Participant characteristics

Of 46 participants, half were female and half male (Table 1). Participants could choose all racial/ethnic identifiers—96% identified as White, 4% as Hispanic/Latinx, and 13% as American Indian/Alaska Native. All participants had insurance with the majority on Medicaid (89%). We asked participants their current methadone dosing regimen at time of interview—the majority (61%) received one to six take-home doses a week. The remaining participants received 13 doses every 2 weeks (19.5%) or 27 doses every month (19.5%). Participants reported recent substance use, with the majority having no past 30-day opioid (89%) or methamphetamine (93%) use (Table 2).

Table 1 Study participant characteristicsTable 2 Study participant self-reported substance use

We identified three main perspectives of COVID-19 OTP policy changes around take-home methadone: (1) Adapting to changing OTP policies throughout the pandemic; (2) Recognizing the benefits, and occasional struggles, with increased take-home methadone dosing; and (3) Continuing policies and procedures post-pandemic.

Adapting to changing OTP policies throughout the pandemicRapid implementation of early policies

In the lead-up to COVID-19 related lockdowns in March 2020, participants recounted concerns about ongoing methadone access, uncertainty about how OTPs would alter policies, and fears about the nature and severity of the pandemic. Once OTP policy changes were announced, however, participants noted their quick implementation.

…One day it was like boom. Everything changed. They kind of worked us up into things might be changing a little bit…giving you the heads up that this COVID thing is getting kind of serious, but they didn't over-react. They didn't panic… They were just really afraid that this COVID was going to take us all out, you know? – [53-year-old woman, P4]

Participants noted rapid roll-out of extensive safety precautions, which they followed to keep themselves and others safe. One participant stated that “no employees or no patients have gotten [COVID] yet so I guess either we have gotten lucky or something is working” [49-year-old man, P39]. While inconvenient, participants mostly reported abiding the safety rules.

Sometimes you don't want to wear a mask, it's suffocating…[but] It's just part of what's going on. If we want to be safe and not catch it, then that's it. I don't want to give nothing to nobody and I don't want to catch nothing. So I'll go with the program…do what I got to do, just to keep safe. [48-year-old man, P2]

Settling into OTP policy changes and new requirements

Participants noted that new policies quickly seemed routine—wearing masks, answering screening questions, and practicing social distancing.

Now everybody is kind of used to it…secondary motions now—are everyday things. It’s like everybody wearing a mask, it’s like [at the beginning], ‘haha what are you doing?’ and now everybody wears them. It’s just natural now. – [53-year-old woman, P4]

…When it first happened, it had us all on edge, but I think that as time goes by and…our daily life adapts to it, I think that we just have a healthy respectful fear of [COVID-19], but we have learned to deal with it. – [41-year-old man, P12]

Rolling back of COVID-19-related increased take-home doses

A few participants from one OTP voiced frustrations about being given increased take-home doses which were rolled back to their prior, pre-COVID, regimen. This policy change happened at the OTP-level around June or July 2020.

I don’t like [going from one month to 2 weeks] at all but, honestly, you don’t rattle the cage too much…I feel kind of put upon in a way because…I shouldn’t be in there with all the people. I am staying away from the grocery stores and everything but my methadone—of course. Anyway, I am not happy, but I’m not mad either. Just disappointed …They said COVID was over basically, I think COVID’s worse than ever. – [64-year-old woman, P19]

Well, personally I think they should have stayed on getting us more take outs… not very long ago they switched back to every day and it seems like the people that were doing good … it seems like they would stay with that because the outbreak isn’t over by any means. – [27-year-old man, P21]

Recognizing benefits, and occasional struggles, with take-home methadone dosing

Participants rarely reported challenges with self-managing increased take-homes. They noted using lockboxes—either self-purchased or provided by OTP staff— and following instructions for dosing.

