The covid-19 pandemic is turning daily pick-ups into an acute public health crisis in the U.S. There’s a better way.
More than a week after U.S. President Trump announced that public gatherings should be limited to no more than 10 people, a line was growing outside a methadone clinic in SoHo. More than two dozen people, some of them wearing masks, many of them older, huddled in the rain while they waited for the doors to open. Most stood shoulder to shoulder. Some had been there over an hour. It’s like this six mornings a week.
“They should give everybody a certain amount so we don’t have to come and pack up like this,” said Miguel (not his real name), a participant who requested anonymity, gesturing to the crowd in front of us. He’s been making the hour-plus commute to this clinic from the Bronx almost every day for three years, but it’s nerve wracking to do it in a pandemic. “They’re gonna give one bottle and I gotta come back again? That’s crazy.”
More than 350,000 Americans are prescribed methadone, a synthetic opioid that treats addiction to heroin and oral narcotics like oxycodone. To receive the medication, patients must report to one of the country’s 1,500 methadone clinics, often every day. We’re in a window when it’s critical for everyone to stay home and practice social distancing as much as possible, and yet many methadone patients are forced to travel significant distances daily to gather in close proximity with dozens of others. Chronic users of opioids frequently have underlying health conditions such as liver disease, and, because opioids impair breathing and covid-19 is a respiratory condition, people who rely on methadone clinics to function are an inherently at-risk population. Those who socially isolate are at increased risk of recurring drug use, of overdose, of ending up in an already-overloaded ER, and of passing the virus to others.
On March 16, the Substance Abuse and Mental Health Services Administration (SAMHSA) expanded methadone regulations so states can request 28-day supplies for patients deemed “stable” and 14-day supplies for patients deemed “less stable.” Clinics in places like Ohio and Pennsylvania have already begun taking up the new policy. Others, like Indiana, are exploring methadone delivery via specially designed lock-boxes. There will be doorstep deliveries for patients under quarantine.
Just like with TSA restrictions and broadband caps and the criminalization of minor offences, the reason methadone regulations can be suddenly waived in an emergency is that they were arbitrary to begin with; their only function was to be punitive. And while expanded take-home privileges in a pandemic are better than nothing, their arrival comes with a couple of glaring problems.
First, even though clinics are now free to offer more take-home doses, it’s still up to individual providers to actually do so. Many of them won’t; methadone clinics are not known for being humane to the people who visit them. “You’d think that at this time there’d be real recognition that forcing people to come and travel daily should be laxer, but unfortunately that’s not how we’re seeing it play out on the ground,” said Alyssa Aguilera, co-executive director of social services nonprofit Vocal-NY. “It’s already a very punitive system. There’s a lot of distrust of patients.”
New York’s Offices of Addiction Services and Supports (OASAS) told Gizmodo that providers are already authorised to begin offering take-home methadone, but it’s unclear how many are actually doing it. Some are simply making participants wait outside. A clinic a few blocks away from Miguel’s was letting people in three at a time; another was assigning numbers to the crowd and calling people in when it was their turn. Participants unanimously reported waiting in long lines, often in close proximity to one other. No one had heard of anyone getting take-homes.
“Nothing yet,” said a participant at an East Village clinic who takes the subway 40 minutes each way from Brooklyn, four mornings a week. “I was wondering what’s going to happen. Are they going to close?”
Second, the expanded regulations are written in a way that’s almost certain to leave behind the most vulnerable. Whether a patient is “stable” enough to take home their methadone is at the discretion of providers. “Factors for determining whether an individual is stable include their ability to safely store medication, their physical or cognitive condition, and their living situation,” an OASAS spokesperson wrote to Gizmodo. Asked whether this disqualified patients for lack of housing and/or for mental illness, the agency responded that that’s up to each provider.
The covid-19 pandemic is making an acute emergency out of something that’s been the case since the beginning: Methadone shouldn’t be relegated to clinics. It should be accessible through primary care.
The practice of siloing methadone, physically and bureaucratically, from the rest of our health care system has been in place since the mid-70s. Methadone is a synthetic opioid, and one of three drugs federally approved as a Medication-Assisted Treatment (MAT) for Opioid Use Disorder. Along with one of the others, buprenorphine, methadone has been repeatedly shown to reduce risk of fatal overdose. Since 2002, Congress has allowed primary care doctors to prescribe buprenorphine from their offices for patients to take home. Methadone, however, can only be obtained at a clinic, a process that for most people involves some combination of daily commuting, urinalysis tests, mandatory counseling, the constant threat of being kicked out for relapsing, and dosing that can be either increased or decreased as punishment for testing positive for drugs like meth or cocaine, which are not opioids and have nothing to do with MAT, which is used to treat Opioid Use Disorder exclusively.
