I had never been in trouble my whole life. Then I got in major trouble,” said Nikki, a 35-year-old woman in Maine who asked to be identified by her first name only. She was recalling the February 2019 morning when she was caught holding a bundle of fentanyl. Cops found her in her car, together with the friend of a dealer who she thinks set her up.
Nikki was lucky. That lack of prior trouble—and likely other privilege factors, like her white skin—meant she was able to slip away that day with only a court summons.
Eventually, her trafficking charge was dropped, and she was able to cut a deal for a deferred disposition for possession. If she stayed out of further trouble, she would avoid jail time altogether.
There was just one problem. Nikki was addicted to illicit opioids.
It has taken far too long, but treatment providers, lawmakers and other authority figures are starting to catch up with a consensus long held by science: Medication treatments, above all methadone and buprenorphine in the US context, are a critically important way to curb overdose deaths and other major complications from chaotic opioid use.
That’s great news—but unfortunately, some providers still don’t understand how much the amount of time it takes to access these treatments can impact not only people’s freedom, but their chances of survival.
For both reasons, Nikki urgently needed to find medication treatment. She had tried buprenorphine several times without success, but she’d always avoided methadone—or “liquid handcuffs,” as it was commonly called on the street.
She didn’t know much about methadone, but she’d heard it was “just as bad as dope,” and even harder to come off from. By then, with almost two decades of opioid addiction behind her, she’d also given up on herself, thinking her case was hopeless. No one had ever told her that some patients who don’t respond well to buprenorphine see great success with methadone.
They had an appointment for her—but only in two weeks’ time.
“I was starting to think nothing would work on me, but then I said, Fuck it, I will try this one last thing,” she told Filter.
Knowing she faced a felony charge and a prison sentence if she got caught copping again, she phoned the nearest methadone clinic.
They had an appointment for her—but only in two weeks’ time.
Nikki had no choice. She needed that appointment, and if they wouldn’t see her for two weeks, then she would have to wait two weeks—and hope her good luck held as she continued using.
“I just had to be really, really cautious, and I had to keep going out and doing what I was doing,” she said.
Nikki was highly motivated to make it to that critical appointment two weeks out. But for many patients, motivated or not, being forced to wait for treatment can end up being the difference between recovery and continued chaotic use, with all the attendant risks.
“What we’ve noticed is, making appointments for people to show up in two weeks are a lot less successful than having somebody come in and being able to take them in right when they’re there,” Justine Waldman, MD, a buprenorphine-prescribing doctor who runs a harm reduction-centered practice in Ithaca, New York, told Filter. She has found that patients who come in for walk-in appointments have much higher retention rates than those who call in and schedule future appointments.
“I think you can get increased engagement if you are better at…making sure the patient’s insurance data stays intact, making sure they have a cab to get to the appointment…making sure their meds won’t run out before their appointment, making sure prescriptions align; all of these various little things are important to keeping patents engaged,” she explained.
It’s common practice for some programs, particularly methadone clinics, to lengthen waits by only offering set induction days. Prescribing physicians may only come into the clinic on one or two mornings a week, which means new patients can only start treatment on those days.
“Those are the people we’re losing, those are the people who never come back.”
Keri Ballweber works as a peer support counselor at a buprenorphine clinic in Illinios. She told Filter that, similar to the model at many methadone clinics, her facility only has prescribing physicians available to meet with new patients two days a week.
“If the doctors are in, [patients] can get the script the same day,” she said. “But if they do a walk-in on any day besides Monday and Thursday, they don’t have a doctor to prescribe, so [the patient] can still do the assessment but they can’t get their medication.”
Then she echoed Waldman: “Those are the people we’re losing, those are the people who never come back.”
With opioid addiction, withdrawal can set in as early as the next day after use. For some heavy users, it can even begin within a few hours. For someone trying to quit, gaining quick and simple access to care is therefore crucial.
It may sound like nothing much to people who haven’t experienced it. But the wait between Tuesday and Thursday can feel like an eternity for someone who is facing withdrawal, turning tricks to pay for their habit, and who doesn’t want to anymore.
In the time between asking for help and getting seen by a physician, a patient may wind up in jail or in the hospital—or in the morgue, with complications like endocarditis or sepsis significant threats besides overdose.
Even if someone manages to avoid these more devastating outcomes, the chaos an untreated substance use disorder can invite into a person’s life may lead them to forget appointment times. Or to lack adequate means to get to the appointment—even if they had bus fare or gas money when they initially called. Or myriad other complications.
In other words, being able to see a patient right away, at that fleeting moment when they have both the means and the motivation to be there, is critical.
Yet on top of these inherent barriers for people with substance use disorder—and on top of programs’ lack of capacity or erection of unnecessary barriers—some US jurisdictions throw up yet another obstacle to patients receiving evidence-based care: prior authorization.
This refers to some insurance providers requiring added information from a physician before they will approve buprenorphine. For patients who can’t afford out-of-pocket costs—which can be several hundred dollars—these additional information requests can take several days to clear up. The clock keeps ticking for the would-be patient: As described in this blog from Health News Review, some have died while waiting.
On January 1, Governor Andrew Cuomo sparked protests on the streets of Manhattan when he vetoed a bill that would have removed the prior authorization requirement for Medicaid recipients in his state.
“A lot of people don’t continue their path for treatment once an obstacle is put in the way, and that’s the whole concept around low-threshold programs.”
Buprenorphine is certainly not the only medication for which prior authorizations are sometimes required. But because of the acutely dangerous nature of the condition it is primarily used to treat, many harm reduction and treatment advocates are calling for an end to this.
“A lot of people don’t continue their path for treatment once an obstacle is put in the way, and that’s the whole concept around low-threshold programs,” said Waldman.
Low-threshold or low-barrier buprenorphine programs are slowly gaining traction around the country as providers begin to recognize what Waldman has found at her clinic, and what Nikki experienced last year: Making opioid use disorder patients wait for treatment is disengaging and dangerous.
Mobile providers are gaining traction as an access point available to low-income people and those experiencing homelessness, who may face additional barriers surrounding transportation to clinics with static locations. Since 2017, a van parked outside of a Baltimore jail has offered immediate buprenorphine access to people released from the facility, as Filter has reported. Opioid-addicted patients who are detoxified while incarcerated are at significantly heightened risk of overdose upon release due to decreased tolerance, so providing targeted services is crucial when it comes to saving lives.
They may also help to reduce glaring disparities: The majority of patients inducting through this Baltimore pilot program, “Project Connections at Re-Entry,” were Black men, in contrast to national statistics, which generally see more white patients gaining access to buprenorphine.
In 2018, both Seattle’s government-funded syringe exchange and the People’s Harm Reduction Alliance (PHRA), a grassroots harm reduction service by and for drug users, partnered with medical providers to offer on-site buprenorphine on demand. A survey of the county program’s data found that the majority of patients were unstably housed—a particularly difficult population to retain through traditional treatment models.
For Nikki, methadone has been a lifesaver. She was able to get through the two-week wait without being arrested or buying an unsafe bag, and she managed to make it to her appointment.
She is overjoyed about the impact this has had on her life. “I can’t believe I didn’t do it earlier, it was like a complete life change,” she said. “It’s like, what? Why did I wait?”
But other patients don’t share Nikki’s luck. If we’re serious about saving lives, it’s time to learn the lesson and stop subjecting people at risk to this dangerous waiting game.