Nation's opioid addiction treatment system during COVID-19 needs reform

Nation's opioid addiction treatment system during COVID-19 needs reform
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Wash your hands. Practice social distancing. This often repeated and important public health messaging is critically important as the nation seeks to contain COVID-19.

Recently, CDC officials encouraged people to have a 2-week stock of their medications. Unfortunately, for people taking medications for opioid use disorder, this simply may not be possible — without critical federal intervention. 

For people who use drugs or are in treatment for an opioid use disorder, the threat posed by COVID-19 may seem remote compared to the immediate risk of overdose, painful drug withdrawal, or the risk of HIV, viral hepatitis, or abscesses that can result from a disruption in harm reduction or effective treatment services.

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The spread of COVID-19 also demonstrates the antiquated, inequitable, and overly strict legal and regulatory structure of the nation’s addiction treatment system, a structure that exacerbates health risks and poses barriers to needed services. 

Medication based treatment for opioid use disorder is already limited and becomes more difficult to access in times of an emergency. Methadone and buprenorphine, two of the medications used in the treatment of opioid use disorder, cut mortality rates in half.

More than one million Americans are on these medications and several million more would benefit from them. These medications are also tightly controlled under "The Controlled Substances Act (CSA)" and other federal laws and regulations.

For example, the CSA restricts methadone access for opioid use disorder to a heavily regulated, special clinic while methadone used to treat pain is dispensed through pharmacies.

The Substance Abuse and Mental Health Services Administration (SAMHSA) also regulate methadone treatment for opioid use disorder, setting strict limits for when someone may receive an “unsupervised” or “take-home” dose. Methadone treatment for opioid use disorder starts with a requirement for 6-days a week of observed dosing. 

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If someone is in a high-risk group or becomes ill with COVID-19, public health guidance tells them to stay home. However, this may not be possible for a patient taking methadone. In some states, patients can only receive a week’s worth of medication to take home if they have been in treatment and stable for three years.

Special exceptions for more than a day’s worth of medication need individual state and federal approval. Missing methadone doses puts individuals at risk for a recurrence of their opioid use disorder, as well as a return to potentially lethal illicitly manufactured drugs such as fentanyl.

Buprenorphine, another medication used to treat opioid use disorder, also has tight prescribing restrictions, although less restrictive than methadone. Buprenorphine prescribers must receive a special certification and training, and can only treat a limited number of patients.

This constrains the number of prescribers and limits the number of possible patients, in the best of times. If those prescribers become ill or otherwise unable to provide treatment, or if their clinic is located in a severely affected area, access to this treatment will become even more limited. 

During uncertain times such as public health emergencies, flexibility for opioid treatment providers is key so patients receiving opioid treatment medications such as methadone or buprenorphine can continue life-saving treatment.

However, the lack of flexibility and burdensome regulations inherent in medication-based treatments for opioid use disorder make the continuity of care difficult. This was the case during natural disasters such as Katrina and Hurricane Sandy when red tape, a lack of communication and transit disruptions caused patients to miss appointments and placed many of them at risk for withdrawal, relapse, and overdose.

One author wrote of her experience during a natural disaster when, unable to receive her regular dose of methadone, she feared for herself and her pregnancy. 

Several states, including Washington state and New York, have issued guidance to opioid treatment providers about continuing treatment services in areas affected by COVID-19. This guidance is helpful, as is the new guidance from SAMHSA allowing more flexibility for take-home methadone during this national emergency.

However, existing federal laws that apply to opioid treatment providers are rooted in stigma and states must still move to adopt SAMHSA’s new guidance.

Today’s COVID-19 crisis will end, but these overly burdensome federal regulations for opioid treatment programs will remain, even if exceptions are made under the declaration of a national emergency.

Restricting access to effective treatment creates substantial barriers to care and keeps people recovering from addiction burdened by high-frequency medical visits and needlessly onerous requirements.

No other treatment for a medical condition in the United States faces these kinds of burdensome regulations. The current crisis has highlighted how fragile the care models are for effective opioid use disorder treatment and should serve as a wake-up call for our Nation to fix this broken system once and for all.

Caleb Banta-Green, Ph.D., MPH, MSW, is a principal research scientist at the Alcohol & Drug Abuse Institute and an affiliate associate professor at the School of Public Health at the University of Washington. He is a health services researcher and epidemiologist and served as a senior science advisor for the Office of National Drug Control Policy in 2012.

Regina LaBelle, J.D., is the director of the addiction & public policy initiative at The O’Neill Institute at Georgetown University Law Center and previously served as chief of staff at the Office of National Drug Control Policy during the Obama administration.

Yngvild Olsen, M.D., MPH, is an addiction medicine specialist in Baltimore City, vice president of the American Society of Addiction Medicine, and co-author of the book “The Opioid Epidemic: What Everyone Needs to Know.”