Covid-19 has streamlined addiction medicine. Will the changes stick?
MAY 12, 2020
Nicole Godinez’s monthly visit to an addiction clinic typically takes several hours: To start, there’s the 35-minute drive to a Nashville suburb, the waiting room, and the paperwork. Then the repetitive questioning from a drug counselor, then the drug test. Finally, there’s the in-person visit with a doctor who refills her 28-day prescription for Subutex, a common but highly controlled medication used to treat opioid dependence.
But in March, Godinez was sure she’d miss the appointment. She’d just delivered twins by C-section, and couldn’t drive. One of her 3-week-old boys was still in intensive care, and she refused to leave his side. And then, of course, there was the pandemic. In the previous two weeks, healthGodinez’s process was almost impossibly simple: She texted her doctor and a drug counselor, who briefly evaluated her via FaceTime and wrote a prescription that she filled at a Walgreens around the corner from her Hendersonville, Tenn., home — a process that, until March, would have been largely illegal.
“The first thing one thinks is, ‘Oh, my God, am I going to be able to get my medicine?’” Godinez, 33, said. “If I couldn’t get it through text, then I wouldn’t get it. I wasn’t going to leave my baby.” officials across Tennessee had reported 4,500 new coronavirus cases. Godinez thought she’d be forced to make an impossible choice: Her own care, or potentially exposing herself and her twins to Covid-19.
Instead, since their birth, Godinez has had an easier time than ever accessing addiction care, thanks to aggressive government reforms in response to the pandemic. Since March, federal officials have arguably done more to reform addiction medicine in the U.S. than they had in the two decades prior — expanding access to some treatments far more quickly and thoroughly than any of the legislative reforms Congress passed even at the height of the opioid epidemic.
Now, as they wield unprecedented freedom to prescribe addiction drugs by telemedicine and evaluate patients by phone, many doctors and advocates say they’re unwilling to relinquish that flexibility without a fight. Already, there is a burgeoning movement to keep many of the new policies in place permanently. Many treatment providers across the U.S. have said publicly that the new status quo represents long-sought change that could positively transform patient care for decades to come.
“You can’t put the genie back in the bottle,” said Stephen Loyd, a Tennessee addiction doctor who treated Godinez and who once served as the state’s drug czar. “This is how it needs to be — always.”
At first, as Covid-19 spread across the United States, addiction doctors and policy experts feared the worst. Between the stress, isolation, and financial hardship the pandemic has left in its wake, many assumed it would wreak particular devastation on the roughly half-million Americans with opioid addiction. One analysis published last week by the Well Being Trust, a public health group, projected that 75,000 Americans would die from suicide and overdose as a result of the pandemic.
The logistics of addiction treatment also became more complicated. Many clinics that provided syringe exchange services or walk-in addiction treatment closed, or reduced their hours, sparking concerns that rates of overdose, or transmission of HIV or hepatitis C, would spike. Others worried that some of the 30 million Americans who have filed new unemployment claims since the pandemic began might lose their insurance and their ability to pay for care.
Even in the face of tragedy, however, the coronavirus has created a natural proving ground for policies that many addiction treatment advocates have been pushing for years.
“The biggest scary part was: How are we going to make sure that we can maintain the same type of treatment availability, especially for people who are early in their recovery?” said Regina LaBelle, the program director for Georgetown University’s Addiction and Public Policy Initiative and a former high-ranking Obama administration drug policy official. “The really interesting part about this is that it’s provided a pilot to test out some of these new approaches.”
Many doctors have taken advantage of new regulations that allow them to prescribe buprenorphine without evaluating patients in person, instead conducting visits by video chat or even by phone.
Thousands of Americans who have long begun every single day with a taxing trip to an addiction clinic for a single dose of methadone, another highly regulated addiction drug, are now receiving 28-day take-home supplies, rendering the in-person visit and potential coronavirus exposure unnecessary. In New York City, some clinics have even delivered methadone supplies by courier — a 180-degree shift away from the federal government’s longstanding and heavy-handed regulation of methadone, an opioid that’s used to treat both addiction and pain.
“We’re seeing changes in the last six weeks that, in some cases, we’ve been advocating for a really long time, and in others, that we didn’t even really think were possible,” said Samantha Arsenault, the vice president of national treatment quality initiatives for Shatterproof, an addiction advocacy group.
The steps represent a stark acknowledgment from physicians and drug enforcement officials: That even for many vulnerable patients with opioid addiction, coming to the clinic could be more dangerous than staying home alone. Yet some doctors say that in some instances, it’s led to unexpected breakthroughs.
Loyd, the former Tennessee drug czar, said telehealth visits have allowed him to gain insight into his patients’ living situations, which has often led to critical discoveries about their life circumstances that he would otherwise have missed.
“I found three patients in the past two weeks that I didn’t know were homeless or living in a car,” Loyd said. “So we’ve been able to hook them up with some housing services that we have access to.”