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?”
Look up Subutex, described as a partial opiate like drug that does not produce euphoria when taken as directed. As soon as addicts discover they can easily get the drug, the abuse will start. They are addicts and will use the cheapest and most available high they can get their hands on. Some will be helped, but many are not ready to quit.
Great article, and I suspect that many of the changes in the ease of medical care delivery and communication should be maintained if/when society is back to “normal”. But the only way we will know if that is a good idea is to STUDY the effects! In the article I kept waiting to hear whether academic addiction research teams are studying the outcomes of this change.
Elephant in the room …
The article makes several good points. And much of the easing of access to treatment seems like a great idea.
However, the article completely ignores the counselors who are working directly with the patients to help them change their lives. The primary goal here is to help people overcome addiction, not some garden variety health issue. Audio and video chat are not sufficient for many patients; they need serious face-to-face counseling to make the huge changes needed to overcome addiction.
That is a good point, but i don’t really agree. IME, most counselors at clinics are rather powerless to effect any change in their patients lives through either lack of experience and knowledge of local resources, a simple unwillingness to burden themselves with “extra” work- counselors often have huge case loads and are simply trying to cross t’s and dot i’s for billing. The requirements to attend group and individual sessions that are largely wastes of time is probably the biggest resistance to MAT that active addicts tell me it’s the reason they do not take advantage of it.
Right, so let’s not allow these addicts access to their medications by video chat because it isn’t perfect. You get my point. Look, there are two main components to beating an addiction….getting the addict to stop taking the drug and helping the addict make changes to their lifestyle/mental state so that they can stop it long term. If an addict is looking for Suboxone or Methadone then they clearly want to stop and get better. That is step one and we should be making it as easy as possible, while being as careful as we can, for them to receive these alternatives to help them do that. You can only hope that they also choose to listen and find mental help to go along with that but to tie them together where have to have both or you don’t get anything is not a good idea for obvious reasons. It has always seemed to strange to me that we have made it so difficult to get a Suboxone subscription. It was literally so hard that many addicts straight gave up on the idea and that is ridiculous. Sometimes our regulatory agencies over think things and have a control issue.
What most people don’t realize is that most addicts hate the lifestyle, hate being addicted, hate themselves for being addicted. The hurdles to access treatment puts it out of reach for too many. Caught in a cycle that requires endless attention, it is not easy to plan far ahead. Being able to access reliable treatment helps tremendously.
This “covid adapted” health and addication care method was long overdue – and ought to stay in operation in perpetuity. Most methadon / buprenorphine users are truly attempting to get out of heavy addiction, and via telehealth care these patients can be very well monitored and supported. To revert to the old-fashioned, over-complicated “pre-Covid” roundabout ways is ludicrous reversal of long-overdue progress.
DHHS says “treat patients anyway you know how”… Seriously if this is where the bar is set then we are in very deep trouble. I appreciate the title streamlining addiction medicine. The real deal is addiction treatment. Medicine alone is not and never will be the treatment
I agree – “Medicine alone is not and never will be the treatment.”
You are wrong. Making the medicine available and easy to access without driving 1 hr to appointments when most people who are suffering from opiate addiction don’t have transportation at all is the answer. They need the medicine period and if they need counseling they can do that with video also.
Hoping that there will be significant support for the pandemic initiated practices outlined in this article. Let our Congress persons hear from us.
I wish you would consider beginning attention made to CDC to amplify the statement to doctors written in April 2019 by Dr Redfield of their concern that’s doctors. Have misapplied the earlier guidelines re prescription opoid because it is harming chronic pain patients losing access to an opiate they have taken responsibly for years. So many states have outlawed prescription opiates for often severe chronic pain entirely. In other states doctors are afraid they will lose their licenses and won’t help patients or will Only prescribe amounts so low it is doing chronic pain patients harm, going against their oath to do no harm. For instance, I’m a 76 year old woman with double scoliosis, arthritis, stenosis, spondylitis, and fibromyalgia. 17 years ago after spinal fusion surgery the surgeon said I’d have to take morphine all my life agreed to by hospital pain Director and primary care doctor. I’ve never abused it, never had a high. Only addicts feel that. My pcp is retiring and can’t find a doctor who will continue my med. frankly, it doesn’t help enough but I’ve never asked for more fearing I’d be seen as an addict. Now there is another crisis as bad as addiction— pain crisis. Patients have committed suicide, bought illegal drugs ( Fentanyl laced with heroin,) now live a life in bed with pain or die from the pain. This crisis was expanded when President Trump ordered Then AG Sessions to completely eliminate opiate addiction. I cannot take any other pain Ed and have tried all and can’t take NSAIDS due to asthma and now COPD. I’m terrified I’ll die from chronic , severe pain. Doctors from medical schools ad others have asked that these strict guidelines be stopped and that CDC update in 2019 be followed, leaving doctors to be in charge of their patients’ needs. It will only work if it is made clear that they no longer need to be afraid of losing their licenses and stop doing much harm. It will have to be repeated and communicated in different ways for doctors and many states have been misled. Stat news would be essential in spreading the word. I read facts re bupropion that cause me to fear that I would not be able to take it. For the record, throughout my long life I’ve done every alternative methods, usually several at a time.yoga instructors won’t take me on anymore for I’m a liability. Even Swedish massage is too painful.Even Feldenkreis teachers won’t work with me anymore. I pray you can help us who are being harmed. Perhaps you could forge a coalition to make this concern a priority. I appreciate the chance to commit.
What could possibly go wrong?
Well, you can’t overdose on Suboxone/Subutex, so the worst case scenario is the possibility of diversion. Most Methadone clinics are not giving out 28-day supplies, but even then, most Methadone overdoses happen to those who are new to Methadone or mix it with Xanax or other benzodiazepines.
Also, whether you choose to believe it or not, most people on these medications are trying to better themselves and take their medication correctly. Like any other situation, there will be those who take advantage and mess it up for others.
“Ry” says you can’t OD on Suboxone. Not true. I spent a week in the hospital a few years back, after OD-ing on that very substance. Medically-induced coma, intubated, ICU–the whole deal. My respiratory system was shutting down. I almost died. So that is a real possibility.
That fact that you think overdosing on suboxone isn’t possible is laughable but extremely dangerous. I hope you are not telling that to people cause you may actually indirectly kill someone. Sorry to be so dramatic but your comment erks me. Also, I don’t doubt your sentiment that individuals on MAT drugs desire to turn their lives around, but they are on those drugs because they couldn’t control themselves in the first place. Prescribing them without ensuring counseling or other practices to get them the tools to overcome addiction is borderline enabling and leaves them no different than those chemically dependent who are not in “recovery”
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