There are many ways in which Covid-19 has dramatically reduced the U.S. opioid epidemic.
Routines are disrupted. Support networks not accessible. Shear reduction services, such as needle exchanges, are closed. Overdoses with opioids are up, chances for treatment are lower, and research has just stopped.
But despite the many delays, the pandemic is also pushing for some necessary innovations in the treatment of opioid addiction disorder. Among the most revolutionary is rethinking the need for daily visits to methadone clinics.
For the pandemic, patients treated with methadone had to receive daily doses at the nearest methadone clinic, long up to the established standard of treatment. “This practice was predicated on the belief that you can not trust the patient, that if the patient is given more than the daily doses they will overdose,” says Nora Volkow, director of the National Institute on Drug Abuse (NIDA)).
Patients would then gradually be given so-called ‘bottle privileges’, such as the ability to take extra bottles of methadone home – that comes in daily bottle doses – and go to the clinic every other day, or once every three days. Before Covid-19, this was a very slow process, requiring at least two years to build up to a one-week delivery. “It can take a period of years to build one to take two-week vials for home,” says Kenneth Morford, an assistant professor of medicine at Yale who specializes in treating opioid addiction in his clinical practice.
Almost during the day, the pandemic required way to continue the treatment, while the volume of people daily access to clinics drastically decreased. A change in federal guidelines now allows stabilized patients to receive a 28-day course of home-based medication, and a 14-day course for patients who are less stable but who – according to the treatment facility – can manage treatment by themselves . (Patients who do not fit the profile can sometimes take two doses at home.)
Another, similar innovation is the use of telemedicine for the treatment of addiction to opioid use. Until early this year, buprenorphine, one of the medications used to treat opioid addiction, could only be prescribed through personal visits with a doctor. But because outpatient services were discontinued to prevent unnecessary risks of coronavirus infection, the policy changed to allow prescriptions through remote visits. This dramatically expands the availability of treatment, especially in rural areas where opioid addiction is more prevalent, and there is a scarce provider. The impact of telehealth during the pandemic has also been recognized by the White House, which includes to promote digital connectivity in rural areas as part of an executive or to promote rural health.
“It would probably have taken years to reach the point we reached within a few months,” said Patrick Marshalek, medical director of the West Virginia University (WVU) Treatment Center in Morgantown and a professor at WVU School of medicines.
Silver linings
Despite the challenges posed by the pandemic, there are also some positive consequences. For example, Morford says he has seen an increase in patients asking to go on opioid addiction treatment instead of continuing to use illegal opioids, for fear of contracting Covid-19 from their dealers, if they are unable to to gain access to substances and for withdrawal.
But probably the most important advance driven by the pandemic is that it helps doctors and health care providers stigmatize opioid treatment. “That has been one of our arguments, that in principle we want to tackle addiction like other diseases, we can not just treat it differently,” says Volkow.
Requiring patients to come to a methadone clinic every day can make it difficult for them to thrive, Volkow explains, because such visits can be logistically challenging and easily interfere with work schedules or personal plans. Relieving people of this obligation, for example by distributing medicines through pharmacies, increases patient retention because the barriers to treatment are lower and it becomes more difficult to miss doses.
“One of my patients said, ‘It’s so fun to take bottles home, because now it feels like another recipe,’ said Morford, adding that in other cases this has helped family members warm up to the idea of methadone. than just any other medical treatment.
The risks of easier methadone access
Although there is still no data to study the effects of patients taking longer methadone treatments, anecdotal evidence gathered by Volkow and David Fiellin, a professor of public health and director of the Yale Addiction Program, suggests has been a significant increase in overdoses associated with home bottles.
But there are challenges. One major problem, Morford says, is that opioid treatment programs currently involve a lot of structure, and thus provide structure to patients. “The nurse who dispenses the methadone does the patient’s eyes every day, and is able to assess them, so with extended take-home, that assessment is not there,” says Morford. Patients may suffer from loss of this structure, such as routine access to medical advice, or therapy.
And there is a risk that patients who are less stabilized may abuse their presence. “I’ve had a few patients who overdosed, and had their bottles taken home,” Morford says. “One of my patients said, ‘I just could not take these bottles home; I’m not used to having them and here I am at home, looking at different bottles. ‘”
There is also another risk: what is known as ‘deviation’, when patients give their methadone to others, either by selling it on the black market or by using their doses to treat friends or acquaintances who experience opioid withdrawal. Westhal Virginia clinician Marshalek therefore prefers to prescribe buprenorphine, especially with the higher flexibility of telehealth. There’s a risk with each [medication] forwarded, and I think the risk might be a bit greater with diverted methadone, ”he says. “[Buprenorphine] is still being abused, and patients may still have an unfavorable relationship in it, but on its own it’s a little harder to overdose than, say, if I have some extra methadone in my hands. “
