# Methadone-involved overdose deaths in urban and rural communities before and after the public health emergency flexibilities for methadone take-home doses

## TL;DR

A policy change allowing more take-home methadone doses during the pandemic led to fewer overdose deaths in large cities but more in some rural areas.

## Contribution

This study is the first to analyze how methadone take-home dose policy changes during the pandemic affected overdose deaths across urban and rural areas.

## Key findings

- Large urban areas experienced a significant decline in methadone-involved overdose deaths after the policy change.
- Rural Micropolitan counties saw a significant increase in methadone-involved deaths without fentanyl co-involvement.
- Noncore counties had a significant rise in deaths involving both methadone and fentanyl.

## Abstract

To mitigate COVID-19 exposure risks in methadone clinics, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a temporary modification of regulations in March 2020 to permit extended take-home methadone doses: up to 28 days of take-home methadone for stable patients and 14 days for those less stable. This study examined the association between the policy change and fatal methadone overdoses across the urban-rural continuum.

This interrupted time series analysis used the U.S. National Vital Statistics System (NVSS) 2018–2022 mortality data to examine monthly trends in methadone-involved overdose deaths before and after the policy change allowing more take-home methadone doses. Deaths were stratified into six urban-rural categories and by co-involvement of fentanyl.

Prior to the policy change, trends in methadone-involved overdose deaths were either flat or declining across all urbanization categories. Following the policy change, deaths decreased significantly in Large Central Metro areas but increased in rural Micropolitan counties. No trend changes occurred in the other urban or rural categories. When stratified by fentanyl co-involvement, Large Central Metro areas experienced a decrease in methadone deaths with fentanyl, though not statistically significant, and a significant decrease without fentanyl. In rural Micropolitan counties, methadone deaths saw an increase with fentanyl co-involvement that did not reach significance, and a significant increase without fentanyl. Noncore counties saw a significant increase in deaths involving both methadone and fentanyl, with no notable change observed without fentanyl.

Results suggest the need to expand methadone access and treatment supports in underserved rural communities, recognizing that factors beyond the policy change may have contributed to the reported associations.

•In response to the pandemic, SAMHSA eased restrictions on take-home methadone doses.•We analyzed the impact on methadone overdose deaths across urban-rural areas.•Large urban areas saw a decline in methadone deaths after take-home policy change.•Some rural areas saw a rise in methadone deaths after the policy change.•Findings suggest bolstering methadone support services in rural communities.

In response to the pandemic, SAMHSA eased restrictions on take-home methadone doses.

We analyzed the impact on methadone overdose deaths across urban-rural areas.

Large urban areas saw a decline in methadone deaths after take-home policy change.

Some rural areas saw a rise in methadone deaths after the policy change.

Findings suggest bolstering methadone support services in rural communities.