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 asked my counselor for a two week take home to a month. She’s new and never knows answers to any questions. It’s sad they care less about helping you and more about money.

    • Gayle,
      I hear you. I often hear this from my son as well. There is little knowledge, and frankly, the counselors are often not educated or interested and do not get paid well. They should be professionals who know what they are doing. Hang in their. I am doing everything I can as a parent to help!

  • Thank you all for sharing your experiences and comments – I have read them all. I’ve seen/heard quite a range from people as OTPs and state agencies figure out what they want to do in response w/ SAMHSA/DEA guidance and changing policies during this COVID pandemic. Will continue advocating! Please stay safe and take care.

  • I have stage 3 lymphoma……been contacting corporate for 2 weeks at my methadone clinic. My reasons for being on methadone are private. Finally, after being exposed to all kinds of idiots coughing and being sick at the clinic…and several calls to corporate, i FINALLY have an order for 14 days of medication. I am completely compliant…I am one of the cash paying, serious people in recovery who happens to have Non Hodgekins Lymphoma. I’ve been made to feel like an albatross….nothing but a giant pain in the ass by RNP. I am sickened and at the same time, relieved to finally have take homes..which I am eligible for ANYWAY as I’ve been clean and sober… enriching my life and health to all degrees. Did it need to get to this point to be heard???? Id really love to know.

    • I had rare form of Large B-Cell Diffuse Non-Hodgkins Lymphoma several years ago; I was fully complaint with the program but still wasn’t able to just be given the maximum amount take home doses (14 days) without having actually to “earn,” the 1st take home, then ya know after 1 month of having 1 take home and remaining complaint, be eligible for 2nd take home, so and so forth. It seems even if you’re gravely ill, methadone programs are so overly regulated, if you have a completely clean patient record with said clinic, you will have to jump through several hoops. It makes you feel like you’re being punished, and the life of an opiod addict is traumatic enough,its unnecessary for clinics to impose such additional measures on a client whom is compliant with the guidelines.

  • A great BIG Thank You to the authors of this article! It is refreshing to see that we, the recovering patients, are not forgotten.
    I mentioned in a previous comment that opiate withdrawal on top of contracting covid-19 is a recipe for disaster in an otherwise healthy individual. Withdrawing is very hard on the body – especially the respiratory system, and the gastrointestinal system (making good nutrition impossible). This alone could cause massive complications for normally healthy people who have worked hard to stay sober for years and have been punished enough.
    Besides, withdrawal symptoms will be difficult to tell apart from a true covid-19 infection. Risking recovery, clinic workers own health, health of patients’ families, the patient themselves is not an option.
    Thank you again for writing this article. Please write more to educate the public and to keep recovering addict patients informed!

  • I go to the methadone clinic in lynn, MA and same thing over 30 people waiting in line to dose and almost everyone only inches away talking and swaying back and fourth. I’m very concerned for my family and I, while my family remains inside I’m putting them and myself at risk by leaving everyday to dose. The clinic has given take homes to a handful of clients while many of us are forced to go. This is very scary for me and I’m terrified that I and many others will be forgotten, left without treatment. Honestly at the very least give clients 6 days or so of take homes at a time reduce the amount of people going daily to just picking up take homes for the time being so we are all not gathered outside possibly exposed. Even tho Lynn is letting 5 people in at a time, inside there are more than 15 people (including staff) at least all in the same room and we are given the option to do counseling which is crazy. Counseling should be cancelled no one should be sitting in a closed room with others for an hour.

    What are other states doing for their clients?

    We are Not immune, ALL LIVES MATTER!!!!!!!!

  • I just wanted to commend all the people who left comments – on their sobriety – and to tell you to not stress over all of this. there will be provisions even if you normally have to go to your clinic daily – they will change it to limit trips and to limit crowding. Give them time to figure it out – it is new for them, too. Remember that they are there to help you. I have been using Google for news on this very subject – and this is indeed the first bit posted on the web about help for methadone patients and clinic workers. It is a shame that methadone patients get treated “less than”.

    I also wanted to mention that in NJ, if you get robbed of your methadone, you need to report the robbery to the police. a copy of the police report about the theft should suffice for the clinic to not punish you. Check your state’s regulations about this. It should be the same for your state. Yes, I know how that feels to have to deal with police but you will just have to put up with any unsavory attitudes – it’s your recovery, not theirs. If the clinic did not tell you about having a police report, they should have. Again, look up your state’s regulations and if this is correct you need to report your clinic for not adhering to regulation. It is now illegal to mess with patients if the patient is a whistleblower or complains about poor treatment. Samhsa (Substance Abuse and Mental Health Services Administration) has been cracking down on this, and notices should be posted all over your clinic telling you about this – as well as informing you in writing of your patient rights. It should be like this in all states (but I could be wrong, so google your state’s laws). If not, your clinic should have the phone number and address of the agency or agencies you can report them too (samhsa and there are other places for help).

