Harm reduction organizations, providers, experts and advocates from across the US are calling on government agencies to eliminate the notoriously burdensome restrictions imposed on medication-assisted treatment (MAT) for opioid use disorder—a move they say would mitigate the dual crises of overdose and coronavirus.
Led by the Urban Survivors Union (USU), a national drug users’ union, the vast coalition has published recommendations on MAT delivery, access and prescriptions during the coronavirus pandemic for the Substance Abuse and Mental Health Administration (SAMHSA), the Drug Enforcement Administration (DEA) and other agencies.
The coalition’s demands come as federal agencies have loosened their stringent MAT rules and guidelines. The DEA has green-lit the use of telemedicine for prescribing buprenorphine and the addition of off-site locations for methadone delivery by opioid treatment programs. SAMHSA has increased the availability of methadone take-home doses.
“Treatment on demand could end the overdose crisis as well as substantially help flatten the curve of new COVID-19 cases.”
While the coalition describes these changes as “a step forward,” it notes that many methadone clinics have not implemented the new federal guidelines. Filter has described how clinics may deem that take-homes should only be offered to certain patients who meet stringent and problematic criteria. The coalition calls for all clinics to allow the maximum allowable take-home doses for methadone patients and also details several ways that these guidelines could be modified even further (for example, allowing methadone to be dispensed in non-clinic settings).
“Treatment on demand could end the overdose crisis as well as substantially help flatten the curve of new COVID-19 cases,” said Jess Tilley, a leader with USU. “Both continue to claim lives at a shocking rate every day in this country.”
Some people “are still attending [clinics] daily” USU member and methadone patient Nick Voyles told Filter of Indiana, where he lives. By requiring frequent attendance, these clinics are still “putting patients at risk for exposure” he pointed out. “You can’t social distance and tell someone to go to a clinic everyday.”
Voyles also has a friend living with cancer who “had to deal with getting a letter from her cancer doctor just to get 14-day of take-homes. She’s been on [methadone] for years.”
Disruptions in access can be dangerous. A patient may turn to the illicit opioid supply, which is heavily adulterated with fentanyl and other substances. Or they may go into distressing and harmful withdrawal. For Voyles, there are mental health implications, too. “Transitioning to a clinic where you’ve been stable for 10 years, it’s traumatic,” he said, speaking from his own experience of being kicked out of a clinic for accidentally using the wrong lid on his methadone bottle.
Among the measures “strongly recommended” by the coalition are: ending most non-consensual discharges from opioid use disorder treatment; suspending administrative detox; giving patients more control over determining the quantity and distribution location where which they take their medicine; and eliminating barriers that prevent clinicians from becoming authorized MAT prescribers. (The full text released by the coalition is at the end of this article.)
The call for action provides an “undeniably comprehensive outline that supports basic human rights,” said Tilley. “Any other approach is just inhumane and based on stigma and fear-based institutional idealism.”
“Methadone is the gold standard for treating opioid use disorder,” said USU President Louise Vincent, “but due to stigma and discrimination many people think that using MAT is simply changing one drug for another. This is not true at all. Methadone is a lifesaving medication that has personally changed my life for the better. I attribute my ability to finish graduate school, start a non-profit and work with a national group to the stability provided by methadone.”
As many harm reductionists have pointed out, the pandemic is only exacerbating the decades-long overdose crisis and the consequences of anti-drug user policies. The coalition’s demands therefore resemble measures already being fought for—but their significance is in part due to USU’s capacity to mobilize such extensive and multi-disciplinary support for the reforms in the face of a pandemic.
“Those signatures are unprecedented. Some of those people don’t even get along. But they can all agree on this.”
Among well over 100 supporting groups are key harm reduction and drug policy reform organizations like the Drug Policy Alliance*, the Harm Reduction Coalition and the Open Society Foundations*, among many, many others. Organizations whose core fields intersect with MAT to greater or lesser degrees—like AIDS United, National Advocates for Pregnant Women and Faith in Public Life—are also listed in large numbers. So are the likes of Faces and Voices of Recovery and the National Alliance for Medication-Assisted Recovery.
“Those signatures are unprecedented. Some of those people don’t even get along,” Voyles said. “But they can all agree on this.”
“In light of the evolving pandemic and the needs of the community, we must not allow fears of overmedication and diversion to outweigh the health risks caused by patients being forced daily to congregate in large groups, or being driven to an adulterated illicit drug supply,” stated the coalition.
For Voyles, the imperative is clear: “The stakes are life and death.”
In order to reduce the risk of COVID-19 infection, involuntary withdrawal, and drug poisoning, the Urban Survivors Union and the undersigned organizations strongly recommend the following measures be taken immediately:
1) The only acceptable standard for discharge of patients from OUD treatment during the COVID-19 outbreak shall be violent behavior that would endanger their own health and safety or that of other patients or staff.
