Covid-19 has streamlined addiction medicine. Will the changes stick?

Nicole Godinez’s monthly visit to an addiction clinic typically takes several hours: To start, there’s the 35-minute drive to a Nashville suburb, the waiting room, and the paperwork. Then the repetitive questioning from a drug counselor, then the drug test. Finally, there’s the in-person visit with a doctor who refills her 28-day prescription for Subutex, a common but highly controlled medication used to treat opioid dependence.

But in March, Godinez was sure she’d miss the appointment. She’d just delivered twins by C-section, and couldn’t drive. One of her 3-week-old boys was still in intensive care, and she refused to leave his side. And then, of course, there was the pandemic. In the previous two weeks, health officials across Tennessee had reported 4,500 new coronavirus cases. Godinez thought she’d be forced to make an impossible choice: Her own care, or potentially exposing herself and her twins to Covid-19.

Instead, since their birth, Godinez has had an easier time than ever accessing addiction care, thanks to aggressive government reforms in response to the pandemic. Since March, federal officials have arguably done more to reform addiction medicine in the U.S. than they had in the two decades prior — expanding access to some treatments far more quickly and thoroughly than any of the legislative reforms Congress passed even at the height of the opioid epidemic.

Godinez’s process was almost impossibly simple: She texted her doctor and a drug counselor, who briefly evaluated her via FaceTime and wrote a prescription that she filled at a Walgreens around the corner from her Hendersonville, Tenn., home — a process that, until March, would have been largely illegal.

“The first thing one thinks is, ‘Oh, my God, am I going to be able to get my medicine?’” Godinez, 33, said. “If I couldn’t get it through text, then I wouldn’t get it. I wasn’t going to leave my baby.”

Now, as they wield unprecedented freedom to prescribe addiction drugs by telemedicine and evaluate patients by phone, many doctors and advocates say they’re unwilling to relinquish that flexibility without a fight. Already, there is a burgeoning movement to keep many of the new policies in place permanently. Many treatment providers across the U.S. have said publicly that the new status quo represents long-sought change that could positively transform patient care for decades to come.

“You can’t put the genie back in the bottle,” said Stephen Loyd, a Tennessee addiction doctor who treated Godinez and who once served as the state’s drug czar. “This is how it needs to be — always.”

At first, as Covid-19 spread across the United States, addiction doctors and policy experts feared the worst. Between the stress, isolation, and financial hardship the pandemic has left in its wake, many assumed it would wreak particular devastation on the roughly half-million Americans with opioid addiction. One analysis published last week by the Well Being Trust, a public health group, projected that 75,000 Americans would die from suicide and overdose as a result of the pandemic.

The logistics of addiction treatment also became more complicated. Many clinics that provided syringe exchange services or walk-in addiction treatment closed, or reduced their hours, sparking concerns that rates of overdose, or transmission of HIV or hepatitis C, would spike. Others worried that some of the 30 million Americans who have filed new unemployment claims since the pandemic began might lose their insurance and their ability to pay for care.

Even in the face of tragedy, however, the coronavirus has created a natural proving ground for policies that many addiction treatment advocates have been pushing for years.

“The biggest scary part was: How are we going to make sure that we can maintain the same type of treatment availability, especially for people who are early in their recovery?” said Regina LaBelle, the program director for Georgetown University’s Addiction and Public Policy Initiative and a former high-ranking Obama administration drug policy official. “The really interesting part about this is that it’s provided a pilot to test out some of these new approaches.”

Many doctors have taken advantage of new regulations that allow them to prescribe buprenorphine without evaluating patients in person, instead conducting visits by video chat or even by phone.

Thousands of Americans who have long begun every single day with a taxing trip to an addiction clinic for a single dose of methadone, another highly regulated addiction drug, are now receiving 28-day take-home supplies, rendering the in-person visit and potential coronavirus exposure unnecessary. In New York City, some clinics have even delivered methadone supplies by courier — a 180-degree shift away from the federal government’s longstanding and heavy-handed regulation of methadone, an opioid that’s used to treat both addiction and pain.

“We’re seeing changes in the last six weeks that, in some cases, we’ve been advocating for a really long time, and in others, that we didn’t even really think were possible,” said Samantha Arsenault, the vice president of national treatment quality initiatives for Shatterproof, an addiction advocacy group.

The steps represent a stark acknowledgment from physicians and drug enforcement officials: That even for many vulnerable patients with opioid addiction, coming to the clinic could be more dangerous than staying home alone. Yet some doctors say that in some instances, it’s led to unexpected breakthroughs.

Loyd, the former Tennessee drug czar, said telehealth visits have allowed him to gain insight into his patients’ living situations, which has often led to critical discoveries about their life circumstances that he would otherwise have missed.

