In cities across the country, morning is peak time at almost any opioid treatment program. The line stretches from the front counter to the back door as patients wait to get their daily dose of methadone. It’s an absolutely essential gathering, but one that runs counter to containing the Covid-19 outbreak.
Efforts by health systems and governments to contain the spread of SARS-CoV-2, the novel coronavirus that causes the disease, have revealed gaping cracks in our nation’s public health and safety net infrastructure. The virus appears to have an outsized effect on vulnerable Americans. We have already seen in a Seattle nursing home how quickly the virus travels in close quarters. It is likely to do the same among the homeless and those who are incarcerated. Missing from the national discussion has been another vulnerable group: patients like ours with opioid use disorder.
Despite ongoing public health efforts, the opioid overdose crisis does not appear to be slowing down. The emergency of Covid-19 could worsen it if we do not preemptively develop and implement response plans.
The Centers for Disease Control and Prevention currently recommends social isolation as a key measure for individuals to prevent getting infected and to curb spreading it to others. Many patients taking medications to treat their opioid use disorder — methadone or buprenorphine — aren’t able to stay home because of government regulations that limit how these medications are prescribed and dispensed.
In the United States, methadone can be dispensed only at highly regulated and monitored opioid treatment programs. There are more than 1,250 such programs across the country that treat more than 350,000 people. Strict rules require most of the people to show up at the program every day to get their dose of methadone. A single opioid treatment program may see thousands of patients a day, a scenario that could foster the spread of the coronavirus.
How will these patients stay safe? Although the Substance Abuse and Mental Health Services Administration (SAMHSA) recently released a guide for opioid treatment programs dispensing methadone during the Covid-19 outbreak, implementing the guidelines is contingent on state regulations and falls short of what is needed.
In the past, experts have called for updated regulations that allow office-based methadone treatment, but nothing has budged. There is now an urgency for this change to occur.
In the setting of an outbreak of a highly contagious infectious disease, requiring patients with opioid use disorder to come to an opioid treatment program to get the medication they need to fight their addiction could have two negative outcomes. First, individuals will continue to come and get their medication even though they have symptoms of Covid-19, possibly exposing other patients passing through the program and the medical staff caring for them to the virus. A second possibility is that individuals will not — or cannot — come because of infection, leading to missed medication doses followed by opioid withdrawal and increased risk of recurrent drug use and overdose.
Both outcomes would harm our patients. And if SARS-CoV-2 continues to spread, it will not be a matter of whether an outbreak will occur at an opioid treatment program, but when.
To reduce patients with symptoms from infecting others, outpatient clinics and urgent care centers have ramped up the use of virtual visits and insurance companies are expanding coverage for them. Federal agencies could mirror this approach by changing policies regarding methadone during a state of emergency. They could make it possible for clinicians to use virtual visits to evaluate patients, allow all patients to take additional doses home, make it possible for surrogates to pick up doses when someone is ill, or deliver doses to those unable to come to the clinic.
The SAMHSA guidance includes some of these options for individuals who are quarantined or those with known exposure or symptomatic infection. Yet given what is known about community transmission of infectious disease and the need for social distancing, limiting these options just to those with likely or known infection won’t be enough to limit spread.
Federal regulation of methadone for OAT has been, and continues to be, dangerously over-restrictive. This new SAMHSA guidance, as usual, errs on the side of restricting access. Even in a pandemic "diversion" control is Priority One. https://t.co/OPayMInRPj
— Corey Davis (@coreysdavis) March 16, 2020
In Canada, pharmacies can dispense methadone. Federal agencies could allow U.S. pharmacies to temporarily do the same if an opioid treatment program shuts down due to an infectious outbreak or other unforeseen circumstance.
Natural disasters and emergencies can significantly disrupt manufacturing and distribution. After Hurricane Maria ravaged Puerto Rico, shortages of medically necessary intravenous fluids occurred in the U.S. The global spread of SARS-CoV-2 will likely lead to disruptions in drug and medication supply chains from outside the United States. For individuals with opioid use disorder, not being able to get a dose of buprenorphine or methadone could result in withdrawal and return to substance use. Government agencies and systems must act now to ensure adequate supply of lifesaving medications for opioid use disorder.
In case of quarantine, patients have been advised to “stock up” on their medications, an option that isn’t available to those with prescriptions for controlled substances like methadone. Regulators must consider granting patients on controlled substances longer prescriptions in preparation for shortages or challenges with accessing the health care system.
