Melissa Weitzel was one of the “lucky” ones. After two years in a treatment plan for opioid use disorder, the 25-year-old earned permission to take home up to four daily doses at a time of methadone, a medication that significantly reduces patients’ risk of relapse and fatal overdose. That meant she had to take the 30-minute bus ride to her treatment clinic, outside of Philadelphia, just three times a week; she’d started out having to travel to the clinic nearly every day to take doses on site.
Now, the Covid-19 pandemic has made Weitzel’s life even easier — and dramatically changed the routines of hundreds of thousands of other methadone patients across the U.S. That’s because in March, in recognition of the evolving issues surrounding Covid-19, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Administration (DEA) eased restrictions on access to methadone. States may now allow “stable” patients — those with a track record of showing up for appointments and abstaining from illicit drug use, among other criteria — to take home up to 28 days of doses. Newer patients can be permitted up to 14 days’ worth. Previously, most methadone patients were required to come to the clinic on all or most days to receive their medication.
The government has also loosened regulations on another effective treatment for opioid use disorder, buprenorphine, which is less restricted than methadone. An initial medical evaluation previously had to be conducted in person, but due to the declared public health emergency, licensed prescribers can now start prescribing buprenorphine to new patients remotely via telemedicine or phone, without ever seeing them face-to-face. Many clinics that require mandatory counseling are also permitting patients to attend those sessions by phone or video chat. Though these changes have been applied haphazardly from state to state and clinic to clinic, sheltering-in-place and social distancing would be all but impossible for these patients without them.
“It feels like now I’m on just a normal medication like everyone else,” Weitzel said. “I feel less like I’m different. Like, if I want to go see my parents and sleep over or something, or if I get called into work for an early shift, I don’t have to worry about going to the clinic every morning.”
Weitzel’s take-home allotment is currently at the lower end of the new guidelines; she receives seven take-home doses at a time. But what may sound like a small change has made her life much easier. “I just take my medication at home in the morning without anyone watching me. It just feels better,” she said. “I was just speaking to my counselor saying, ‘Dang, it’s really gonna suck when it goes back to normal.’ Those of us doing fine with this many take-homes are gonna be like, ‘Well, why can’t we keep them?’”
So, why can’t she?
Although methadone and buprenorphine are much longer acting than oxycodone or heroin and produce little to no euphoria, they are still opioids, and to differing degrees they activate the same receptor sites in the brain as other opioids. As such, they’re mired in red tape and burdensome regulations that have hindered their accessibility, even during the deadliest overdose crisis in recorded history. Entrenched fears that patients will misuse the medications or exchange them on the illicit market have long governed how, when, and where patients can receive these life-saving medications — and which doctors can prescribe them. But the coronavirus pandemic is proving those age-old fears and stigmas to be unfounded, while revealing new and better ways to treat hard to reach patients.
I spoke with several patients and providers about what the new treatment landscape has been like since the regulatory tweaks have been put into place. The response has been overwhelmingly positive. Like Weitzel, many expressed a desire to keep the new normal.
Hansel Tookes, an assistant professor at the University of Miami Miller School of Medicine, agrees that the fewer barriers for patients like Weitzel, the better. “The barriers to starting [medication] — the man-made barriers — are nothing more than perpetuation of the punitive, carceral culture that we use to treat substance use disorders,” he said. “Low barrier medications for opioid use disorder is one of the key components to using a scientific approach to mitigate the opioid crisis.”
The new way of doing things is both more humane and more scientific. For buprenorphine, new patients can undergo their evaluation by telemedicine appointment or over the phone, from the comfort of their own home. This allows them to avoid the humiliation of showing up to emergency rooms and clinics in withdrawal, and it saves already overwhelmed hospitals and emergency departments from unnecessary visits. After the evaluation, the prescription can be electronically submitted to a pharmacy and picked up just like any other medication. Typically, new buprenorphine patients receive a weeklong supply, which can be increased to a monthlong supply over time, and follow-up visits can also be done remotely.
“The barriers to starting [medication] — the man-made barriers — are nothing more than perpetuation of the punitive, carceral culture that we use to treat substance use disorders.”
“Of all of the things that have gone wrong with this pandemic, this is one good thing that has happened,’” said Laurel Hallock-Koppelman, a family nurse practitioner and an assistant professor at Oregon Health and Science University in Portland, who started prescribing buprenorphine remotely via telemedicine during the pandemic. “It’s really easy to do from home. It’s really easy to keep a patient in their safe space.” She said that’s important because a lot of her patients with substance issues have been stigmatized and harmed by the medical field in the past, which becomes yet another barrier to overcome in their treatment.
“That’s the difference,” Hallock-Koppelman said. “They’re in their home or where they’re living, wherever they’re staying, and they can be real.” She also noted that having fewer visits to the clinic, including for mandatory counseling and follow-up appointments, creates more opportunities for her patients to work or save money they would have had to spend on expensive child care.
Indeed, Weitzel mentioned that she’s saving money now by only commuting to the clinic outside Philadelphia only once a week. “If I was running late, I have to take an Uber, which could be expensive. Now, I’m saving money,” she said.
Joan Fleishman, a psychologist and program coordinator at OHSU, said the new rules align with a harm reduction approach, which aims to “meet patients where they’re at” –– only now, it’s quite literal. “This has allowed us to start treating opioid use disorder just like any other chronic condition,” Fleishman said. “It’s allowing the access that many of our patients who are entrenched in their substance use disorder need, and we’re seeing patients who were not able to engage with our program in-person actually begin to re-engage with us with telephone and virtual visits –– they’re showing up!”
Since 1999, more than 750,000 people have died from drug overdoses in the U.S. The Covid-19 pandemic is now colliding with the overdose crisis and creating a storm of risk factors for people with addiction. Social isolation, financial shock, and unemployment are all potential triggers. Nora Volkow, the director of the National Institute on Drug Abuse, recently told Politico that she predicts overdose deaths will spike again due to the effects of the pandemic. “We can’t afford to focus solely on Covid,” she said. “We need to multitask.”
One way to ensure that overdose deaths don’t jump during this period of isolation and uncertainty is to listen to public health experts and advocates, who for years have been demanding easier access to treatments of opioid use disorder. They’re finally getting what they want, though how long it will last is unclear. A SAMHSA spokesperson told Mother Jones that the relaxed policies will hold during the pandemic. For now, it’s an open question what treatment will look like when the threat subsides.
Yes, it will be important to study the impacts of these relaxed regulations to understand whether they increase or decrease drug-related harms. But so far, the sky isn’t falling because people are showing up for fewer appointments and jumping through fewer hoops to access the medication they need.
Just as the overdose crisis will outlive this pandemic, so should these more lenient rules.