“I found three patients in the past two weeks that I didn’t know were homeless or living in a car,” Loyd said. “So we’ve been able to hook them up with some housing services that we have access to.”

Other doctors have argued the new allowances for telehealth and medication delivery could result in a sweeping expansion of treatment services in rural areas, where finding qualified doctors to conduct in-person visits is often difficult.

In Washington, Congress has already capitalized on the momentum. In a recent package of coronavirus-related stimulus relief, Congress passed a controversial and long-stalled measure that aims to prevent doctors from unknowingly prescribing opioids to patients recovering from addiction. The new measure allows health providers to freely share information concerning a patient’s full treatment history with one another.

Other lawmakers are eyeing further changes. An aide to Rep. Paul Tonko (D-N.Y.) told STAT that the congressman was pushing to include a bill to allow any doctor with a prescriber license to treat patients using buprenorphine as well — eliminating the current requirement that doctors undergo an eight-hour training.

Tonko’s efforts, and the enthusiasm displayed by many addiction advocacy groups across the U.S., represent the first step in a broader effort to codify the changes permanently. If prescribing buprenorphine by video chat, supplying weeks of take-home methadone, and allowing addiction doctors to evaluate patients by phone prove successful, some advocates say federal officials would be hard-pressed to explain a return to the old system.

“You never want it to take a pandemic to achieve positive change,” said Emily Brunner, a physician and former president of the Minnesota Society of Addiction Medicine. “But there are changes that you’d like to see kept in place, just from the perspective of meeting patients where they are.”

Other advocates, while welcoming many of the temporary changes, have expressed only cautious optimism, particularly regarding methadone, a drug that, when misused, can easily lead to overdose. Others fretted the changes to privacy laws could leave addiction patients vulnerable to stigma and discrimination. And, many stressed, while expanding treatment for opioid addiction is likely to help thousands of Americans, it does little for others addicted to other drugs including methamphetamine, cocaine, and alcohol.

Mark Parrino, the president of the American Association for the Treatment of Opioid Dependence, a group that largely represents methadone providers, recalled that one of his board members had recently mused that there had never been more of the drug in patients’ hands.

“We have to hope that most of it is being used as dispensed, and not being sold on the black market or being misused by the patient,” he said, adding that he had heard a small number of anecdotal reports that some patients had overdosed on take-home medications.

Parrino stressed that those reports were only anecdotal — but that he also expects federal regulators, including the Substance Abuse and Mental Health Services Administration, to return to a more typical regulatory structure in the future.

A SAMHSA spokesman said in a statement that the agency “would continue to monitor those flexibilities and how they are working,” noting that many would require action from Congress to remain in effect.

It is difficult to overstate the scope of the changes that the federal government has made to addiction medicine since late March.

Beyond allowing 28 days of take-home methadone and first-time buprenorphine prescriptions by telemedicine, the Centers for Medicare and Medicaid Services — the safety-net agency that is by far the largest funder of U.S. addiction treatment services — announced it would reimburse health providers not just for video telehealth visits but for audio-only visits as well.

The move allowed health providers across the country, including addiction clinics, to stay afloat financially even without treating patients face-to-face.

The Department of Health and Human Services has also announced it would effectively stop enforcing many privacy laws, so long as doctors made a good-faith effort to treat patients safely. The change opened a world of new possibilities for health providers, allowing them to communicate with patients using commercial video chat applications like Skype, FaceTime, or WhatsApp instead of specialized, privacy-compliant video services that many patients didn’t have access to.

The message was clear: The federal government was telling doctors to treat patients any way they knew how.

“Every day, there was a new policy change, a new regulation relaxation,” said Tom Hill, the vice president of practice improvement for the National Council for Behavioral Health, a D.C.-based group representing mental health providers across the country. “It was just amazing, because some of these things, we’ve been advocating for a long time.”

If patients like Godinez have their way, there might be no going back. Speaking by phone on a recent afternoon, she reported needing just 10 minutes with Loyd, the physician, and another five minutes with a counselor to complete her full check-up.

After nearly three years in treatment, Godinez says she has never had an easier or more convenient time accessing care from Loyd — a welcome development, given the pandemic and a newly packed schedule that revolves around caring for her twin boys.

“He checked up on me, and I said I was going to run out of medicine on Sunday,” she recalled. “He said, let’s FaceTime. Literally, I was in the NICU next to my baby, and then he saw me, and he sent [the prescription] over to the Walgreens. I didn’t have to do anything.”

For Godinez, it was a stroke of luck that federal regulations slackened when she needed care most. But to many addiction treatment advocates across the country, it was a sign of things to come — and a case study in the way things should be.

“What we’re seeing with this pandemic is an effort to say: Let’s drop the restrictions, and let’s just do whatever we need to do to meet patients where they are,” said Arsenault, of Shatterproof. “Why isn’t that the way that we approach medicine all the time?”