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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.

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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.

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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.

  • I am a young person. Only 28 years old I have a 2 year old son, I’ve been clean and doing fantastic since methadone helped save my life. I am in a constant panic worried we’ll all be forgotten and left to fend for ourselves bc of the reputations people in our situation have. I pray to god something is done soon or we are addressed about what we can do. I just cannot imagine how many people like me out there are freaking out just the same.

    • Don’t freak out, they are figuring it out! You will not be forgotten – your clinic does care! Remember, this ain’t the “Walking Dead”! Its just a few weeks to mitigate the spread of the virus and there will be help from many places. You can’t get evicted right now, you are eligible for govt assistance due to covid-19! You will be okay, worry about tomorrow when it gets here, and stay sober! You can do it! Stressing will not help!

  • I am not a drug addict and never have been. I take methadone due to chronic back pain. Have been on a small dose for years, without ever asking for more than prescribed. I now ask to be able to get a 3 month supply, as all patients of any medication are told to do. I am trying to self quarantine, to do my part to stop this maniac panic. Instead, treated as a person who “uses”. Come on, help a person out!!

    • It’s not necessarily that they’re treating you as somebody that uses there are legal guidelines behind opiates that makes it so they’re not allowed to give three months of supplies of certain medications any narcotics and widely abused medications are not allowed to be given out at 3 months at a time because there are people that abused it and those people would end up out of it by the middle of the first month and then not have their medication for the next two and a half months and there’s lots of other reasons to this also cuts down on people selling their medication I know in your situation is frustrating but they can’t make exceptions for each person because of course every person swears that they aren’t going to do anything bad and that they have good intentions

  • I have been a THS for 25yrs and daily dose 80mg of methadone . I also have bipolar 1 , PTSD , manic mix episodes/depression, and in my past have attempted suicide twice. Please please realize I have worked real hard to be where I am today which is alive with underlined medical conditions , but alive and for the first time in a long time want to stay alive. I am 50yts old with 2 daughters and 3 granddaughters and wish I could stay in my apt to keep the risk lower for getting CV-19. I like what you said and would love the chance to stay home like everyone else. It seems we are targets.. I am.more scared of being sick then dying. Please email me if you hear anything as my clinic has no info and my case manager left amd does mot work there anymore. Thank you

