Louise Vincent of Greensboro, North Carolina, says methadone, a medication that curbs opioid cravings, lets her lead a normal life. “Methadone works best for me. It allows me to go to grad school,” she says. Vincent directs the North Carolina chapter of the Urban Survivors Unions, an organization of former and current drug users advocating for the human rights and decreased stigmatization of their community. She notes that even before the pandemic of the novel coronavirus, medication-assisted opioid treatment could have used improvements. “I am chained to my city,” she says, and estimates as many as 500 people show up to her clinic during the early-morning window when patients are allowed to pick up their daily medication. Especially for new patients, clinics typically distribute a dose a day per person, to help wean them off stronger drugs while preventing them from overdosing or “diverting” the drug to other people. Eventually, patients can take home multiple portions. The coronavirus pandemic has complicated an already fraught but essential treatment, as hundreds of people standing in line together goes against the six-foot social distancing recommendations from the Centers for Disease Control and Prevention.
For people addicted to opioids, daily visits to treatment centers for medication, syringe distribution, or other harm-reduction efforts can be a lifesaver. Now, as the COVID-19 pandemic worsens, providers are struggling to continue offering services safely. In March, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) updated its guidance for opioid treatment programs to allow participants to take home up to 28 days of doses. The Harm Reduction Coalition has also published national guidelines for participants and volunteers with organizations to continue giving out supplies, information, and other essential resources to the drug-using community, especially people who are homeless or have few other support systems. As opioid overdose deaths continue at a rate of nearly 4,000 per month, many providers vow to do whatever it takes to keep people safe.
As inconvenient as daily methadone dosing can be, it prevents the debilitating experience of opioid withdrawal. “You sweat, you’re agitated, you get diarrhea, you feel like you’ve got the worst case of the flu ever. Most people will you tell you they think they’re gonna die,” says Dr. Charissa Fotinos, an addiction-medicine doctor and Washington State Healthcare Authority’s deputy chief medical officer. “Opiate withdrawal is so uncomfortable that people can’t tolerate it, which is why it’s so important not to get them to that point. At a fever of 103, they’ll take whatever they need to.”
Fotinos is working to keep methadone patients in Washington from experiencing painful withdrawal, or worse — overdosing out of desperation to feel better. She helped draft state guidelines for opioid treatment during the COVID-19 outbreak. These included specific recommendations for people to receive take-home doses earlier in their treatment than they would under normal circumstances.
Washington guidelines now recommend most patients who need daily doses visit the clinic every other day, with the population split into two different pickup schedules, to halve the number of daily visitors. Depending on their “stability” as a patient, elderly people or those with other health conditions may take home up to two weeks of medication. Dose check-ins, where a doctor determines how much medication a patient is eligible to receive at one time, can now be done via secure video call, thanks to new federal guidelines for telemedicine.
“We tried to separate out people who didn’t need to be there,” Fotinos says. And they did so with the above-and-beyond support of representatives from SAMHSA and the DEA (“They gave us their cellphone numbers,” she says). They’ve been able to keep all 29 treatment facilities in the state open serving 12,000 people. Fotinos hopes the eased restrictions might even change the way people think about opioid treatment in the future. “Maybe this will calm the fear around managing people with substance-use disorders,” she says. “If we put the same restrictions around people’s insulin and blood-pressure pills, people would be dead in the street.”
In Vincent’s state of North Carolina, the Department of Health and Human Services has also increased flexibility in telemedicine and take-home doses for methadone patients “to help thin out the number of people in the waiting rooms and ensure access to medication,” says a representative for HHS. Yet Vincent says she still sees dozens of people in line outside her clinic in Greensboro. She and her fellow organizers are drafting an open letter to providers, encouraging them to request more take-home doses from the state. “When I have to go stand in line with all the people and there’s not quick action, I’m getting the message that I don’t really matter,” Vincent says. “There are people there with comorbidities like COPD. I would think the people who were the most at risk would be the people we take care of first.”
Vincent thinks providers are worried most about patients diverting their medicine to other people, something she claims is extremely uncommon among people who qualify for take-home doses. “I would say the risk to our health right now trumps the risk of diversion,” she says.
Outside of treatment facilities, harm-reduction organizations also aim to limit the negative impact of drug use, offering everything from safe-injection sites and needle exchanges to Narcan training sessions and distribution of clean syringes or fentanyl test strips. Now, many organizations are trying to marry safe-drug-use supplies and advice with information on preventing the spread of COVID-19, while keeping providers safe at the same time.
Christine Rodriguez, who recently launched a harm-reduction program in Baltimore with a focus on helping the drug-using community during “system-disrupting emergencies,” helped write nationwide guidelines for the Harm Reduction Coalition. Advice for users includes avoiding sharing pipes or nasal tubes, washing your hands before prepping drugs, and stocking up on Narcan and fentanyl test strips in case emergency services are overwhelmed by cases of COVID-19.
Mike Gilbert, an epidemiologist who volunteers with the Portland People’s Outreach Project in Oregon, says they’ve switched from a self-serve table where people take whatever supplies they need to “more of a lunch-counter format,” with prepackaged kits and bags they hand out. In a city with a significant homeless user population, he worries about social distancing during a chilly March. “People are doubling up in tents for warmth,” he says. “It’s hard to promote behaviors that are impractical to apply to people sleeping in a confined space.” Plus, staying together can help prevent overdose deaths. “People can go off on their own and sleep, but then for folks who use drugs, social isolation can lead to increased overdose risks.”
The People’s Harm Reduction near Seattle has provided mobile sinks at distribution sites so staff and participants can wash their hands. They also switched up the self-serve model of giving out supplies. “We have bags, everyone’s gloved up; we try not to have any physical contact,” says executive director Shilo Jama. “We’re dedicated to staying open.”
Getting treatment now may be an uphill battle. Bill Kinkle, a registered nurse who is in recovery himself while also working as a care coordinator at CleanSlate, a Philadelphia outpatient addiction-medication clinic, has seen drug users unable to begin treatment at in-patient facilities because of the pandemic.
“Several treatment centers I’ve called were requiring people to get tested for coronavirus before they’ll consider taking them in,” Kinkle says. “The ER will do a questionnaire and screening, but if you don’t have symptoms, they’re not testing you.” He says at least one recovery house he called said they’d essentially locked down and decided not to accept new patients for fear of bringing in the coronavirus. The situation is even more dire for those without housing. “There are people on the street experiencing homelessness saying, ‘I don’t want to do this anymore,’ and they’re being denied access to treatment.”
One bright spot Kinkle has observed is the loosening of restrictions on telemedicine, which can be useful for opioid treatment. “If I can’t get them down to the office, we can use Zoom or a telemedicine app and engage them right on the street corner,” he says. Most often, though, he just goes out with a pocket full of Narcan to hand some out and talk to drug users he meets.
“I know outreach workers are struggling with the idea of social distancing and self-quarantine,” Rodriguez says. “They don’t want these people out there without resources, information, and supplies. They are the folks who have the best relationships with the vulnerable, marginalized communities, with people who use drugs.” For providers, the HRC guidelines recommend measures like sanitizing surfaces in delivery areas and preparing for staff shortages due to illness.
Providers say they’ll keep coming out for their communities, though, to help however they can. “Needs-finding is the biggest thing right now,” says Gilbert, the night before taking supplies to users in Portland’s homeless encampments. “That’s gonna be my aim tomorrow. I need to hear what people are needing, and then I can work to provide that.”