Skip to Main Content

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.

advertisement

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.

advertisement

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.

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.

  • The most progressive guidance in history was issued to OTPs from SAMHSA that isn’t mentioned here, allowing 14-28 days pretty much across the board is needed (see https://mailchi.mp/e74a2d86f8aa/covid-19-guidance-from-samhsa-and-dea). SOTAs across the county are approving this language. The problem resides with the PHYSICIANS who aren’t wanting to approve these take-homes. We are also getting mass reports to NAMA of OBOT buprenorphine docs not wanting to write more than 1 week Rx of buprenorphine and using re-fills (that still require pharmacy visits) vs. writing for 4 weeks. This is a problem with physicians – not the system. The system is allowing liberal TH dispensing. Docs won’t do it!

  • I am 65 years old and have to drive 50 miles to my clinic and back. I have one week take homes now. I called Monday and told my counselor that I live in a senior citizens building on lock down. My counselor did not care… she stated if I did get sick they would dose me at the hospital when treated for the virus. WTF? I have had no relapses or dirty drops in 18 years in this state. I get only a week take homes because that is all Indiana allows they say, even with my 18 years of compliance on methadone. No need to tell you this drug saved my life and my childrens lives, many of us know this to be true. My counselor was not even in today so I got to talk to another one which is going to see about getting an exception for me to not have to go there and possibly bring back a virus back to my neighbors who are all seniors. I always knew we were thought to be a lower class of citizen but Darn..do they not even care about themselves? They are putting their health in danger at this time as well!

  • My daughter has a heart condition and still has to go to clinic daily. Not safe for her!

  • I go to a clinic in Marion,Indiana and at any given time there is a line of 40 or more even though they only let 6 people in at a time there are still huge crowds lined up head to head so it really does not make a difference if they keep u outside or inside if your in groups ur chances of getting sick is the same… I don’t understand why everyone else can get months worth diabetes medication high blood pressure medication heart medication antibiotics but we as methadone users have to go skiing in these lines everyday and take a chance I’ll take it and back you are family I have a mother that’s really ill that lives with me 4 kids ranging from 14 to 2 years old and a wife that is paralyzed and losing brain function from GOD only knows what the Dr.s say they can’t really find out what is wrong with her that I also have to get to the clinic everyday by carrying her down the stairs with help of two or three other people getting her into the car what’s her screaming in agony it’s like we’re a bunch of criminals. I respect anybody that’s went to a substance abuse or treatment center to get better and get help but the nation looks at us like we’re nothing but a bunch of drug addicts and criminals because we’ve done this they need to educate ourselves a little bit if it wasn’t that been for the methadone clinic I would have been dead or in prison buy children would have no father I would have nothing so it has saved me.. the point I’m trying to make is we are people too and we deserve to get our medication in increments to take home and be safe just like everybody else in America I would feel horrible taking this disease back to my mother or my two-year-old daughter and have to bury them just because I couldn’t get a take home it is inhumane..for everyone out there that’s in substance abuse and addiction treatment therapy I respect you so much and I’m praying you all stay safe

    • How about the poor drunks with liquor stores all shuttered in various locales? They may riot and break into liquor stores, make moonshine and drink rubbing alcohol etc. We need to make methadone treatment for addicts as easy as possible just like need to make booze available for drunks who need to prevent DTs.

    • I read your post and I am so sorry for what you have to go through to get your medication. I am on a clinic as well and today they started giving 28 take homes to people with 5 or 6 take homes already. Doing this made the waiting in gatherings incredibly long and crazy. It’s long and crazy anyway but it’s much worse due to the people leaving with take homes. Everyone else has to continue to go daily. Which is kind of crazy. Why dont they just do 5 or 6 take homes to start and stagger the traffic a bit. It’s too crazy for everyone to come the same times to pick up when necessary. So I think if they did like 50 ppl a day w take homes we might have a better chance of keeping ppl safe and apart. I am proud of anyone that it doing the program and changing their life. Your seem like an amazing parent and husband and son. Keep on keeping on. Stay safe.

    • We are in New Haven ,ct and all the clinics are backed up because less and less staff are showing up to work.we are in line waiting with 20 or more people toget dosd,,all that it takes is one person to infect the 1,800otherclinic members!!! But it seems the government wants to thin Us out ,so they don’t want to give us take home bottles…which puts a very large part of every community at risk and severely risks spreading the virus!

