Fentanyl overdose deaths have surged during the coronavirus pandemic, likely driven by isolation, disrupted life routines, and decreased access to opioid use disorder (OUD) treatment and harm reduction services. Data from the Centers for Disease Control and Prevention show 2020 opioid overdose deaths rates in most U.S. states to be the highest in history [1], including in Massachusetts [2].

Methadone, a first-line medication for OUD, reduces all-cause and overdose mortality [3], increases treatment engagement, and prevents harm related to injection drug use, including HIV and hepatitis C [4, 5]. Patients face multiple barriers to accessing methadone in the U.S. Since methadone first became widely available for OUD in the 1970s, methadone for OUD is only available to outpatients through opioid treatment programs (OTPs). The Drug Enforcement Agency and the Substance Abuse and Mental Health Services Administration license and certify OTPs, respectively, and set detailed requirements for clinic characteristics, patient eligibility, dosing standards, observed dosing, and counseling [6].

The number and capacity of OTPs nationally is insufficient [7]. Restrictive zoning regulations, insufficient insurance coverage, and understaffing contribute to inadequate capacity, which can lead to long waits for intake appointments. Rural areas are particularly underserved, and patients may need to wait more than a year and commute long distances to access an OTP [8]. Delays in treatment increase the risk of continued drug use, infectious complications, and overdose death while decreasing the likelihood of eventual treatment initiation [9]. Black individuals, persons experiencing homelessness, and those with criminal justice involvement experience even higher barriers to methadone for OUD [10, 11] contributing to racial, ethnic, and socioeconomic treatment inequities.

The “72-hour rule” (Title 21, Code of Federal Regulations, Part 1306.07(b)) provides an important exception to the requirement that methadone for OUD only be provided outpatient in licensed and certified OTPs. This exception allows physicians who are not registered as an OTP to administer “narcotic drugs to a person for the purpose of relieving acute withdrawal symptoms” for up to three days while arranging for ongoing treatment [12]. The medication must be administered directly to the patient and cannot be prescribed, and no more than one day’s medication may be administered at a time. To date, the 72-hour rule has been used primarily in emergency departments (EDs). Note that for inpatients admitted to the hospital for medical or surgical problems, there are no limits to administering methadone for withdrawal or OUD [12, 13].

Substance use disorder (SUD) bridge clinics [14,15,16], many of which are hospital-based, provide low-threshold, on-demand access to medications for addiction treatment and may have the clinical infrastructure needed to administer methadone for emergency opioid withdrawal management. Bridge clinics also have strong connections to community partners and expertise in linking patients to long-term OUD care. Thus far, bridge clinics have focused on low-barrier buprenorphine access. To our knowledge, there are no published examples of bridge clinic administration of methadone for emergency withdrawal management with linkage to long-term methadone treatment.

Application of the 72-hour rule in the bridge clinic setting promises benefits for patients. Rapid, low-barrier opioid withdrawal management can reduce ongoing opioid use and overdose risk, decrease avoidable ED presentations for opioid withdrawal, facilitate timely OTP referrals, and allow time to address barriers to OTP linkage. Here, we describe the first case of methadone administration for emergency opioid withdrawal treatment and direct OTP linkage in Faster Paths, a low-barrier outpatient bridge clinic at a safety net hospital in Boston, MA. The patient provided informed consent to publish this case report.

Faster Paths opened in 2016 and serves approximately 650 patients/year, offering rapid access to medications for addiction treatment; HIV, hepatitis C, and sexually transmitted infection prevention and treatment; harm reduction services; and linkage to long-term MOUD treatment and community resources [16]. At the time of this case, medication services included buprenorphine and naltrexone for OUD; naloxone for opioid overdose reversal; naltrexone, acamprosate, and disulfiram for alcohol use disorder; and outpatient medical management of opioid, alcohol, and benzodiazepine withdrawal. The clinic is staffed by internal medicine physicians, many of whom are board certified in Addiction Medicine, nurse practitioners, a nurse care manager, and rotating fellows and residents. Referral sources include the ED, local addiction treatment and harm reduction programs, word of mouth, and the inpatient Addiction Consult Service.