High Wire is Maia Szalavitz's reported opinion column on drugs and drug policy.
Rose Bigham lives in the epicenter of Seattle’s COVID-19 outbreak, just a few miles from Evergreen Health Kirkland, the hospital where the disease has already killed 28 people. She visited their emergency room recently for an injury and may have been treated by one of the doctors who is now seriously ill from the virus, before he became symptomatic. Due to several complex pain conditions, the 51-year-old former Microsoft manager has not only been on disability since 2013, but also has a compromised immune system.
Nonetheless, she had to break state-ordered quarantine on Wednesday in order to get essential pain medications. And she will have to do so several more times, due to pharmacy regulations that do not allow controlled substance prescriptions to be electronically transferred from one drugstore to another.
Without her prescriptions, her health will be threatened by overwhelming pain complicated by opioid withdrawal symptoms—but when she ventures out, she is at high risk of catching the coronavirus. Bigham has never shown signs of addiction during her more than 10 years taking opioids, but she is still not allowed an early refill. Other patients across the U.S. are also reporting similar problems with both doctors who require in-person visits and pharmacies.
Meanwhile, patients taking opioid medications to treatment addiction—methadone and buprenorphine—are seeing the federal government lift barriers that restrict their lives by requiring them to visit clinics frequently, often daily. While the roll-out of this change has not always been smooth and some states and doctors are maintaining their own restrictions, it has been easier to make big changes in the addiction treatment system than it has been in the more fragmented chronic pain field.
The COVID-19 epidemic is revealing some strange truths about the United States' wildly ineffective policies towards opioids. Surprisingly, while plans for treatment for people who depend on methadone and buprenorphine to treat addiction are working reasonably well in some places so far, pain patients who need opioids seem to be getting much more haphazard care.
For example, while Bigham’s situation has been made worse by the crisis, Ayana Jordan’s methadone patients in Connecticut have simultaneously been freed from the red tape that requires many of them to visit her clinic daily. Jordan is an assistant professor of psychiatry at Yale School of Medicine.
Typically, for most patients, “take home” doses sufficient to last more than a week or two are difficult to obtain due to a mix of federal and state regulations that impose strict requirements.
During the pandemic, however, the federal government has begun allowing states to permit long-term, stable methadone patients to pick up a month’s supply at a time—and newer patients or those who have had recent relapses can get up to two weeks. Many states are facilitating the ability of their programs to make these medications available, which is a freedom that advocates have spent years fighting to obtain under more typical conditions.
“They're ecstatic in terms of that flexibility,” said Jordan of her patients, “But what is heart wrenching for me is that this is something that should have always been available to them…. I think it's absolutely criminal, quite honestly, that that administration literally waited until there was a pandemic in order to change regulations that should have been changed years ago.”
Indeed, addiction activists like Philadelphia’s Brooke Feldman have long argued that cutting the regulations that require daily or near-daily clinic visits and mandatory attendance at counseling sessions would help fight the overdose crisis. Research supports that view. But, until we had a pandemic that threatens the entire population—and not just people at risk of overdose—there was little momentum towards making this change.
This is not to say that pandemic planning for addiction treatment is going perfectly—nor to argue that all pain patients are being put at risk. I’ve heard from both addiction patients who have had pharmacy and clinic issues and from pain patients whose care has been smoothly handled.
For example, Vicky, a methadone patient in Manhattan told me that there was “mayhem” at her clinic last week after patients were told that everyone would get a month’s supply. However, only those who pushed their way to the front of the crowd were actually able to get that much and when she returned the next day, “they changed their tune,” she said. Now, the staff said they would determine take-homes for each person rather than giving everyone a month’s worth. At first, she was given only three days' worth, but as of Monday—after being made to wait outside in public again—she was given an additional 21-day supply.
And some states are not giving methadone patients the freedom that the federal emergency declaration allows at all, according to patients and experts who are following this aspect of the crisis.
Still, the overly restrictive system that regulates addiction care has clear rules that can be lifted during emergencies—while our far more vague policies about pain care mean that doctors remain scared to prescribe more freely, even when it should be permitted in a pandemic.
“The body of regulatory pressures that govern prescribing for pain in long-term recipients is not some neat restrictive rule that can be lifted or waived,” said Stefan Kertesz, professor of preventive medicine at the University of Alabama at Birmingham School of Medicine.
Again, ironically, this means that the strict rules that typically burden addiction patients are easier to remove in an emergency than the inchoate fears of doctors that their opioid prescribing will stand out to regulators or law enforcement. Methadone clinics know exactly where the lines are drawn, but pain doctors are allowed to use their judgment—until a state medical board or the Drug Enforcement Administration decides that they can’t.