    • I agree 100%… I go to a clinic in Toms River, NJ and they too have us daily reporting. Unlike your building our building only has 6-10 people waiting at any time, the turn around rate is crazy tho they just get them in and out super fast. However every time I come here I break my self quarantine. I wish they would just give us bottles already and stop this nonsense I am beginning to get scared going out and have an 8year old son I don’t want to anything to happen too…. I just wanted to comment and tell you how much I agree and appreciate you sharing your “story”. I hope things get easier for you as well.

  • I live in Ct. been in recovery 9yrs never a relapse never failed a urine test, my Dr. prescribes on a cash only basis even though I have insurance to cover all office visits. Doctor no cash no script, made me come to him , then set up my next office visit 4 weeks out. I feel that I’m being put at risk along with others in his waiting room. I am 64 and so is my Doctor, so imagine my surprise when he didn’t even see me. I fear if his office is forced to close and he can’t collect his fee I won’t receive care. I am considering tapering off on my own because I’m afraid of getting severe withdrawal symptoms if he stops prescribing from his private practice

    • that would be a smart decision, better safe than sorry. addicts or pain patients concerns will be at the end of a very long line.

  • Methadone shouldn’t have to be our dirty secret, but it is it made me a better person. To bad we have to have red flags all over our lives just Cuz you can function normally.

  • I live in Brockton ma and go to the clinic and its horrable do to the fact that a lot of Quincy patients go to Brockton now due to the fact that there’s not really a man things are changing so what are they going to do about people that don’t get take homes but what what are they going to do about this is not fair that guy don’t want to go to the clinic every morning do the fact that in sitting on a line and sitting a group of 10 to 30 people coughing all the time with the condition cough and what is going on the nurse is the coughing people are saying they have it and they’re still in line because I got to get dose like please help us it’s not fair for the ones that been sober and doing the right thing please help

  • This is so true!! I only go in twice a month, but it’s terrifyingly stupid that my clinic plans to stay open. I have a grandmother and a 7 year old that I live with. So they are not only endangering their staff and patients, but their families! I’m lucky enough to be a patient that drives, but many have to take the bus as well to get to the clinic. This is insanity. My psych Dr has already moved to teletherapy a week ago. This is a gaping hole in the safety of cities. Personally, I’m scared.

  • I’ve driven dozens of patients to these clinics the clinics are a racket for drug addicts to use when they run out of cash to avoid withdrawal, the pharmacy laughs all the way to the bank and addicts take the drug forever; its just an even more addictive drug with even worse withdrawal; agony that lasts months.

    • Well, I think you can piss off with that comment because I go to one and I go to work because I would have probably been dead without it. Guess what, this is the only thing I do. Besides smoking cigarettes I guess which is another habit I need to quit. However, when referring to attics like that, how about don’t put everyone in the same category because not all of us got where we ended up because of choice or curiosity or Pleasure or fun or whatever the hell… I hate that I’m still there and I hate what methadone has done to me! I’m terrified to get off of it from all the horror stories I’ve heard of the withdrawals in the length of time it takes to wean. But I do know that if it weren’t for this as an option… I’m more than likely would have continue taking 15 pills a day Because of a tolerance that got so high that it makes me sick thinking about. And I never was taking them because I wanted to get high… I didn’t want to get sick anymore. The doctors got me sick, big Pharma aided them, and it was up to me to find a solution to stop taking them. One dose daily… That’s it… The alternative is way worse, I’ll give it that, but absolutely I would rather go through withdrawal from Percocet for a week then methadone for two months. Terrified… And also terrified what’s going to happen with this shut down stuff… I agree that if they make it impossible for people to get their medicine, there’s going to be a lot of overdoses and deaths… This should have been taught about whether people like you agree with it or not it is here and part of life for others and something that needed to be addressed and wasn’t so now more people have to suffer at the hands of those who didn’t give two shits to give it a thought!So, my hope is that you or anyone else like you doesn’t have family Relying on any kind of help to be so big. We come in last place… Anyways… Think if we make comments next time please! Yes I see a lot of people at my clinic that makes the clinic stigma even worse… But then when I walk in I think to myself that this shit really does work and those people suck for making it lookBad. But if you stop for a second and look at those that you get help and saved by the help they provide, then maybe the perspective can be back to positive one day we all have choices to do right with what we’re giving in life. Doesn’t mean everything is bad because you can make it bad that’s all

  • I am on the methadone clinic in Lynn Massachusetts I have a heart disease I think it is absolutely absurd that they refuse to give us take homes. It basically says to everybody probiotics let them all die we’re not important enough

Comments are closed.