Getting treatment for an opioid use disorder can be complicated, often requiring daily visits to receive addiction medication under the supervision of a provider. While guidelines have been relaxed to reduce barriers for those seeking care, it’s not clear how effective the changes have been.
“Their barriers are huge here,” said Kim Brown, the founder of Quad Cities Harm Reduction (QCHR), “and they’ve been exacerbated by the pandemic.” QCHR distributes supplies, including naloxone, the medication used to reverse opioid overdoses, to drug users across Illinois and Iowa.
On this episode of the podcast we speak with Brown about how the pandemic is affecting access to opioid treatment as providers navigate a new regulatory landscape.
Since January 2020, Direct Relief – through a donation by Pfizer – shipped 863,680 doses of naloxone to harm reduction groups, clinics and health centers across the United States, including Quad Cities Harm Reduction, which received 650 doses of naloxone, as well as personal protective equipment for their volunteer staff.
Getting treatment for an opioid use disorder can be difficult. During a pandemic it’s even harder. People are navigating a changing landscape with shuttered programs and ambiguous new treatment guidelines. And they’re doing it even as overdoses are on the rise.
BRENDAN SALONER: I think what’s really changed is that with the pandemic many programs, frankly, just shut their doors.
Brendan Saloner is a professor of health policy and management at Johns Hopkins University. He studies access to treatment for those with opioid use disorders.
SALONER: I think, you know, there was a moment of panic back in March when places realized this was spreading very fast and nobody really knew how to contain it. So, in that immediate aftermath of the emergency, there was this move to completely shut off these points of connection with care. And for many patients that was very devastating. People lost one of their main sources of continuity, not only with medication and with treatment, but also with the community of people that was there for them and part of their support network.
For many opioid treatment involves taking one of two drugs: methadone or buprenorphine. These are both opioids that act by binding to the same receptors in the brain as heroin or oxycodone, but they don’t have a euphoric effect. They help by reducing cravings and preventing withdrawal symptoms.
During the pandemic, the federal government has lifted certain regulations around the prescription of these drugs. The intention is to reduce barriers as social distancing and shutdowns make getting to a doctor’s office more difficult, but it’s not clear how effective these measures have been.
RAFANELLI: What regulatory changes have been made around prescribing addiction medication?
SALONER: So it’s still the case that patients can only get methadone through opioid treatment programs. What happened under the regulatory changes is that patients can now get more days of what’s known as take-home methadone, meaning methadone that they’re allowed to take out of the clinic and give to themselves at home, so that was a big deal. And that was done very deliberately to try to reduce crowding in the clinical setting. For buprenorphine, right now it’s still is the case that not every doctor or clinician can prescribe buprenorphine. It’s also regulated under a separate set of federal regulations called the X waiver. So to get buprenorphine a doctor has to have this additional credential or license from the federal government. So the X waiver still exists, even though there was some attempt recently to get rid of it. But what has changed is that doctors that prescribed buprenorphine right now are not needing to meet the same kinds of face-to-face requirements around initiating patients and then continuing patients in their treatment. So there again the intention has been to try to limit the number of times the patients actually have to come into their doctor’s office to get their medication.
But the new laws are somewhat ambiguous leaving it up to providers to interpret.
SALONER: The real tricky thing is that, although there has been some greater allowances of this take-home methadone–you know, allowing patients to not have to take the medicine every day in the clinic under observation–not a lot of guidance is out there about who should be eligible for take-home methadone. The federal regulation is pretty ambiguous about what a “stable” patient is who would be eligible to get up to 28 days of take-home methadone. And that ambiguity has, I think, given rise to very, different kinds of treatment protocols in different clinics. Some clinics are having those patients coming in very often to get their dispensed medication.
That’s been the experience of Kim Brown who runs Quad Cities Harm Reduction in Iowa and Illinois. The group distributes supplies to people who use drugs, including Naloxone or Narcan–the medication used to reverse opioid overdoses.
