There are many ways in which Covid-19 has dramatically worsened the US opioid epidemic.
Routines are disrupted. Support networks inaccessible. Harm reduction services, such as needle exchanges, are closed. Opioid overdoses are up, opportunities for treatment fewer, and research is all but halted.
But despite the many setbacks, the pandemic is also pushing some necessary innovations in the treatment of opioid addiction disorder. Among the most revolutionary is rethinking the need for daily visits to methadone clinics.
Prior to the pandemic, patients who were treated with methadone had to receive daily doses at the nearest methadone clinic, long the established standard of treatment. “This practice was predicated on the belief that you can’t trust the patient, that if the patient is given more than the daily doses that they’ll overdose,” says Nora Volkow, the director of the National Institute on Drug Abuse (NIDA).
Patients would then progressively acquire so-called “bottle privileges,” or the ability to take home extra bottles of methadone—which comes in daily bottle doses—and go to the clinic every other day, or once every three days. Prior to Covid-19, that was a very slow process, requiring at least two years to build up to a one-month supply. “It could be a period of years for someone to build up to have two weeks of take-home bottles,” says Kenneth Morford, an assistant professor of medicine at Yale who specializes in opioid addiction treatment in his clinical practice.
Almost overnight, the pandemic required a way to continue treatment while drastically reducing the volume of people accessing clinics daily. A change in federal guidelines now allows stabilized patients to receive a 28-day course of medication to take home, and a 14-day course for patients who are less stable but who—according to the treatment facility—can manage treatment by themselves. (Patients who don’t fit the profile can sometimes take home two doses.)
Another, similar innovation is the use of telemedicine for the treatment of opioid use disorder. Until early this year, buprenorphine, one of the medications used to treat opioid addiction, could only be prescribed through in-person visits with a physician. But as outpatient services were suspended to avoid unnecessary risks of coronavirus infection, the policy changed to allow prescription through remote visits. This dramatically expands the availability of treatment, particularly in rural areas where opioid addiction disorder is more prevalent, and there is a scarcity of providers. The impact of telehealth during the pandemic has been recognized by the White House, too, which included boosting boosting digital connectivity in rural areas as part of an executive oder to promote rural health.
“It probably would have taken us years to get to the point we got to in a couple of months,” says Patrick Marshalek, the medical director of West Virginia University (WVU)’s treatment center in Morgantown and a professor at WVU’s school of medicine.
Despite the challenges posed by the pandemic, there are a few positive consequences, too. For instance, Morford says he has seen an increase in patients asking to get on opioid addiction treatment rather than continuing to use illegal opioids, for fear of contracting Covid-19 from their dealers, or being unable to access substances and facing withdrawal.
But arguably the most important progress pushed by the pandemic is that it is helping doctors and healthcare providers de-stigmatize opioid treatment. “That has been one of our arguments, that we basically want to address addiction like other diseases, we cannot just be treating it completely differently,” Volkow says.
Requiring patients to get to a methadone clinic daily can make it difficult for them to thrive, Volkow explains, as such visits can be logistically challenging and easily interfere with work schedules or personal plans. Freeing people from that obligation, for instance by allowing distribution of the medications through pharmacies, increases retention of patients, because the barriers to treatments are lower and it becomes harder to miss doses.
“One of my patients said ‘It’s so nice to be able to have take-home bottles, because now it feels like another prescription,'” Morford said, adding that in other cases this has helped family members warm up to the idea of methadone as just another medical treatment.
The risks of easier methadone access
While there isn’t yet data to study the impact of having patients handle longer treatments of methadone, anecdotal evidence collected by Volkow and by David Fiellin, a professor of a professor of public health and director of Yale’s program on addiction medicine, suggests there hasn’t been a significant increase in overdoses linked to take-home bottles.
But there are challenges. One key issue, says Morford, is that opioid treatment programs currently include a lot of structure, and therefore provide structure to the patients. “The nurse who’s dispensing the methadone is putting eyes on that patient every day, so is able to assess them, so with extended take-home that assessment isn’t there,” Morford says. Patients might suffer from losing that structure, as well the routine access to medical counsel, or therapy.
And the risk that patients who are less stabilized might misuse their prescription does exist. “I did have a couple of patients who overdosed, and had overtaken their take-home bottles,” Morford says. “One of my patients said ‘I just couldn’t handle these take-home bottles; I am not used to having them and here I am at home, looking at several bottles.'”
There is another risk, too: what’s known as “diversion,” or patients giving their methadone to others, either by selling it on the black market or using their doses to treat friends or acquaintances experiencing opioid withdrawal. West Virginia clinician Marshalek for that reason prefers prescribing buprenorphine, particularly with the higher flexibility of telehealth. “There is risk with any [medication] being diverted, and I think that risk is maybe a little bit greater with diverted methadone,” he says. “[Buprenorphine] is still misused, and patients still can have an unhealthy relationship with it, but in and of itself it’s a little bit harder to overdose on than, say, if I got hold of some extra methadone.”