Some surprising states are stepping up to take care of people with addiction. Indiana, for example, is best known in the addiction field for a 2014 HIV outbreak among people who inject drugs, an outbreak that then-governor Mike Pence facilitated by dithering for nearly a year before allowing health officials to provide a supply of clean needles. This week, however, Indiana announced that it would provide lockboxes for patients to store their newly-permitted monthly or biweekly methadone supplies, along with that the overdose-reversing drug naloxone.
Justin Phillips is executive director of Overdose Lifeline, which has been charged with distributing the lockboxes. Phillips herself is in recovery from alcohol and she lost her son, Aaron, to an opioid overdose in 2013. She founded the organization after learning about naloxone only after her son had died. She estimates that 4,000 to 6,000 boxes will be needed and her group is also providing doses of naloxone along with them.
That’s because, even though it would be hard for stable patients who take only methadone to overdose on it (even if they took extra doses early), overdose could occur if they begin taking it irregularly by skipping doses to take heroin or using it with alcohol or benzodiazepines.
Yale’s Jordan sees this risk as minimal for stable patients, noting that many patients make big sacrifices to attend the clinic every day, like taking multiple buses or driving for hours. They do that, she said, “because they want to stay in recovery, because they don't want to use.” She added, “The fact is that they're going to do everything possible, quite frankly, to protect their doses, because they don’t want to be dopesick. So it's not about taking it all at once to overdose or get high.”
Buprenorphine carries an even lower risk of overdose than methadone because of a pharmacological quirk: Increasing the dose beyond a certain point produces no additional changes in mood or breathing. This “ceiling effect” means that without mixing in other substances, overdose is rare and even then, it’s less likely than with methadone.
For those whose use is more chaotic and involves continued problematic use of substances, however, the risk is greater. Jes Cochran is the founder of the Indiana-based harm reduction group, the Never Alone Project, and has had personal experience of injection drug use. So far, she said, no one is reporting disruptions in the illegal drug supply, but that could happen and changes in supply are linked with overdose risk.
“I think our folks are going to take care of each other,” she said, “We always have because no one else has ever been there to do that.” Her group will distribute naloxone and is advising that people buddy up over the phone in order to support each other in case of an overdose. She also recommends that people call the Never Use Alone hotline if they are in isolation and have no other choice. This group provides verbal support to callers and will call for help if someone stops responding due to an overdose.
Another pandemic-fueled change that has encouraged advocates is the lifting of the regulation that requires that addiction patients be seen by a doctor in person before they can be prescribed medications like buprenorphine. During the epidemic, they will be able to consult doctors via telemedicine, which means many more people will be able to get into treatment. This will be particularly helpful for people who are homeless or disabled. (Telemedicine is now also allowed for opioid pain medication, but again, there is less clarity for physicians who treat pain about the exact rules.)
“It's game-changing in general for people who use drugs,” said Kim Sue, medical director for the Harm Reduction Coalition, noting that she will be able to start many more patients on buprenorphine immediately as a result. It will allow her to “see” people whether they are at home in quarantine or anywhere else that makes it difficult to get to a doctor’s appointment.
“The fact that they were so flexible and able to change these regulations in the setting of our emergency crisis right now reflects the bureaucratic indifference generally towards people who use drugs. Just being able to, like, snap their fingers and all of a sudden make this change. It's kind of sad and amazing at the same time,” Sue said.
Meanwhile, other long-awaited policy changes are improving care for people who take drugs. In Connecticut, according to Jordan, people with opioid use disorder and unstable housing are immediately being provided with free hotel rooms or other accommodations, so they can reduce risk to both themselves and others, while also having a safe space to store their medications.
In Baltimore, police are not arresting and prosecutors will not prosecute people for drug possession, essentially achieving decriminalization of use, a policy that advocates have long said is necessary in order to provide true medical care for addiction. Philadelphia has gone even further, refusing to prosecute or arrest people for any nonviolent crime during the epidemic, including drug sales. New York, Ohio and California are also releasing some people charged with drug crimes from jail (though not as many as activists would like), another policy change long sought by reformers.
No one wants a pandemic. But a great deal of good could come out of the cessation of policies that have long caused harm, particularly to the poorest and most marginalized people. Researchers at Yale and other universities are planning to study the outcomes of the relaxed regulations, increased housing access, and changed law enforcement. This means that for people with addiction, the post-virus world could possibly be more utopia than dystopia. Now, we have to ensure that similar changes are made to liberate pain patients—and that counterproductive laws and regulations are not re-imposed after the crisis passes.
Editor's Note: This story was supported by the journalism nonprofit, the Economic Hardship Reporting Project.
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