During unprecedented times such as a global pandemic, established protocols need to be modified to best serve patients and limit potential harms. Patients with addiction and their doctors deserve clear guidance about how to stay safe during such times.
Ximena A. Levander, M.D., is an addiction medicine and clinical research fellow at Oregon Health and Science University in Portland, Ore. Sarah E. Wakeman, M.D., is an addiction medicine physician at Massachusetts General Hospital in Boston, medical director of the hospital’s Substance Use Disorders Initiative, program director of the MGH Addiction Medicine Fellowship, and assistant professor of medicine at Harvard Medical School.
I am currently trying to quit heroine yet also think I might have Corvid-19. I do not know who to turn to in order to get help. I am starting to develop a cough and am extremely nervous on who to turn to. I don’t know who to contact and am personally very embarrassed to show up to a dr and say “Hey I think I might have Corvid-19 and also trying to get off heroine.” If someone could help point me in the right direction it would be greatly appreciated. I just don’t know how to go about this. Thank you.
I wish that was the case but today I asked my clinic if they can give me take homes and they said no. My response was so u guys are giving people take homes who failed drug tests for meth but not me?, They tried to tell me I failed my first test when I first started going to the clinic which is not true because I actually had gotten a script from the ER.. I feel like a lot of the people who work there are very judgmental.
My thoughts on this situation is more then a thought but rather a opionin. Give the clinics patients a two week subscription. Maybe even the patients a pill form script for methadone for a months time. Let them pick up the scripts once a week Hope things work then selves out. I’m Buffalo NY one clinic has given a two week script of the methadone and another still has people going every day. It should all be longer doses so we can prevent spread of this sickness. Thank you for asking for a comment on the matter. Good bless and pray for a cure soon
The rules are changing. Hold tight and understand that you do get medication from a medical facility. The reason things are changing is to save lives. No one is going to put all of your lives in danger in order to save other lives.
Many clinics are already implementing the new rules and guidelines, just as different states started implementing different measures to keep people safe your clinics will do the same. It may not be all at once but it will happen.
As for those who are commenting completely made up numbers about personality disorders or talking about addicts being compulsive liars, it’s those false stigmas that need to change. We are surrounded by addicts who live very normal and productive lives. Methadone does not get people high. Yes, it’s physically addictive but so are many many medications everyday people take.
There are many people on methadone who live completely normal lives. It doesn’t matter the reason they started on methadone to begin with, it matters what they did afterwards.
People who do the best on methadone and are able to eventually taper off are often those from supportive middle class families. That is a good indication that it’s not about the addict, it’s a support and poverty issue. Trying to bash anyone who is already scared because they need to function says a lot more about you than them. These people need support and like everyone they need to know their basic needs are being met. Yes, methadone and other medications are a basic need.
Thank you for the most comprehensive and understanding article to date I’ve ever read about MAT and safety amidst novel covid…. I was a loud voice advocating for something to be done during this crisis (novel Covid) as I have stage 3 cancer and am petrified to go into the clinic. I’ve earned the privilege of a 3 day a week schedule…my stage 3 cancer makes these visits wrought with anxiety. People are STILL coughing all over and being sick…not taking ANY precautions because they are so IGNORANT!!! The clinic has signs EVERYWHERE as to how to hand sanitize properly and cough into their sleeves…..yet..some just go on in their ignorant little worlds, acting like idiots, jeopardizing everyone else. Thank you to whom ever finally made the decision to treat us (methadone treatment folks) like human beings. We are that. And some of us, are much more than that. Peace,love and safety to all
You have just said everything I wish I could of. Thank you for that. You really helped people on here to think in a positive an constructive way. Good bless and from my family to yours stay blessed and stay safe. Take care. Ty again.
OK fine heroin users or injecting drug users treated with methadone often have antisocial personality disorder (impulsiveness, dishonesty, self centered) click the link if you want. Mr. Macneil, I also find it useful to observe and think about what dozens-hundreds of these patients do and seem to have in common and say gee could this be related? After all heroin users become antisocial and methadone is a more powerful opiate… only unlike heroin it gets so deep into their bodies it even gets into their bone marrow and effects them sexually or how about the fact when some come off they say its like a bad acid trip boy it sounds like it effects their minds doesn’t it?
I am deeply concerned about this. My daughter has hep C and TB and a 3 year old and is off the the clinic stuffed in a room with no ventilation where she also contracted TB. She has been stable in methadone for years. This is St Joseph’s Hospital Clinic in Yonkers, NY. What do we do ~ who do we contact? Thank you for thus piece butbi am feeling as helpless as they are.
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