I really don’t have a challenging part. I thought it went very easy. When I took one I saved the bottle, when I take the next one I save the bottle and I bring those back show them to the nurses…So I wouldn’t even really say there was any difficult or frustrating parts to it to be quite honest.” [27-year-old man, P22]

Overall, participants recognized how increased take-home doses, and thus coming to the OTP less frequently, had the anticipated outcome of reducing risk of spreading COVID-19. “Not having to come here [to the OTP], that right there is probably the best protection [from COVID] you can get.” [44-year-old man, P30]. Participants shared additional benefits beyond reducing infection risk by having increased take-homes earlier than they would have under pre-pandemic protocols.

Enhanced self-esteem and feelings of normalcy

Receiving increased take-homes, with the added responsibility to manage their medication, resulted in feelings of pride for some participants. These participants valued the trust their OTP was giving them, which gave them more self-confidence.

I didn’t feel nervous… that I would take them all at once or have trouble taking them every day. I didn’t feel like I wasn’t being monitored properly because I wasn’t coming into the clinic all the time…When you get your take-homes it’s like you feel you are being trusted to take care of yourself, and do the right thing…it felt great…that I was on the right track in my recovery. – [39-year-old woman, P29]

Participants also valued how increased take-homes, and reduced OTP visits, provided them with a sense of normalcy and stability.

[I am] able to live a normal life without having to come in every single day. I have a baby at home and stuff so that’s initially why I joined the clinic…Not having to come in. I feel a little more independent. I feel when I do get a job it will be a lot easier…I just enjoy being able to be more like a normal person, just having my medication at home. [31-year-old woman, P15]

Reinforcing and supportive of recovery

For some participants, having more take-homes supported their ongoing recovery through a sense of accomplishment and reward.

I get all these take-homes and then soon in 53 days, I will get a month worth of take-homes. I will only have to come in once a month and that will be great…I don’t have to stop what I am doing to come in to dose. And it also helps me with my recovery just to get these benefits of take-homes…It makes me feel proud of myself. – [39-year-old woman, P9]

Other participants found that spending less time in the OTP helped their recovery as staying home allowed them to avoid unstable patients. Seeing “people that aren’t staying clean and can be nodding out” was triggering for some participants to “go get high” – [60-year-old woman, P33].

Unfortunately, the people who come here…my old people [are] the people you try—necessarily to not spend that much time with anymore…I like to try to stay away as much as possible. I’d rather not see a lot of them if I don’t have to…Especially since I have been doing good for a while, kind of earned it anyways so I felt safe from my sobriety. It worked out good. – [38-year-old man, P35]

Reclaiming time spent traveling doing other rewarding activities

For participants, many of whom lived far from their OTP, increased take-homes significantly reduced time traveling and was helpful for those who “can’t afford the gas to get [to the OTP] every day”—[29-year-old woman, P20]. Participants noticed reduced stress with not needing to “[get] up an hour earlier every day” in order to dose before work— [45-year-old man, P14].

With the added time, participants shared engaging in rewarding activities. Living in rural communities, many chose to spend time outdoors:

I was able to go camping with my mom and not have to worry about asking for extra doses. I went and saw my son and I didn't have to ask for extra doses 'cause I already had them. Just made it a little easier. A lot easier. – [51-year-old woman, P18]

It gives me a little break. [I can do] other things, like going to the river. I went and floated this weekend, and just hanging out with dad and barbecuing and doing yard work and stuff like that. – [48-year-old man, P2]

Participants with children, particularly women, noted significant benefits to increased take-homes – not needing to arrange child care and having more time for family.

I am a single mom and…especially now that I am back to work, it is nice and convenient for me because I have to be to work at a certain time and it's hard for me to guarantee that I can get in [to the OTP] as often…it's definitely made it easier. – [33-year-old woman, P11]

Struggles with take-home methadone

While most participants expressed success with increased take-homes, a few participants acknowledged challenges others may have experienced. “I know from talking about it in group, some people can feel overwhelmed with all the take-homes and some people don't trust themselves.” – [38-year-old woman, P29].

