BOSTON – According to a new study from Boston Medical Center’s Grayken Center for Addiction, methadone administration for opioid withdrawal with direct opioid treatment program admission under the “72-hour rule” is possible in an outpatient bridge clinic and resulted in a high number of completed referrals to opioid treatment programs, along with high one-month retention rates. The findings in Drug and Alcohol Dependence show that a hospital-based bridge clinic model of care has the potential to improve methadone access amid the highest rates of opioid overdose death in U.S. history.
The CDC estimates that more than 80,000 people died from opioid overdose in 2021, with the majority of deaths attributed to synthetic opioids, like illicitly manufactured fentanyl. Despite this surge, access to evidence-based treatment for opioid use disorder, including medications for opioid use disorder, remains inadequate.
Methadone for opioid use disorder treatment is restricted to licensed opioid treatment programs with substantial barriers to entry. One pathway to methadone administration outside of treatment programs is the “72-hour rule” – a federal regulation that allows other providers to administer methadone for opioid withdrawal symptoms for up to 72 hours, while arranging referral for ongoing treatment. Many providers are unaware that administering methadone for opioid withdrawal management is permitted under this regulation, and those who are aware may assume that this use is limited to emergency departments, though federal regulations do not limit the care setting.
In March 2021, Boston Medical Center’s Faster Paths, a low-barrier, hospital-based, outpatient substance use disorder bridge clinic implemented a new pathway to treat opioid withdrawal and facilitate treatment program linkage under the 72-hour rule. Patients with opioid use disorder experiencing opioid withdrawal were offered emergency opioid withdrawal management with methadone administered in the clinic for up to 72 hours, while simultaneously addressing medical and psychiatric conditions, providing nurse care management, and rapidly referring them to local opioid treatment programs for ongoing care.
In the study, methadone was administered during 150 episodes of care for 142 unique patients, the majority of whom used fentanyl. In 92% of episodes, a plan for ongoing care was in place within 72 hours. Among the 121 patients referred to primary opioid treatment program partners, linkage (87%) and one-month retention (58%) rates were high. The observed rates of successful linkage and one-month retention were significant considering the complexity of barriers faced by this population.
“This study highlights both the lack of adequate access to methadone for those who could benefit from it and the significant potential of using the 72-hour rule to provide low-barrier pathways to methadone,” said first author Jessica Taylor, MD, the medical director of Faster Paths at BMC’s Grayken Center for Addiction, and an assistant professor of medicine at Boston University School of Medicine. “We need federal regulatory reform to reduce the barriers to methadone treatment entry. And, with opioid overdose death rates higher than ever, it is also critical that we take advantage of pathways, like the 72-hour-rule, that are allowed under current regulations.”
These results demonstrate that offering emergency methadone withdrawal management and opioid treatment program linkage in an outpatient bridge clinic is both feasible and results in timely access to methadone treatment. There is substantial untapped potential to expand rapid methadone access by scaling up 72-hour methadone pathways to bridge clinics, emergency departments, and other outpatient medical settings.