“I’m great! I’m having so much fun!” Bill Kinkle tells me on the phone.
His happiness is jarring. After hours of phone interviews with a variety of attorneys, patients and healthcare workers, each one beginning with an obligatory sigh and update about life in the midst of COVID-19, I don’t know how to respond to Kinkle’s joy. If it had been a text message, I would have assumed he was being sarcastic. But his jubilance sounds sincere.
Cautiously I ask him what’s going on—what’s got him in such a good mood?
He tells me he’s walking the streets of Philly, talking to people who he identifies as possibly addicted to drugs, offering them low-barrier treatment. Kinkle is a care coordinator at CleanSlate Outpatient Addiction Medicine, a treatment provider that offers opioid use disorder medications in the forms of buprenorphine and naltrexone.
Armed with a smartphone, he began offering people the chance to engage with a doctor right then and there—and walk away with a buprenorphine script.
Prescribing laws around such medications are stringent, particularly for opioid-based therapies like buprenorphine and methadone, but the federal government recently relaxed many regulations as part of the attempt to slow the spread of the novel coronavirus. This includes several changes by the Department of Health and Human Services to the rules governing telehealth, giving providers more leniency around how and where they can engage in electronic health communications. The Drug Enforcement Agency (DEA) also temporarily suspended a law that required buprenorphine patients to see an X-waivered physician in person at least once before being able to receive prescriptions by telemedicine.
When those changes took effect, Kinkle (who has written for Filter) hit the streets. Armed with a smartphone, he began offering people the chance to engage with a doctor right then and there—and walk away with a buprenorphine script. He obviously wasn’t happy about the pandemic, he was just excited to finally have the ability to offer people truly low-barrier, evidence-based treatment—the way it should always be.
“A lot of people I meet on the street, they are so used to having strings attached to treatment,” said Kinkle. “A lot of people say, ‘We don’t believe you.’” In fact, at the time we spoke, nobody had yet taken up his offer to utilize telehealth, although a few people did accept his facility’s other offer of a complimentary rideshare to the clinic.
Why was it so hard to gain access before, when it’s now suddenly so simple?
The current regulatory situation is exactly what Kinkle and countless other advocates have been pushing for. But why was it so hard to gain access to these measures before, when it’s now suddenly so simple? And what does that say about how our government and our society view people who use drugs?
“I’ve been advocating for increases in funding for [medication-assisted treatment], increases in access and general societal acceptance of MAT for 15 years, and I’m always pushing the boulder up the hill,” said Kevin Moore, a clinical psychologist and administrator at Crossroads Treatment Centers, which has branches in multiple states, and author of the book Integrative Medicine for Vulnerable Populations. “We are always chipping away and chipping away and doing our best [to advocate for better access to evidence-based treatment], but things don’t change much. Then in one week they change everything for a virus that [so far] kills a fraction of the people [compared with] opioids.”
Alongside lifting of telemedicine restrictions, some of the sweeping but temporary changes include allowing opioid treatment providers—often called “methadone clinics”—to dispense up to 28 days of take-home methadone to patients considered by clinics to be demonstrably stable, or 14 days to those considered less stable but still able to handle it.
Under normal circumstances, most methadone patients in the United States have to dose while being observed at their clinics every day, slowly “earning” individual take-home doses over months and years of program compliance. Typically that means that their drug tests are negative for all non-prescribed substances, including alcohol and marijuana, and they have stable housing and are not displaying symptoms of acute mental illness. Most clinics are only open for a handful of hours each morning, making daily dosing incredibly restrictive. Patients are often left to navigate personal barriers on their own, sometimes having to choose between keeping a job with early hours and getting their medication, for example.
Now, clinics are suddenly able to give out multiple doses at a time in order to limit viral transmission. Although not all clinics are taking full advantage of the relaxed regulations by giving out 28 days’ supply to everyone, many are offering one or two weeks of take-homes to patients who are used to coming into the clinic six or seven days a week.
Methadone and buprenorphine patients around the nation also report relaxations of rules surrounding group and individual therapy; some group meetings are canceled altogether, while telehealth is being widely utilized for one-on-one sessions.
But even with these changes, patients still face problems that other people don’t. During a time when people are being labeled “vectors” for making grocery runs, many methadone and buprenorphine patients have no choice but to make frequent trips outside.
They expressed gratitude at still having access, but also wish they could go into the clinic less often, to reduce potential exposure to the virus.
Sioux, a 39-year-old methadone patient in Missouri who asked to be identified only by their first name, recently switched from buprenorphine to methadone and has not been at their new clinic very long. Until last weekend they only received a single take-home dose for Saturdays, when the facility was closed. They now receive an additional take-home dose for Sunday. They expressed gratitude at still having access to their medication, but also wish they could go in less often, to reduce potential exposure to the virus.
“I’m more concerned about if the buses stop running,” said Sioux. “If they do, I would not have a way to get to the clinic. It would take an hour to walk, both ways.” Transportation is one of many interrelated problems that affect patients during this time, even if providers themselves remain open.
Another issue that is likely to become more acutely problematic in the next two-to-three weeks is how self-pay patients who have lost wages will fare once those last paychecks run out.
For people who use illicit drugs, all of the issues facing addiction medicine patients are compounded by the illegality and harsh stigma they face, lacking even the slight-albeit-fickle approval afforded to those engaged in treatment.
“We would have anywhere from 10 to 15 people just kind of being with us everyday [in our drop-in center], usually people who are experiencing homelessness or trying to maintain some semblance of stability and connectedness to people,” said Chris Schaffner, program manager for the JOLT Foundation, a harm reduction provider in Central Illinois. “With restrictions on the number of people who can gather…we are not able to do that right now. That breaks our hearts.”
Their syringe distribution program is still running, but at a much slower pace. They are only allowing one person through the doors at a time, and clients are not able to collect items themselves. Instead, the staff, like those at many other harm reduction programs, are bagging requested items like sterile syringes and water, and other supplies needed to mitigate the harms of injection drug use.
It demonstrates with glaring, unflinching clarity that many of the rules that have been in place for decades don’t make sense.
For patients who don’t report symptoms of illness, they receive their bags at the door. For those who aren’t feeling well or who may have had contact with someone who is infected with the virus, staff bring the bags to the curb. Schaffner said that he’s working with the local health department to try to lift bans in Peoria County that currently prevent his organization from engaging in mobile delivery of syringes.
Still, the number of people the center serves has declined over the past two weeks, which concerns Schaffner. He is worried that people will resort to reusing syringes if they aren’t able to get in for supplies.
The urgent need to dramatically change policies in order to continue access to essential services for people who use drugs demonstrates with glaring, unflinching clarity that many of the rules that have been in place for decades don’t make sense. And the fact that so many people are still being left behind even with major relaxations to policies and laws—whether through unwillingness or unreadiness—eclipses any attempt to pretend that these populations are not treated as second-class citizens.
“What it says to me, and what I think many of our people who access our services feel it’s saying is, ‘These people are disposable,’” said Schaffner. “They’re not important, they’re an afterthought. Public health strategies don’t center on the marginalized—they’re scared to death out here.”