    SAMHSA WEBSITE (the “about us” page):
    https://www.samhsa.gov/about-us

    And the home page:
    https://www.samhsa.gov/

    I am also a methadone patient since 1995, and I was one of the very first persons in NJ allowed the 27 day take home program. I worked very hard for that, and was vigilant about protecting my privacy and my medication. If I can do it, so can you. I went from having nothing – not a car or license, a place to live, or a job – to regaining all these privileges. I will continue to work hard to keep those privileges. I now have a home, a car, a license, good credit (finally!), a wonderful husband, four grown successful children (a mechanic, a doctor and a business owner and a teacher) and four lovely and intelligent granddaughters. I would have none of this if it weren’t for methadone maintenance. Nobody could ever guess otherwise that I am a methadone patient. My life has its ups and downs but I have learned to deal with it. Methadone gave me that chance. The clinic staff gave me the understanding and the tools I needed – that chance – to get and stay sober.
    There is nothing more important than my recovery. There is nothing more important than your recovery – for the sake of you, your loved ones, your life!

    If you think things at clinics are unfair now, you would never believe how it was back in the 80’s and 90’s where most recovery clinics were rather abusive and were not honest. You were truly at the mercy and whim of people who did not care. I was lucky that I lived close to a clinic that was founded by a man who cared, and staffed by people who carried on that principal. I was lucky that I found a clinic that gave truly good treatment.

    Don’t stress over what you think might happen during this pandemic, because stress will make you sick. Worry about tomorrow when it gets here. If you have been doing what you are supposed to – to stay clean and sober, you have nothing to worry about. You will not be forgotten. Use that concern of yours to help the situation, call your state, call your clinic, call any and all agencies involved in your state’s methadone regulation. Remember that what is happening here is NOT the Walking Dead story! You have the internet and Google, use them!!

    If you have not been straight with yourself about being clean, NOW is a good time to start because you have that chance. You won’t get left behind if maintaining sobriety is your goal – even if you are just starting now. Don’t bs yourself, because when you do, it is apparent to others. When your head is straight, others can see that too.
    If you do get unfairly denied treatment that everyone else is getting, or if your state does not make provisions for this, document it, scream loud about it! Call tv stations & newspapers, post it everywhere on the internet – because methadone is truly our life saving medication – and it is just as important as insulin for a diabetic, as important as high blood pressure meds & blood thinners for a heart patients. People who have no personal experience with opioid addiction have nothing to say about it. It is YOUR RECOVERY – TAKE CONTROLL OF IT!! And remember that your clinic workers – the nurses, doctors, clerical staff, and the counselors are all there to help you. They do care. You might run into one or two who do not seem that way. Don’t let that ruin your sobriety. There is always going to be that one difficult wrench in the system. Sobriety is learning to deal with that in yourself because you cannot control anything in this life but YOUR OWN SELF and your own attitude. Accept no excuses from others and from yourself. use all of this to learn from, stay sober and help others to do the same.

    Please post here if you run into trouble. Maybe together we can help and make a difference!

    • Mama i am also in NJ long time on methadone who do you recommend i get in touch with i am trying to help others get their medication to stay safe at this time?

    • The federal government gave the states the go-ahead to allot up to 4 weeks for complaint, low-risk patients, and up to 10 days I believe for higher risk clients. Now I’m from Massachusetts, so I don’t know what the norm is, but virtually every clinic in Massachusetts is privately owned, and hence each clinic can elect or choose not to give take homes. I’m on literally only 3 mgs (ive been dosing down for long time in hopes of get off completely) and I have nearly a perfect record in terms of maintaining compliance, but even at that, I was still only given 6 days. Im curious what it takes to get the max 4 weeks a clinic can give!?!

  • Some methadone clinics are closed in Maine two of them are five minutes away from the one I go to and the one I go to is staying open and people stand out side waiting wile five people are allowed in the building at a time there are twenty or thirty or more out side standing way to close together cause none of them know how to give a little personal space on a normal day let alone now with the crazy virous going on it’s scary one guy stood in line and said he was going to cough all over everyone and infect us all . This should not be happening in South Portland Maine at the Discovery House where we go to drink our medication on a daily basis.
    Yes there are people who get a take-home dose on some days but there are hundreds of us who don’t and go there daily . It’s crazy the other to clinics Merramack in South Portland also is closed down gave out a week take home and Cap in Westbrook Maine also did the same we were told by the nurse at Discovery House she then said but we’re staying open . Crazy to me . Is there a way to change this . I thought people were not suposto have gathering of no more than ten ,this morning at
    4:45 AM there was
    over 30 people on the ramp
    to get inside
    Discovery House.

  • So what happens , and what to do if not allowed to refill pain meds in 2 weeks? What if office is closed, or we can not get to pain doctors office? – Need info and direction soon. What is gov, doing about this?

    • Methadone treatment patients shouldn’t be too worried as OTP facilities are considered critical and alternate plans for patients to receive their medication must be in place before any facility closure. And like the article says, worst case scenario regulations would can temporarily allow for written prescriptions for patients to get medication from pharmacies.

  • Another important issue is that withdrawal symptoms will wear down an otherwise healthy patient, who will certainly have negative issues should they contract the covid-19 virus. In some cases, withdrawal will not be differentiated from the virus, and withdrawal symptoms will absolutely make a bad virus much much worse, possible more deadly fir the methadone patient than it already is.
    This issue needs to be resolved quickly. Many methadone patients have been clean and functioning for years. A catastrophe like unavailability to be able to safely go get their medication will be as much a disaster for them as it will be for patients who are in the early stages of recovery, not to mention the exposure risk to all patients and all the wonderful human beings who’s career it is to help them.

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