KIM BROWN: I founded QC Harm Reduction officially in 2015, but we were out on the streets slinging Narcan from 2012 onward. I’d get my hands on Narcan one way or another and it went to the drug users in our community.
She says during the pandemic, many of those enrolled in opioid treatment programs haven’t benefited from the new rules.
RAFANELLI: Can you talk about the regulatory changes and how they’re affecting the drug users that you know?
BROWN: Folks with an opioid use disorder, who are a protected class under the ADA, were supposed to get take-homes for a month, at the least take homes for two weeks, to keep them safe. They didn’t follow those mandates. If somebody had drugs in their urine, they refused to give them take homes and demanded that they get on the city bus or try to find a ride to get to the clinic every day between 6:00 AM and 12:30 to get their dose during a pandemic. Those are the barriers that have been placed in front of our participants.
According to the law providers are allowed to administer urine tests to patients undergoing opioid treatment. When and how frequently is up to their discretion. And because guidelines around what is considered stable and unstable are vague, some providers may use a urine test to decide. As Brown has found, those deemed unstable may not be eligible for multiple weeks’ worth of take-home medication, meaning they need to go to a clinic every day to take their prescription.
While the pandemic has made accessing daily treatment more difficult, providers are experiencing challenges of their own.
RAFANELLI: Tell me a little bit about how the pandemic is affecting your operations at QC Harm Reduction and the people that you reach.
BROWN: In January and February we were really getting up and running over in Rock Island, getting all our services set up and we were paying attention to the pandemic, but I don’t think anybody realized the significance of it, right, until it got significant. So, I think part of the struggles for our drug users is many of them are unhoused. The shelters decided to house all of our unhoused folks–well, as many as they could–in the motels on the outskirts of town. They could be in Davenport, they could have been over here out by the airport, they could be in Bettendorf, but they housed them in motels to help people stay physically distanced from other folks and to try to keep folks safe. Once that happened, it was kind of like everybody scattered. Does that make sense? Once they were in the motels, then they had rules to follow. It was almost like everybody quit moving around in the Quad Cities. And when we went out on outreach to find the folks that were moving around, they were very seldom where they always were before the pandemic started. They were indoors door shut away, following rules and not out engaging with us on a weekly basis.
Across the nation, drug overdoses have increased substantially during the pandemic, according to data released by the CDC.
Drug related deaths were up 20% in the 12 months leading into spring 2020. While the numbers show death rates rising before the pandemic, the biggest spike occurred between March and May of last year. The CDC attributes these increases primarily to the polluted drug supply.
RAFANELLI: I know there’s been disruptions in the drug supply chain. How have these disruptions affected drug users in your community?
BROWN: In this area, they’re encountering a lot of adulterated methamphetamines, a little bit of heroin. We don’t have that much heroin here in our area right now. It’s almost all fentanyl. And they were reduced to buying the methamphetamines, a little bit of heroin here and there, but by and large, most of the drug supply that came in through here was adulterated with fentanyl. And if people weren’t testing their dope, they were overdosing and dying because they weren’t familiar with the amount of fentanyl that was present in that particular batch of dope. I know in Illinois overdose death rates went up approximately 19%–those numbers could have changed. And I believe Iowa’s went up to like 35 or 36%. And it was because people were using, they were self-isolating, right? So they were using alone. You never use alone, but they were using alone because they were isolated in motel rooms. They were isolated in housing apartments. They weren’t with people. They were using extremely adulterated dope, not testing it if they didn’t have the strips. But if you’re alone and you’re isolated and you can’t get somewhere, you’re going to do what you do. And what they were doing is using alone with no one there to look after them in the event of an overdose isolation.
RAFANELLI: So you think isolation is the main driver behind the national increase in overdoses?
BROWN: I think it had a lot to do with it. Don’t you?
This transcript has been edited for clarity.