A couple of participants expressed personal concerns around receiving increased take-homes including “start[ing] to feel almost complacent in a sense, that there wasn't any effort that I needed to put into obtaining my medication” [29-year-old man, P10] or being too early in methadone treatment.

Now, I like coming in everyday because I think it keeps you on track…I think it's better for people at first…I wasn't even getting take-homes, and all of a sudden here I am getting two weeks of my medicine so it was kind of a lot…For me it just wasn't good at the time because I was still pretty new in my sobriety, you have to trust in yourself and everybody is different. – [44-year-old woman, P25]

Continuing policies and procedures post-pandemic

OTPs nationwide made numerous COVID-19 related policy modifications including increased take-homes, workflow improvements, social distancing, and disinfecting protocols [28]. These changes were intended to prevent COVID-19 infection—to keep patients and staff safe. Participants were asked to provide their perspectives on what clinic policies and changes might be helpful to maintain after the pandemic passed.

COVID-19 protocols could prevent spreading other infections

Clinics implemented changes to minimize viral spread including plexiglass shields, limiting numbers of individuals in waiting rooms, increased sanitation procedures, and required face masks. Overall, participants thought maintaining some of these safety measures after the pandemic passes would be wise, given they also prevented other infections.

I think that they still should have the glass shields…I mean, [it’s] not just COVID, you can still get the flu from people. For somebody like me, getting the common cold can be-- that's what I went to the hospital for, my grandson gave me the rhinovirus which is the common cold. So, it's not just COVID. – [49-year-old woman, P44]

This, in turn, meant they were less likely to spread infections to others, particularly family members and children.

The fact that it's limited amount of people, not so crowded in here, you know? So I feel a lot more comfortable sitting in here waiting when it's not as many people and for the fact of not spreading any diseases or colds. – [29-year-old woman, P20]

Social distancing created a more supportive environment for recovery and mental health.

Participants also noted unintended positive effects of social distancing – less people in the waiting room –reduced crowding created a healthier mental health atmosphere.

I like how it's not as crowded…That's nice because when there [are] too many people in the waiting room, it triggers anxiety and it does a lot on the head. PTSD sort of type thing when everybody gets loud…So now…it's usually pretty quiet and not hectic. – [29-year-old man, P16]

Some participants noted that less intermingling had reduced confrontations and would be a worthwhile policy to maintain beyond the pandemic.

[I would continue] the social distancing, just making sure that there's not a lot of people in the waiting areas. It gets crowded and people are standing and people that don't get along here so it causes more problems… [this is] a small, community… a lot of people know a lot of people -- some people that go here that are still in the addiction…you always see someone that you know or that you have a problem with. So a lot of fights seem to happen. – [31-year-old woman, P3]

A few participants noted how social distancing, particularly requiring people wait outside, might need reexamining during inclement weather conditions. Waiting room capacity limits would, at times, necessitate clients queuing outside. Participants noted that other workflow streamlining were generally moving patients more quickly through daily dosing procedures—“in and out”—which was an improvement “that works out for everybody”— [53-year-old woman, P4].

Desiring of more tailored, individualized OTP services

With many participants experiencing added benefits of take-homes, but a few needing or wanting more support, the COVID-19 pandemic highlighted to participants the previous inflexibility of federal guidelines. Some participants expressed hope for more individualized care in the future.

I would like to see is maybe not having to come in quite as often…Everybody is different. Everybody should be looked at on an individual basis…maybe the people who make their appointments, the people who are making an effort to make a change, and that are certainly trying to utilize the program…I would hope for…less having to come in just to dose. I don't mind taking seven days at a time. I was okay with the Monday, Wednesday and Friday. I thought that was very fair because I was still able to have contact with counselors…even if I didn't have an appointment. – [27-year-old man, P22]