“The stakes are life and death”: Addiction treatment’s Covid-19 challenge

When the Covid-19 pandemic forced much of the US to lock down in the spring of 2020, officials and experts worried the necessary social distancing measures would make another public health crisis — the opioid epidemic — worse. Addiction treatment is traditionally done in person, and restrictions on gatherings and closed businesses would make it much less accessible.

So the federal government responded by easing rules for getting into treatment virtually — making it easier for treatment providers to retain patients and attract new ones. Even before the pandemic, experts had been calling for making treatment easier to get in the US, and the new rules were a big step forward.

But with vaccines for the coronavirus moving through clinical trials and the end of the pandemic in sight, advocates are worried that the old rules will snap back into place — making it harder, once again, to get people into addiction treatment.

Officials relaxed federal rules in several ways. They allowed doctors to prescribe buprenorphine, an evidence-based medication for opioid addiction, over video or audio calls without requiring an in-person evaluation. They also made it easier to prescribe the medication across state lines, which previously required prescribers to be licensed in both states. And they eased rules for take-home doses of methadone, another proven opioid addiction medication, which traditionally is administered daily to patients at an in-person clinic.

State and federal officials also made it possible for public health insurance programs, like Medicare and Medicaid, to pay for telemedicine addiction treatment services. And some places received permission to go further — for example, delivering methadone to patients rather than requiring they pick it up in person.

Providers say the changes really helped. Many of them had to go virtual almost overnight, as the threat of the coronavirus became clear to much of the country. But they had feared they wouldn’t be able to prescribe necessary medications at all, given the arduous rules on such drugs, possibly putting their patients at risk of relapse, overdose, and death.

Things haven’t gone perfectly, but the relaxed rules, providers and experts say, have helped avoid the worst of it.

“It was incredibly challenging [for us], as it was for all providers,” Alexis Geier-Horan, vice president of government relations at the addiction treatment provider CleanSlate, told me. “Thankfully, we really didn’t lose many patients. … That was only possible because of what the federal government did in response to public health emergencies.”

Addiction treatment has long been difficult to access in the US. According to federal data, only 1 in 10 people with a drug use disorder get specialty treatment. Multiple problems play into that treatment gap, including a lack of local providers, high costs, and poor insurance coverage. Much of the treatment provided lacks evidence, or even rejects evidence-based modalities, and can even be downright fraudulent — leaving potential patients resistant to getting care in a broken system.

That’s why, even before the Covid-19 pandemic, activists and providers were calling for making it easier to prescribe addiction medications. Pandemic or not, some patients have always struggled with transportation, or lived in underserved areas that would require a lengthy trip to get treatment. For these patients, getting prescriptions by telemedicine or phone, or simply having to go to a clinic less often for medication, would help.

On the flip side, the patients who now rely on these services to get treatment, regardless of the pandemic, could stand to lose if the relaxed regulations expire. That’s what those in the field are now worried about: If those patients lose their means to treatment, they might give up on it altogether.

That would come at a particularly calamitous time for the opioid epidemic. Even before the pandemic, drug overdose deaths were trending up. But with the pandemic and continuing spread of the potent opioid fentanyl, overdose deaths have skyrocketed this year: On April 2020 (the latest month of data), there were nearly 78,000 drug overdose deaths, based on preliminary federal data — a 13 percent increase from the same time last year, setting up 2020 to be the worst year for overdose deaths ever.

That’s not, advocates and experts say, a sign that the measures easing access to addiction treatment failed, but rather that the measures didn’t and couldn’t go far enough to address a rapidly worsening overdose crisis. While the measures likely helped ease some of the pain brought on by Covid-19, they couldn’t resolve all the hurdles to treatment in America. That’s a case for building on the relaxed rules, not taking them away when the pandemic subsides.

“The stakes are life and death,” Kelly Clark, president of the advocacy group Addiction Crisis Solutions, told me. “We know, absolutely, that people who are taking their maintenance medications like buprenorphine for opioid addiction have a decreased chance of dying prematurely because of their addiction compared to those who aren’t on medications. This is very clear.”

