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.