Helping patients stay in recovery from an opioid addiction was never easy. The coronavirus crisis made it harder.
Nationwide, addiction treatment clinics are expanding their hours, hiring more staff to take people’s temperatures, providing home delivery and curbside pickup for medication, and revamping procedures to limit human contact in what has been a high-touch health care service.
Without more money, the cost of retooling their services could put some providers out of business.
At West Midtown Medical Group, a methadone clinic in Manhattan, New York, the once-routine business of providing roughly 900 patients a daily cup of lifesaving addiction medicine has been upended.
Allegra Schorr, one of the clinic’s owners, predicts much more change in the weeks ahead.
“The reality is that there are just no good answers here,” Schorr said. “Every day we use our best clinical judgement to limit transmission of the virus. But at the same time, we’re trying to keep our patients in treatment and protect them from overdose. It’s a balancing act, and it’s extremely challenging.”
In mid-March, the federal agencies that regulate addiction treatment medications methadone and buprenorphine temporarily loosened some long-standing rules.
The two medications, both narcotics, have been shown to be at least twice as effective at helping people stay in recovery from opioid addiction as therapies that do not include medications. (A third medication approved by the U.S. Food and Drug Administration, naltrexone, sold in injectable form as Vivitrol, is not a controlled substance and doctors do not need a special license to prescribe it.)
The Substance Abuse and Mental Health Services Administration and the Drug Enforcement Administration ruled that methadone clinics could allow most patients to take home several days’ or weeks’ worth of medication, packaged in individual doses, instead of requiring them to show up at a clinic every day and risk exposure to the virus.
And the DEA gave physicians and nurses authorized to prescribe buprenorphine, which patients can take at home, the flexibility to begin patients on the drug using telemedicine and phones instead of an in-person visit, which has been required.
Methadone clinics, however, are still required to perform a thorough in-person physical exam before starting patients on that anti-addiction drug. An industry trade group, the American Association for the Treatment of Opioid Dependence, asked SAMHSA to allow providers to substitute an exam performed through telemedicine. The agency said no.
For both medications, however, SAMHSA agreed that counseling and medication management could be conducted by phone or telehealth technology.
The treatment providers Stateline contacted for this story — who run outpatient clinics in Alaska, Arizona, California, Indiana, Louisiana, Maryland, Massachusetts, Montana, Michigan, New York, North Dakota, Ohio, Rhode Island, Texas, Wisconsin and Wyoming — all said they were using one or both methods to reach patients.
So far, the federal government hasn’t advised residential treatment programs — where patients live together and are seen daily by providers — on how to curtail the virus’s spread.
Instead, state health departments are filling the gap, said Mark Dunn, director of public policy for the National Association of Addiction Treatment Providers. “States are way ahead of the federal government on this,” he said.
New Jersey, for example, was first to require checking everyone’s temperature before entering treatment property. Most state health departments have been quick to provide the recommendations and resources providers need to stay as safe as possible right now, Dunn said.
In general, the addiction treatment industry and addiction physicians are encouraging people experiencing addiction to seek treatment despite risks related to the coronavirus crisis.
“Now is not the time to avoid treatment,” said Dr. Yngvild Olsen, medical director for Baltimore treatment center Institutes for Behavior Resources and vice president of the American Society of Addiction Medicine board of directors.
“There are rumors that treatment programs are shutting down and not taking any new patients.” For the most part, Olsen said, that is not true.
“The big concern is, ‘How do you reduce anxiety and maintain connectedness for individuals for whom isolation is often a characteristic of their disease?’” Olsen said.
The addiction medicine group is updating its website with the latest federal and state guidance on how to treat addiction safely, as well as its own guidance on all facets of addiction treatment.
For people in recovery from opioid addiction, social isolation can trigger relapse. And research indicates that natural disasters, war, financial collapse and other major crises can lead active users to increase their intake as a means of coping.
At the same time, the illicit drug trade appears to be thriving, according to the National Drug Early Warning System, and the deadly drug fentanyl, which is responsible for most opioid overdose deaths in the United States, is still cheap and plentiful.
Despite predictions of a coming surge in addictions, treatment providers interviewed by Stateline did not report an increase in demand for services since the coronavirus crisis began in early March. In fact, some said they had seen a slight decline in new cases.
Still, psychiatrists and addiction experts say that as more people in recovery relapse and vulnerable drug users seek help, treatment providers should expect a surge in new patients.
“But I think that a lot of the treatment world is in essence paralyzed because they don’t have certainty about how to move forward,” said Dr. Alphonse Roy, professor of addiction medicine at Tulane University and medical director for Longbranch Healthcare, a residential treatment center in Metairie, Louisiana.
Based on his experience in New Orleans after Hurricane Katrina in 2005, Roy said he expected addiction, mental illness and suicides to rise in the coming months.
“I heard about the horrific impact addiction would have on people who were affected by Katrina,” he said. “But I didn’t see it in the treatment environment until several months and, in some cases, years later.”
For now, Dunn of the treatment providers association said, most treatment centers are using standard infectious disease precautions while still taking in new patients.
But some have cut operations because of sick staff and patients and a lack of supplies such as personal protective equipment, he said.
Another major problem, Dunn said, is maintaining the income needed to cover the additional costs of taking everyone’s temperature before they enter the clinic, providing extended hours to avoid crowding, offering home and curbside medication deliveries and other necessary precautions.
On top of that, some residential treatment providers reported a dramatic increase in patients who leave treatment against medical advice. Many fear infection and want to return to their families.
And families planning an intervention and individuals who may have resolved to seek treatment are now putting those decisions on hold. That limits providers’ ability to cover overhead expenses, Dunn said.
For methadone clinics, the cost of extra medication and staff needed to create take-home doses, as well as the extra security to store the medications, also has created cash flow problems.
In Cranston, Rhode Island, Linda Hurley, CEO of CODAC Behavioral Healthcare, a nonprofit addiction treatment provider with eight clinics in Rhode Island and one in Massachusetts, said she’s counting on help from the state’s Medicaid agency, which insures the vast majority of their patients.
CODAC and other providers have asked Rhode Island’s Medicaid agency to pay for treatment a month in advance, based on the average of the past three months’ reimbursements, as Medicaid agencies in at least four other states have done, she said.
“We’re doing what we have to do for patients,” Hurley said, “but someone soon will have to help us if they want us to continue.”
In New York, Schorr, who heads the state’s Coalition of Medication-Assisted Treatment Providers and Advocates, has asked New York’s Medicaid agency to recalibrate its payment structure to account for an increase in take-home medications.
As it stands, Schorr said, treatment facilities are paid by the number of patient visits. If those visits are cut in half because of take-home medications designed to limit patient exposure to coronavirus, that means revenue is cut in half. That needs to change, she said.