    • Hi Bunny I was so happy for you after I read your story,so I feel I have to contact you in regards of the law for all who take methadone,In which I also take it everyday..Our story is almost exactly the same..Methadone saved my life,I have now been the Methadone Maintenance Program in New Jersey I actually go to the 1 in Phillisburg NJ.I also like you have 1 child who is now 24yrs old! There has got to be something we can do to change these super strict rules in affect for addiction recovery, We really are NO DIFFERENT THEN SOMEONE WHO NEEDS INSULIN TO LIVE A NORMAL LIFE..I LOVE MY LIFE NOW AND I AM VERY PROUD OF MYSELF,AND VERY PROUD OF YOU AS WELL!!! I would not be here 2dy talking to a fellow addict,if not for my methadone. They want everything closed except you said it methadone patients. The laws must be changed ASAP In a way I really believe the laws put in place for people like YOU AN I,think we don’t mean anything. But most people still think if your on Methadone we are not clean and sober,which is very sad bc it is sooo far from the truth. We who use methadone have been stigmatized as garbage BC we are still getting high its just legal..MAKES ME SO SAD 4 ALL OF US IN RECOVERY WITH METHADONE.. So I am reaching out to you to ask what you think we can do,So we are not put at risk of getting it BC of these ridiculous Federal law put on Methadone.. And from being on it soo long I went to a clinic to live again and be here 4 my son my husband,oh and I HAVE NOT SLIPPED,NOR HAVE I GOT ANYMORE CHARGES ALL BC OF THE MAT PROGRAM. MAT is the term we use in New Jersey point I’m trying to get too is no addict goes 4 methadone bc we want to stop and live a normal life again..Its not a forced program, ITS FREE WILL 4 ADDICTS LIKE U AN I STARTED BC WE WERE DONE_BROKEN,AND JUST WANT TO STOP. I’m sorry if my words are all over the place,I now have permanent brain damage bc I started having seizures from my drug abuse so bare with me gun.I’m sorry about that sweety. So here is what I’m trying 2 say is MOST GO WILLINGLY, So Its sooo sooo very wrong to treat us recovering addicts who take methadone like we are just TRASH… If we wanted to continue with being high we could just go to pain management clinic 2 legally get high on pills, or we can buy drugs on the street.. But we do not bc we NO LONGER WANT TO BE THAT PERSON..I’m 43 and was a using addict for at least 20yrs. I started very young,anyway the laws on methadone should be changed! BC WE ARE NOT TRASH WE LIVE/WORK PAY TAXES JUST LIKE ANYONE ELSE!! IT IS A MEDICATION WE MUST HAVE TO SUSTAIN OUR LIFE. IT IS A DISEASE THAT IS A FACT IT DOES CHANGE YOUR BRAIN AND CAN NOT BE UNDONE. IF SOMEONE HAS CANCER PER SAY,OR BACK PAIN THEY CAN GET METHADONE PILLS FROM THE PHARMACY?? HOW IS THAT OK? AND NOT OK FOR US..BC OUR FEDERAL GOVERNMENT JUST THINK WE DO NOT MATTER,BUT OTHERS DO? I was thinking of maybe starting a petition for all methadone scripts be given to us..ESPECIALLY NOW WITH THE VIRUS GOING AROUND. IDK PLEASE CONTACT ME BACK THERE MY EMAIL OR ON HERE..AGAIN IM SOO HAPPY 4 YOU!!!! IM SURE YOU HAVE HAD SOME HARD STRUGGLES.. SO CLAPS 4 YOU… PLEASE MESSAGE ME BACK MAYBE WE CAN START A PETITION ON EVERY SOCIAL MEDIA SITES FOR SIGNATURES 2 CHANGE OUR FEDERAL LAW ABOUT METHADONE RECOVERY… I REALLY HOPE TO HEAR BACK FROM YOU

    • If you have been on the methadone for this long and aren’t using and have all clean you is shouldn’t you have take outs?? I guess all states may be different but where I live in the clinic I go to we get takeouts I’m currently and I’m 13 meaning I get 13 takeout so I coming every other week but yesterday when I went to pick up my medication they gave me 27 take outs because of the virus and they said anybody that is an M 5 or higher gets 27 takeouts so I’m not sure where you’re at on that but I hope you get some takeout so you don’t have to keep going out

  • Well said! I feel like we are being forgotten and left behind! I too have been on methadone for 10 years….not 1 single dirty UA. I had a month of take home
    In December I was the VICTIM of theft and to punish me for being a victim I have to do daily dosing. I have kidney disease, asthma, diabetes and a seizure disorder! Very high risk population falling through the cracks. If exceptions are made, than do media announcements and mandate carry outs! They should be notified of any changes! Please people don’t forget us!

  • That’s like myself, I take medications twice a day for my epileptic seizures and depression and if I don’t have either I start to have mental breakdowns and seizures that can cause me to end up in the hospital and that’s not good because I have a very weak immune system to due to being on meds for 30 years since I started having seizures!

  • Being a person who has lived with chronic pain for 30 years, and who has been on opioids for numerous issues for 20 years, I want to know what the plan is in Oregon to get opioids to patients like me. The law says I have to see my pain management doctor once a month in order to be evaluated, with random urine/drug testing, once a month. I am also subject to being called in for a pill count at any time to make sure I am taking my medications properly. I do all of this, gladly, because I know what it’s like to be in severe, constant pain.