Buprenorphine comes with its own set of issues; less than 10% of primary care doctors have successfully applied for the onerous SAMHSA waiver required to legally prescribe it, and even then there are caps on the number patients they can treat with it. But it more or less allows people to maintain a regular work schedule, and spares them the enormous stigma of having to show up every day to a public place where there can be only one explanation for why they’re there.
“Buprenorphine is designed more for long-term stability, whereas methadone maintenance is designed for chaos,” said David Frank, a postdoctoral research fellow at New York University’s Behavioural and Science Training in Substance Use Research program. “It’s almost impossible to be stable. I don’t mean this in a conspiracy way, I mean this in a sociological way: It’s designed for people to fail.”
Despite the name, methadone maintenance is not a regimen that’s conducive to being maintained. Frank has been on methadone for 18 years, an unusually long streak made possible by the fact that he only has to visit his clinic every 28 days. He attributes this arrangement to a combination of luck, privilege, and having been on methadone a very long time. “Take-home privileges are very difficult to get,” Frank said. “When I started sort of getting into the straight life while at the same time being on methadone, I knew it was going to be almost impossible with how punitive methadone is, going in every day.”
Methadone clinics are notoriously subject to redlining and often poorly accessible by public transport. It’s common for people to travel two hours every morning to obtain the dose they need to function for the rest of the day, a schedule that often makes it difficult if not impossible for people to hold down a steady job. So much of daily life revolves around reporting to the clinic on time that methadone is colloquially known as “liquid handcuffs.”
“The barriers come out of this arcane, highly regulated system that hasn’t changed, hasn’t been modernised in 40 years,” said Dr. Marc Larochelle, a primary care physician specializing in addiction at Boston Medical Centre and assistant professor of medicine at Boston University School of Medicine. “There’s a lot of NIMBYism. No one wants a methadone clinic near them, so they tend to be in inner city areas, which leads to the perception that [methadone versus buprenorphine] falls on race or class lines.”
Methadone and buprenorphine only lower risk of fatal overdose for those who stay on them for a period of at least several months”something the nature of methadone access frequently makes impossible. Along with a laundry list of other state and federal requirements, expanded take-home privileges are normally subject to pre-set timetables. Patients aren’t eligible to get a 14-day supply at a time until they’ve been enrolled in a program for one year. For a 28-day supply, two years. A recent study co-authored by Larochelle found that more than half of subjects on methadone or buprenorphine were disenrolled by their commercial insurance by the one-year mark.
The disproportionate level of bureaucracy around methadone has much less to do with addiction than it does with criminalization. Politicians and law enforcement often complain that MAT is simply “substituting one drug for another””a legal way to provide a criminalized substance to a criminalized population. Justifications for the level of regulation hinge on sensationalised and often outright manufactured claims about diversion, the term for giving or selling prescribed MAT to people without prescriptions.
Update: This language has been removed and replaced with much, much better guidance that permits states to request blanket 28 day take-homes for stable patients and 14 days for others. Fantastic work, everyone! https://t.co/N84piLWJzZ
— Corey Davis (@coreysdavis) March 17, 2020
“Not only is it overblown, but we should welcome diversion,” Frank said. “It’s safer to take the diverted methadone than it is to take the fentanyl-laced dose! But that fear of diversion is why we have the abstinence-based [programs], why we have the no take-homes, that’s always their excuse”˜oh, what if people divert, what if people divert.’ So what?”
The extraordinarily high threshold for accessing daily methadone and the stigma associated with doing so, is a big part of the reason less than 20% of the 2 million-plus Americans with Opioid Use Disorder are receiving MAT. In the middle of a pandemic, this leaves the most vulnerable people still getting methadone via practices like spitbacks, where patients who have to take their dose while a provider watches will hide it under their tongue, or swallow to later purge, so they can give or sell it to someone who’s unwilling or unable to enroll at a clinic.
“It can be an afterthought, this area,” said New York Assemblymember Linda B. Rosenthal, who has been working to get prior authorizations for people on Medicaid waived the way they are for those on private insurance. “People are dying and we have ways to help them, and we’re not taking advantage of it.”
Methadone clinics are predicated on the idea that the medication they dispense is a privilege, not a right. There is no other area of health care where we require patients to demonstrate, on an almost daily basis, that they deserve their medicine. Expanded take-home privileges are a push in the right direction, but they’re not going to reach nearly as many people as they need to. And they fall far short of the more logical, and more humane, step that countries like Canada, Australia, and Great Britain have long since taken by simply folding methadone maintenance into primary care.
“This strategy has been locked in place because changing it requires an act of Congress,” argued public health clinicians calling to amend the Controlled Substances Act so buprenorphine-authorised physicians could also prescribe methadone. “But the current public health emergency could serve as the catalyst for altering the law so that methadone could be delivered both within the current methadone treatment clinic model and in primary care settings.”
That editorial was published in July 2018. The country has been in the midst of an acute public health emergency for years, just one that was easier to ignore because it mostly affected people who use drugs. Now it affects everyone.
Kastalia Medrano is a journalist based in New York.