The pandemic has changed addiction treatment, and some hope the changes last
Medicines that help people stop using opioids are heavily regulated, and people seeking them usually have to navigate in-person doctor visits, daily stops at a clinic, frequent urine tests, and other requirements that derail or discourage many.
But, in response to the coronavirus pandemic, federal officials have loosened rules for the medications methadone and buprenorphine, in order to limit in-person contact between providers and patients.
The result is an experiment some experts have been seeking for years: making medicines for opioid addiction more easily available, then seeing whether that results in more people getting, and staying in, treatment.
"We think we're seeing beneficial things, but we want to formally test them to find out the positives and negatives," said Caleb Banta-Green, principal research scientist at the University of Washington's Alcohol and Drug Abuse Institute. "Are we able to get more people in care? Are we able to keep them in care longer?"
Methadone and buprenorphine are opioid medications that can be prescribed to help people stop using other opioids, such as heroin.
One rule change by the federal Substance Abuse and Mental Health Services Administration, or SAMHSA, allows doctors to prescribe buprenorphine virtually, without seeing the patient in person.
Banta-Green said, previously, patients had to schedule a face-to-face meeting with one of the relatively few doctors authorized to prescribe buprenorphine to treat addiction.
"Many people are not able, in the midst of their opiate addiction, to get to the two or three or four appointments they have to get to to finally get the medication," he said.
For buprenorphine patients who have access to phones for telehealth appointments, he said, there are signs no-show rates for follow-up appointments are "plummeting," meaning more patients are sticking with treatment.
But patients who are homeless and can't access telehealth, he said, aren't able to reap the benefits.
Another rule change by SAMHSA allows providers to give out 14-day or 28-day supplies of methadone to some patients during the pandemic. Usually, methadone patients have to show up at a clinic to take their dose under supervision six days a week until they're considered "stable" enough to take home multi-day supplies of the medication.
Banta-Green said the rules, in part, are a safety measure since methadone is a powerful opioid that can be dangerous for patients and people they live with. But he said he believes there's an element of stigma as well.
"There is this, in my opinion, kind of this control aspect to it: 'These are people who are addicted, addicted people are bad and untrustworthy, and therefore we're going to control their access to this medication because they don't deserve to be able to access it in other ways,'" Banta-Green said.
The loosening of restrictions during the pandemic, he said, gives researchers a chance to study whether supplying patients with longer-term supplies of methadone allows more people to access and stick with treatment.
"People have been asking for this for a long, long, long time," Banta-Green said. "The take-home restrictions for methadone, while they're understandable, they've been so onerous and over the top that we really feel like we need to try something different."
Banta-Green is among 12 members of the federal Interagency Substance Use Disorder Coordinating Committee who wrote a letter to federal officials last week asking for the rule changes to stay in place long after the pandemic, possibly for several years, so researchers can study their effects.
But, in other ways, the pandemic's upheaval has made life harder on people with addictions to heroin and similar drugs.
Syringe exchanges, lifelines for people who use heroin, have had to radically change how they operate, severely curtailing their ability to evaluate and connect with patients.
The Tacoma Needle Exchange, the oldest legally-sanctioned syringe exchange in the United States, has closed its drop-in sites around Pierce County and instead uses a van to deliver clean syringes directly to people who need them.
Paul LaKosky, executive director of the Tacoma Needle Exchange, said the number of people the organization serves is down by as much as three-quarters.
And the lack of face-to-face interaction, he said, means it's much harder for the organization to perform its secondary role as a clearinghouse for other forms of help.
"An outreach worker would say, 'Hey, you know that abscess looks really bad, do you want to see a doctor?'" LaKosky said. "Or, 'You sound really bad, do you have a cold or something?’ And we may have referred them for medical services. That’s not happening these days because people aren’t coming up to the site with the same frequency."
The medical and social services offered at the syringe exchange were, in some cases, the only services clients would get, LaKosky said.
"It’s their only link to the broader system of healthcare services," he said. "So if we turn them away there, there’s nowhere that they’re going to be able to access services."
The Tacoma Needle Exchange plans to experiment with re-opening one of its drop-in locations in August, using plexiglass barriers and other distancing measures.
LaKosky says, at that time, staff will get a sense of how many health problems have gone untreated over the past five months.
Another question that remains unanswered is whether the stresses of the pandemic are driving more people to use addictive substances. Banta-Green said there isn't conclusive data, but many of the known reasons people use drugs are present in people’s lives.
"Traumatic events, survival, financial insecurity, emotional escape," he said. "I mean, this is a very traumatizing time. All those things are going on right now."