    Now we have Covid-19 happening. This is the first article I have seen which even remotely addresses what people who take opioids, Buprenorphine, Belbuca, methadone, etc., are supposed to do to get their drugs in the middle of a pandemic. If I lose my opioids, the diseases I have for which I am taking them for will kill me. Just Covid-19 will kill me yet I have to leave home to sit with other patients in order to get drugs with a compromised immune system. If my doctor gets Coronavirus, who steps in to take his place? There are so many questions and things that need to happen for patients with chronic pain in the face of this disaster that aren’t even being asked!

    For patients who are stable, they need to make telecommuting an option, and/or the ability to have prescription refills for opioids that are monitored by the pharmacies or docs from home. That used to be the law – until people abused it. Now I am paying for it.

  • Some states are changing things during the pandemic. Contact your state’s Methadone authority.
    The rules and regulations regarding methadone is different state to state with federal guidelines as well.
    Almost every state has ‘phases’ people can climb depending on the amount of clean time they have. Those with less clean time are at greater risk of relapse, overdose, and complications therefore they are not allowed the same amount of take home bottles as someone who has years of clean time behind them. Other things may play a factor into these ‘phases’ like mental health, lack of stable living conditions, etc.
    Many states are changing the rules during this outbreak to reduce the possible spread of COVID-19. Some states only allowed at most 2 weeks worth of take home bottles for those who have the most clean time. Some of those states are doubling everyone’s amount of take home bottles. I’m not sure if the states that already allow a months worth are allowing more than that but you can call and ask.
    I’m guessing if your state hasn’t changed the rules yet, hang tight because they will.
    Clients are not the only people who might feel like they are being put in danger. Nurses and other staff are there all day, often long after dosing hours. They don’t make these decisions so remember to be kind, they are worried too. Also remember that some people may be more at risk therefore more worried as well. The lines at methadone clinics are not often places you see a lot of compassion. That can change, especially in these times. No one who is elderly or sick or has to have their children waiting with them should be made to stand in line outside for hours. If you refuse to let them cut in front of you at least save their spot so they can wait in their vehicles. A little kindness goes a long way these days.

  • I having been going to the methadone clinic in beckley WV for seven years now. I normally get two weeks of take homes but lost them for 30 days over not getting an hour of counseling in last month in feb. I haven’t failed a drug screen in seven years now. Our clinic two days ago just said they r limiting ten people in at a time and out counseling is now optional until end of April and take homes won’t be affected. I now have two more weeks of my 30 days and they still won’t give them back to me. Which to me is crazy. My boyfriend just started the clinic and has to go daily. They only allow ten people inside but we like most other clinic are all standing outside in line. How does this help anyone??? We r still around a lot of other patients. Sometimes 30 plus. If u are sick with the virus u r still gonna come daily because u need ur meds. What r we supposed to do? R we not people to? I think they all need to weigh the options and see what is worse. Give addicts take homes for a few months and risk them not doing right to keep them in the future or risk getting hundreds or even thousands sick. If all clinic in this country keep patients coming daily they are risking making thousands sick. Patients nurses doctors employees. Patients bring children and babies with them to the clinic. Why r they putting us all and our families at risk? Anyone going to the clinic is at least making an effort to change their lives. We shouldn’t be treated like we don’t matter. Good luck to everyone.

    • Well said! I feel like we are being forgotten and left behind! I too have been on methadone for 10 years….not 1 single dirty UA. I had a month of take home
      In December I was the VICTIM of theft and to punish me for being a victim I have to do daily dosing. I have kidney disease, asthma, diabetes and a seizure disorder! Very high risk population falling through the cracks. If exceptions are made, than do media announcements and mandate carry outs! They should be notified of any changes! Please people don’t forget us!

  • Iam in a clinic in NYC and I only go 2 times a week I haven’t given the program a dirty urine in over 10 years . I really don’t think the government gives a shit about people who are methadone. Programs are only about making money and they will stay open until someone comes in and spreads the virus to the staff this could be avoidable but when it comes to people in recovery we are the last people they care about..everything in NYC is closed except for methadone clinics…even with a pandemic they are willing to infect 100s of people because of the stigma that comes with people being on methadone. They probably don’t give a shit if we all die

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