The present study approached the issue of the impact of the COVID-19 pandemic, which has led to date to three quarantine periods and to restriction measures characterized by social distancing and housing isolation, on the management and administration of received MOUD by patients under MAT. The main findings indicate that the management and administration of MOUD by patients themselves during prolonged periods of quarantine were affected by sociodemographic variables, such as “Age”, “Educational status”, “Place of residence”, “Security level” and “Years in OKANA”, as indicated through alterations in the dimensions “Substitute administration and pandemic measures”, “Mood” and “Biopsychosocial support” and “Accessibility to the therapeutic programs”. Furthermore, patients under MMT were able to cope with dimensions “Mood”, “Sociability” and “Substitute administration and pandemic measures” compared to their BMT counterparts.
According to the literature, patients with OUDs have been affected by the COVID-19 pandemic and subsequent restriction measures to a great extent, experiencing increased stress, loneliness, and insecurity, as well as serious health concerns due to opioid use (Tracy et al., 2021). Furthermore, factors that exacerbate the negative impact of COVID-19, such as social stigma, lack or restriction in the availability of MAT program services (i.e., medical care and psychosocial support), and residency in rural areas, appear to have a negative impact on treatment retention and overdose prevention (Corace et al., 2022; Krawczyk et al., 2022; Lister & Lister, 2021; Nunes et al., 2021; Rosenblum et al., 2011). Moreover, changes in mood are directly linked to factors such as stress and craving and could potentially encourage members of a vulnerable group (e.g., OUD patients) to use alcohol or drugs to cope with the COVID-19 pandemic (Taylor et al., 2021). Additionally, changes in mood state were observed in BMT patients, which is in line with recent results prior to the pandemic era in OUD patients. These changes were positively related to educational status and negatively related to security level, whereas higher educational status was accompanied by enhancement in mood for seeking drug substances and parallel illicit drug use in BMT patients. The insecurity was linked to mood, a result that is in agreement with research findings that have indicated the relation of bad mood with the administration and retention in treatment leading BMT patients to dropout from MAT programs (Hser et al., 2014; Mattick et al., 2014; Panlilio et al., 2019). However, to our knowledge, herein is presented for the first time relevant evidence regarding patients under MAT during the COVID-19 pandemic.
Conversely to BMT patients, pandemic restriction measures seem to affect MMT patients to a greater extent in the PANMAT/Q dimensions “Substitute administration and pandemic measures”, “Biopsychosocial support from the therapeutic programs”, “Sociability” and “Accessibility to therapeutic programs”, which are correlated to variables, namely, “Educational status”, “Security”, “Chronic disease” and “Years in MAT programs”. These findings indicate that MMT patients can more efficiently cope with the intention often encountered in patients to self-manage their substitute administration under stressful periods that can easily lead to overdose risk. Similarly, the dimension “Accessibility to the therapeutic programs” was related to the magnitude of the buprenorphine dose. In particular, the patients receiving higher doses faced more intense accessibility difficulties. In this context, it has been implied that financial stressors, social isolation and disruptions in the MOUD supply chain increase the social vulnerability of patients under MAT, leading to MOUD manipulation and poor outcomes of the medication (Bart et al., 2022).
The findings of the present study have revealed that many stressors and social variables potentially lead to manipulation of the MOUD by patients themselves, which is in line with recent data that have demonstrated increased dispensation of MOUD during the COVID-19 pandemic (Haggerty et al., 2022). Indeed, barriers to retention on treatment, including stigma, lack of treatment availability and lack of biopsychosocial support, led to drug-seeking behaviors and dropout from MAT programs (Nunes et al., 2021).
Although methadone and buprenorphine are key substances widely applied as treatments in OUD patients, lowering craving, stress and depression, MAT patients were marked with high levels of psychological consequences that provoked social disruptions during an outbreak such as the COVID-19 pandemic (Liu et al., 2021). The adverse effects of stress are mediated through the reward system, leading to the activation of biological factors (i.e., corticotrophin-releasing factor, cortisol, pro-inflammatory agents), which promote the development of negative emotions interrupting the decision-making process and increasing the risk for relapse and overdose (Bardo et al., 2021; Liu et al., 2021; Ruisoto, & Contador, 2019). Research findings imply that there is an underpinned relationship between drug dependence and environmental factors interacting with psychoendocrine systems, as these systems have been demonstrated to be more sensitive to social disruptions with a dysregulation of hippocampal glucocorticoid receptors (Ajonijebu et al., 2017; Fattore & Melis, 2016). Furthermore, the interaction between socioeconomic level and DNA alterations has been demonstrated and indicates the impact of environmental stimuli on the physiological and behavioral responses related to drug-seeking regimens (Ajonijebu et al., 2017). It has been shown that craving and drug-seeking behavior that are triggered by social factors, such as social isolation, induce neurogenic changes in the function of domanimergic and serotonergic systems that potentially lead to modified neurotransmission (Araujo et al., 2005; Matsuda et al., 2001), affecting retention on treatment and increasing the risk for relapse.
Indeed, the COVID-19 pandemic is not the first extreme situation with a severe impact on MAT patients and services. Previous studies have shown that natural disasters, socioeconomic and health crises were correlated with disrupted MAT services, the emergence of barriers confining access of the patients to clinical settings and the lack of clinical planning resulted in increased drug use, especially when medication access was interrupted (Bart et al., 2022; Maxwell et al., 2009; Pouget et al., 2015). Of note, extreme or disastrous situations are accompanied by disruptions in several social parameters whose consequences last for many years, influencing vulnerable populations in their societal progress or integration (Friedman et al., 2006).
Several aspects of our study may limit the generalizability of the findings. First, there was a difference in the population of MMT and BMT patients. Second, our sample lacked racial diversity (most of them were Greek) and adult participation. Finally, the results related to MOUD manipulation did not intersect with urine results to exclude concurrent illicit drug use.