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In cities across the country, morning is peak time at nearly any opioid treatment program. The line stretches from the front counter to the back door as patients wait to get their everyday methadone dose. It’s an indispensable gathering, but one that runs counter to containing the Covid-19 outbreak.
Efforts by health systems and governments to contain the spread of SARS-CoV-2, the novel coronavirus that causes the disease, have shown gaping cracks in our nation’s public health and safety net infrastructure. The virus seems to have an outsized effect on vulnerable Americans. We have now seen in a Seattle nursing home how suddenly the virus travels in close quarters.
It is required to do the same among the homeless and those who are incarcerated. Missing from the national discussion has been added an obvious group: patients like ours with opioid use disorder. Notwithstanding ongoing public health efforts, the opioid overdose crisis does not appear to be slowing down. The emergency of Covid-19 could worsen it if we do not preemptively develop and implement response plans.
The Centers for Disease Control and Prevention currently suggests social isolation as a crucial measure for individuals to prevent getting infected and to curb spreading it to others. Many patients taking medications to treat their opioid use disorder, methadone or buprenorphine, cannot stay home because of government regulations that limit how these medications are prescribed and dispensed.
In the United States, methadone can be dispensed only at greatly regulated and monitored opioid treatment programs. There are more than 1,250 such programs across the country that treat more than 350,000 people. Strict rules require most people to show up at the program every day to get their dose of methadone. A single opioid treatment program may see thousands of patients a day, a scenario that could foster the spread of the coronavirus.
How will these patients stay safe? Although the Substance Abuse and Mental Health Services Administration (SAMHSA) recently released a guide for opioid treatment programs dispensing methadone during the Covid-19 outbreak, achieving the guidelines is contingent on state regulations and falls short of what is needed.
Experts have called for updated regulations that allow office-based methadone treatment, but nothing has budged. There is now an urgency for this change to occur.
In the setting of an outbreak of an extremely contagious infectious disease, requiring patients with opioid use disorder to come to an opioid treatment program to get the medication they need to fight their addiction could have two adverse outcomes. First, individuals will continue to go and get their medication even though they have symptoms of Covid-19, possibly exposing other patients passing through the program and the medical staff caring for them to the virus.
A second possibility is that people will not — or cannot — come because of infection, leading to missed medication doses followed by opioid withdrawal and increased risk of recurrent drug use and overdose.Both outcomes would harm our patients. And if SARS-CoV-2 continues to spread, it will not be a matter of whether an outbreak will occur at an opioid treatment program, but when.
To reduce patients with symptoms from infecting others, outpatient clinics and urgent care centers have ramped up virtual visits, and insurance companies are expanding coverage for them. Federal agencies could mirror this approach by changing policies regarding methadone during a state of emergency.
They could make it possible for clinicians to use virtual visits to evaluate patients, allow all patients to take additional doses home, make it possible for surrogates to pick up quantities when someone is ill, or deliver amounts to those unable to come to the clinic. In Canada, pharmacies can dispense methadone. Federal agencies could allow U.S. pharmacies to temporarily do the same if an opioid treatment program shuts down due to an infectious outbreak or other unforeseen circumstance.
Natural disasters and emergencies can significantly disrupt manufacturing and distribution. After Hurricane Maria ravaged Puerto Rico, shortages of medically necessary intravenous fluids occurred in the U.S. The global spread of SARS-CoV-2 will likely lead to disruptions in drug and medication supply chains from outside the United States. For individuals with opioid use disorder, not getting a dose of buprenorphine or methadone could result in withdrawal and return to substance use. Government agencies and systems must act now to ensure an adequate supply of life-saving medications for opioid use disorder.
In the case of quarantine, patients have been advised to “stock up” on their medications, an option that isn’t available to those with prescriptions for controlled substances like methadone. Regulators must consider granting patients on controlled substances more extended drugs in preparation for shortages or challenges with accessing the health care system.
During unprecedented times such as a global pandemic, established protocols need to be modified to serve patients best and limit potential harms. Patients with addiction and their doctors deserve clear guidance about how to stay safe during such times.
