Innovative Strategy

  • “72-hour rule methadone” is an exception to federal regulations that allows non-opioid treatment program (OTP) physicians to administer methadone for up to 3 days to a patient presenting in opioid withdrawal while ongoing treatment is being arranged.
    • Medications must be administered (i.e., given under observation in the ED/clinic), not prescribed.
    • No more than 1 day’s medication administered at one time unless the provider applies for a waiver and then they can dispense (but not prescribe) a 3-day supply.
  • Methadone is highly effective treatment for opioid use disorder (OUD).
  • Outpatient access to methadone for treatment of OUD is limited to highly regulated OTPs with many barriers to admission, including long waitlists in some regions.
  • Use of illicitly manufactured fentanyl may make buprenorphine inductions more difficult and the treatment less acceptable.
  • Improving access to methadone is an important equity goal, as Black patients, people experiencing homelessness, and people with criminal-legal involvement experience higher barriers to OTP entry and retention.

Potential Benefits to Community

  • Expedite access to long-term methadone treatment at OTPs.
  • Provide up to 72 hours of clinical stabilization and support to patients who face barriers to enrolling in OTPs via traditional pathways.
  • Flexibility to treat opioid withdrawal with clinically appropriate dose of methadone (i.e. not limited to OTP dosing guidelines).
  • Reduce ongoing opioid use and overdose risk.
  • Reduce avoidable ED presentations.

Estimated Time from Planning to Implementation

~ 4 months

Cost Considerations

  • Cost of automated medication dispensing cabinet that interfaces with electronic medical record (EMR) if not able to use existing cabinet EKG machine, if not already available
    • Baseline EKGs are required in some clinical circumstances for OTP referral Cost of IT analyst time, if required
    • Set up interface between medication cabinet and EMR if new to your setting
    • A way to enter patient photos and scan IDs into EMR also helpful, but not required
  • Pharmacy support for medication inventory
  • Any additional provider, nursing, case management time needed to support increase in clinic

Operational Considerations

  • Need to establish a network of partner OTPs to receive referred patients as “direct admissions”
  • May require affiliation agreements
  • Leverage existing navigation infrastructure: recovery coaches, nurses, social work staff
  • Need infrastructure to securely store methadone on-site with protocols for inventory, waste and administration documentation in the EMR
  • Confirm appropriate facility licensure
  • Lawyer at hospital to review DEA guidance and approve practice

Evaluation Metrics

  • Number of people treated under the 72-hour protocol
  • Proportion of people initiated who linked with community OTP

Acknowledgements

We wish to express our thanks to all community partners who have implemented these programs during the HEALing Communities Study. Key insights from these partners were crucial in the development of these resources that will be important tools for programs looking to build on the successes of these strategies to reduce fatal overdoses

Publications