2) Administrative detox shall be fully suspended during the pandemic and patients shall be provided the opportunity to request dose increases as needed, given that the illicit drug market will continue to experience fluctuations and patients need access to these life-saving medications. Patient doses shall not be reduced during the transition to take-home care unless they request adjustments to their doses, or documented medical emergencies require it and patients cannot consent due to medical crises, as may be the case with severe respiratory distress resulting from COVID-19 infection.
3) Referrals for COVID-19 testing shall be made available at all opioid treatment programs (OTPs), as well as syringe service programs. Staff shall receive training to recognize the symptoms of COVID-19 and be familiarized with protocols to refer patients for further testing. Harm reduction providers can also play an essential role in “flattening the curve” of transmission by identifying cases, making medical attention available to those who test positive, and teaching life-saving harm reduction skills to help people stay safe during this crisis. Plain language and evidence-based public health materials about COVID-19 prevention, symptom identification, and treatment should be available in locally prominent languages at all locations for participants and their communities.
4) During the COVID-19 national emergency, healthcare professionals–including doctors, nurse practitioners, physician assistants, and pharmacists–shall not be required to complete the previously-mandated training and waiver to prescribe these medications, thereby making MAT available in all settings. Prescribers shall not have limitations on the number of patients that they can treat. Naloxone and other overdose prevention tools (i.e. fentanyl test strips) shall be prescribed or made available with all dispensed medications in compliance with state law.
5) Opioid treatment programs (OTPs), prescribing clinicians, and pharmacies shall actively work to expand access to methadone treatment through the medical maintenance/office-based and pharmacy-delivery methods currently allowed by federal exception/waiver. The existing OTP regulations for the dispensing of MAT shall be temporarily adjusted to require all pharmacies to dispense these medications. This will reduce the risks of transmission associated with daily clinic attendance and person-to-person contact. In accordance with SAMHSA recommendations, lockbox requirements for take-home dispensing shall be suspended. Standard dispensing protocols for other opioid medications are deemed sufficient, since child- and tamper-proof bottles are already in use for methadone and buprenorphine. (Per SAMHSA’s TIP 43, Chapter 5: “Some programs require patients to bring a locked container to the OTP when they pick up their take-home medication to hold it while in transit. This policy should be considered carefully because most such containers are large and visible, which might serve more to advertise that a patient is carrying medication than to promote safety.”)
6) Take-home exception privileges shall be expanded to the maximum extent possible, limited only by available supply and operations for delivery. Any bottle checks that clinics wish to conduct shall be conducted by tele-medicine. Take-home schedules shall be authorized for individuals in all medical settings, including pharmacies and mobile vans. In light of new SAMHSA guidelines, clinics shall allow 14 to 28 days of take-home privileges to as many patients as possible. Patients testing positive for benzodiazepine or alcohol use shall be allowed the take-home privileges outlined in SAMHSA guidelines, but may be additionally required to check in via telemedicine for the purpose of decreasing the risk of adverse reactions, including overdose. Access to take-home doses is critical to keep patients engaged and retained in treatment.
7) Telehealth and service by phone shall replace any and all in-person requirements and appointments as the primary means of service provision until social distancing guidelines change. Toxicology requirements shall be suspended for the duration of telehealth-based services. Telemedicine services shall include waivered platforms, such as telephone intakes and video conferencing, as some patients may have different access needs.
8) The regulatory in-person requirements for methadone inductions shall be lifted in order to be consistent with the new policy changes for buprenorphine inductions. Clinic-based in-person appointments shall conform to social distancing requirements and OSHA guidelines for the management of the COVID-19 pandemic.
9) DEA restrictions on mobile medication units shall be revised to accommodate delivery of medications to individuals who are sequestered in their homes, are quarantined, or live in rural communities that are 15 miles or more from the nearest opioid treatment program.
10) State and federal Medicaid dollars shall be expanded to cover all costs for take-home medications not otherwise covered by insurance for patients experiencing financial hardship due to COVID-19. In states that did not expand Medicaid, the state shall be the payor of last resort.
In the interest of saving lives and adhering to existing public health protocol for management of COVID-19 transmission, it is necessary to make significant revisions to existing regulatory standards. This is a critical time to take decisive action for the protection of patients, providers, their families, and the community. As our healthcare system reaches full capacity and becomes overburdened by COVID-19-related emergencies, as seen in Italy and Spain, providers on the front lines will be forced to make life and death choices. These recommendations outline a plan of primary prevention that will minimize the burden on our healthcare system and save lives during this national emergency.
We, the undersigned, are a coalition of direct service providers, community advocates, public health officials, medical professionals, human rights groups, people in recovery, treatment professionals, members of impacted communities, and many others. We ask SAMHSA, the DEA, and all other federal, state, and local regulatory bodies and health authorities to adopt these recommendations fully and immediately in light of the COVID-19 pandemic.
*The Drug Policy Alliance and Open Society Foundations have provided restricted grants to The Influence Foundation, which operates Filter.
Photograph by Helen Redmond