One photo shows a long line of people standing close together while waiting for methadone at the counter of an opioid treatment program in Minneapolis last Friday. Another shows a crowded waiting room last Saturday at a similar clinic in Winston-Salem, N.C.
These images, collected by an advocacy group, show that many people are having to risk Covid-19 infection to get their addiction-treatment medication — weeks after the federal government relaxed rules that require people to show up at clinics every day to get methadone.
Aimed at reducing the spread of the novel coronavirus, the new rules allow people considered “stable” to take home up to a 28-day supply of methadone under a blanket exception, and people considered “less than stable” to take home up to a 14-day supply. But advocates for people recovering from addiction say compliance with the new guidelines has been inconsistent.
Methadone patients and staff from more than half a dozen states have sent photos and videos and called with complaints, said Zachary Talbott, president of the National Alliance for Medicated Assisted Recovery (NAMA). About a third of the complaints are from staff. “They’re calling because they’re worried about the patients, and they’re concerned that there is no social distancing,” he told STAT. They’re also worried about themselves, because they have no personal protective equipment.
Talbott received reports from clinics in Massachusetts and Florida that people who had tested positive for Covid-19 were still having to pick up their methadone treatments in person, putting staff and other patients at risk.
“If supermarkets can enforce social distancing, why can’t OTPs?” asked H. Westley Clark, a psychiatrist and professor of public health at Santa Clara University who formerly directed the federal agency that regulates opioid treatment programs, called OTPs.
“They can,” said Talbott. “They can do it with tape on the floor.”
In the past month, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Administration, which together regulate OTPs and the addiction treatments methadone and buprenorphine, eased the regulations for taking home methadone, and allowed new patients to be started on buprenorphine based on a telephone call only. SAMHSA also issued guidance to OTPs for patients quarantined at home.
But some programs have been slow to respond to the crisis. Talbott detailed some of the abuses in a letter sent Wednesday to Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD), the membership association of opioid treatment programs. A copy was obtained by STAT.
It describes reports from eight states of clinics performing “call-backs” and “medication counts,” requiring clients with take-home doses to come in, which defeats the purpose of the federal rule changes. Clinics with no social distancing protocols still require in-person group counseling sessions and regular attendance — even for people with chronic health problems and lung conditions that put them at increased risk for infection, and for those with confirmed positive tests for Covid-19. At one clinic, infected clients were told that the program could not figure out how to implement protocols for tracking methadone if they took it home.
Most of the treatment programs in the country “are doing it right,” Talbott said of following the new rules. But there’s a “substantial minority of bad actors.”
Among the good: OTPs in New York City, where Covid-19 has hit the hardest and there are 32,000 methadone patients. The programs there — and in the rest of the state — are following social distancing, as required by the state. They have also increased the number of doses clients can take home, but not immediately going from a daily to a two-week supply. Instead they start with two or three days, increasing based on stability.
The New York City Department of Health estimates that almost half of the methadone patients will need to be isolated because of possible exposure via a contact, or an actual infection. This could make it challenging for many to get methadone, unless they have 28 days of doses, pharmacy delivery, or some other way to get their treatment.
The complaints support a letter urging more steps to protect people treated with methadone from Covid-19 and enforcement of the new methadone guidelines. The letter is being circulated for signatures among advocates and treatment experts by NAMA, the Drug Policy Alliance, and the North Carolina-based Urban Survivors Union, and is expected to posted online Thursday.
Notably absent from this sign-on letter is the trade association representing OTPs. But Talbott and AATOD’s Parrino both told STAT that the group takes these problems seriously and is going to investigate the complaints.
Parrino said he is concerned about patient safety, as well as treatment programs’ liability because of the subjectivity inherent in the new rules. “Stable” is not a clinical term, and SAMHSA is leaving it up to the OTPs to decide who is stable enough for 28 days of take-home medications, and who among the “less stable” can get 14 days, he said.
Clark said it’s important to strike the right balance among competing risks. He said social distancing for unstable patients is a better way to protect them from the coronavirus than giving them too many take-home doses. “Handing over large amounts of opioids to anyone puts them at risk, their children at risk, and the community at risk,” he told STAT. “Since we’re dealing with intersecting epidemics, we need to recognize the need for caution.”
NAMA wants the additional steps called for in the letter to remain in force until the Covid-19 pandemic is brought under control. Among these steps are expanding access to methadone delivered by the pharmacy, increasing take-home privileges to the maximum extent, and suspending urine testing.
But many of the other groups that have signed, including the Drug Policy Alliance, want to see the OTP system revamped or even eliminated completely.