately, due to concerns about methadone's more complicated metabolism, it is typically only accessible through programs that are separate from the rest of healthcare and face more onerous regulations," says Alexander Walley, MD, MSc, director of BMC’s Grayken Addiction Medicine fellowship and medical director of Massachusetts's Department of Public Health’s Opioid Overdose Prevention Programs and the Bureau of Substance Addiction Services.
"This metabolism does need to be respected. Yet in the hands of an experienced, trained provider, it's as safe as any medication."
To date, using methadone to treat opioid withdrawal under the 72-hour rule has mostly been done in emergency departments, often during times of weather emergencies or natural disasters, when methadone clinics are closed or patients have trouble reaching a clinic, says Walley.
Among outpatient providers, Taylor thinks it's a widely held belief that the rule can only be used in the emergency department. The idea for applying the 72-hour rule at Faster Paths was born out of frustration and urgency that the demand for methadone wasn't being met.
Providing addiction support to people with COVID-19 who were experiencing homelessness further motivated the team to find a new treatment pathway.
"Many guests had opioid withdrawal and wanted to initiate methadone. But their COVID-positive status was an added barrier to the already significant challenge of starting methadone through standard outpatient pathways," says Taylor. "We learned that we needed better ways to rapidly deliver methadone for opioid withdrawal to outpatients who wanted to be connected to long-term care."
When the team reviewed regulations with the hospital's legal counsel, they realized that nothing in the rules limits the location of 72-hour rule methadone administration to an emergency department. What's more, because it's based in a hospital, Faster Paths had a lot of the infrastructure, support, regulatory benefits, and relationships with local methadone clinics to quickly get a pathway like this off the ground.
In March of 2021, Faster Paths treated its first patient with methadone under the 72-hour rule. Two months later, with clinical protocols and partner agreements in place, the pathway was ready to formally launch.
“On the one hand, it feels good to offer a service like this that isn't readily available," says Taylor. "On the other hand, what a terrible indictment of our system that we've had to create this workaround pathway to get patients access to a life-saving medication."
Fentanyl, the synthetic opioid largely to blame for the dramatic rise in opioid overdoses the past eight years, has driven the exploding demand for methadone at Faster Paths.
"What we're seeing is that methadone is more important than ever now, because of the influx of fentanyl into the opioid supply," says Taylor. "People are having a harder time starting buprenorphine because of what we call precipitated withdrawal. This happens when someone takes buprenorphine too soon after taking another opioid like heroin or fentanyl, which causes them to get sick from opioid withdrawal."
Why is the switch from fentanyl to buprenorphine tougher than the switch from heroin to buprenorphine? Research on this topic is still emerging, says Walley. But he thinks the rough transition has to do with fentanyl's interaction with body fat.
"Fentanyl is fast-acting and does not last long when taken acutely or once or twice. But it's lipophilic, which means that it can be deposited in fat tissue. We think that the buildup of fentanyl in the fat of daily users increases the risk of precipitated withdrawal when people start taking buprenorphine."
With heroin or oxycodone use, he says patients typically wait 12 hours to start buprenorphine without substantial risk of precipitated withdrawal. With fentanyl, it takes up to 72 hours or longer for many to tolerate starting buprenorphine–if they can tolerate it at all.
"Asking people to be abstinent for 72 hours is too tall of an order for those with opioid use disorder. If it was easy for them to be abstinent, we wouldn't have this problem that we have."
Six months after piloting the pathway in March, Faster Paths saw a 50% jump in the overall number of patients, according to Taylor, most of which was due to visits for 72-hour methadone. In that period, there were 150 encounters among 142 patients for methadone withdrawal management. Among a group of 121 patients referred to two opioid treatment programs, 87% attended.
"Our patients face many barriers, including high rates of homelessness, criminalization, lack of transportation, trauma, and medical and psychiatric comorbidities. An 87% linkage rate is very high, and we're incredibly excited that our pathway is getting patients to the next step of long-term care," says Taylor.
Retention rates have been promising as well: 58% of the 121 patients remained in care one month later.
"I think the early days of the pathway have demonstrated it's a needed service, it effectively links people to care, and they are sticking with their care."
Making methadone treatment more accessible is a point of advocacy for Taylor, Walley, and the team at Faster Paths. For others as well. The National Academy of Sciences Engineering and Medicine, in a 2019 report, recommended loosening regulations and allowing patients to work with their providers to decide which medication is best for them.
"We need laws, regulations, and policies that really focus on making the life-saving treatments for opioid use disorder—methadone, buprenorphine, naltrexone—available whenever and wherever people need it," says Walley.
That would mean allowing methadone in primary care and in pharmacies, as it is in the U.K., Canada, and Australia. In the U.S., the medication one gets often depends on where one shows up for care.
Using the 72-hour rule, Faster Paths has come one step closer to the truly offering patients the choice of all three medications in one setting on demand.
"Ambivalence is a hallmark of addiction. Most people with opioid use disorder have some ambivalence about continuing to use. At the same time, they have ambivalence about seeking treatment," says Walley.
"When people are open to treatment, we need to be able to offer it to them and we need to be able to offer the best treatment for them in a way that works for them."