Providers now worry the lax rules could go away soon

Two of the three federally approved medications for opioid addiction, methadone and buprenorphine, are among the most regulated drugs in the country. Methadone is only administered at specialized clinics — requiring patients to go to a clinic as often as daily to get it, and only letting them earn the ability to take some doses home over time. Buprenorphine can be prescribed by a doctor and picked up at a pharmacy, like other medications, but it still requires the prescriber to go through a special certification, and starting a patient required an in-person medical evaluation.

Then the Covid-19 pandemic came, almost immediately making these requirements unfeasible for patients and providers who now had to get and do treatment virtually.

So federal agencies took advantage of the federal public health emergency declared to combat Covid-19 to ease the rules — making telemedicine, including video and audio calls, more feasible for buprenorphine, and easing rules for methadone take-home doses. Local and state agencies followed suit.

But the changes are only in effect until the public health emergency expires. That’s left advocates and providers worried, and they’re increasingly sounding the alarm — as early as possible — to get Congress or other officials to act. They’ve called on federal lawmakers to pass the TREATS Act, which would make many of the rule changes permanent, as soon as possible.

“Speaking for [the American Society of Addiction Medicine], ASAM would love to see the TREATS Act passed with any kind of legislation that goes through during this lame-duck [period], so that we don’t have to face this other unknown coming into the year,” Clark, former president of ASAM and vice chair of the group’s Covid-19 task force, told me.

The typical argument for keeping the old rules comes down to fears of diversion: that the medications will be diverted to a black market for recreational uses. Buprenorphine and methadone are opioids, and, though they’re very effective for treating addiction, they can be misused. So loosening access to either too much, the argument goes, could lead to the drugs ending up in the wrong hands.

As the Drug Enforcement Administration put it, “Under normal circumstances, DEA would not consider the initiation of treatment with a controlled substance based on a mere phone call to be consistent with the framework of the [Controlled Substance Act] given that doing so creates a high risk of diversion.”

Providers take these concerns very seriously, and have adopted a range of practices, such as regular urine screenings, to make sure people are actually taking their medications and not relapsing. Many providers are concerned that loosening the rules too much, and simply doing treatment virtually, could make it harder to prevent diversion.

At the same time, some experts argue that concerns about diversion are overblown. For one, some research suggests that diversion is a result of people not being able to legally obtain buprenorphine or other treatment, forcing them to resort to illegal means of getting the medication. So the stricter regulations could be causing more diversion, not preventing it.

That indicates a balancing act is needed. If it turns out, in the pandemic, that expanding telemedicine for buprenorphine increases access without much more, if any, diversion, then maybe the right balance is more toward a laxer regime than the longstanding laws and rules suggest.

“These agencies are trying to balance the public safety side of making these changes with the public health side,” Geier-Horan, who previously worked on addiction treatment under the Obama administration, said. “From a CleanSlate perspective, the benefit of these things far outweighs those [diversion] concerns.”

Some researchers are working to find out if that’s the case, studying how virtual treatment has worked throughout the pandemic. A JAMA Psychiatry article noted there’s a dearth of research on the role of telemedicine in addiction treatment, including whether it improves access and can be done without significantly increasing diversion.

“That could be really helpful in getting people on board,” Allison Lin, lead author of the JAMA Psychiatry article and an addiction psychiatrist and researcher at the University of Michigan and the VA Center for Clinical Management Research, told me. “We do need more research to provide that data. We don’t have those kinds of answers just yet.”

Short of that, providers are sharing their own experiences, arguing that they’ve been able to maintain a level of care, and even gain some patients, throughout the pandemic despite the obvious disruptions Covid-19 has brought on. But they also worry that losing the new tools they have now could lead to the opposite result once the pandemic is over, fueling a drug overdose crisis that’s already getting worse.

Effective addiction treatment is inaccessible to many Americans

Although the Covid-19 pandemic has in some ways overshadowed it, America’s opioid epidemic is still in full force. It’s in fact gotten worse this year, based on the data we have. The widespread sense of isolation and despair that many people have felt this year, coupled with greater difficulty finding help for such problems as many places close down, has contributed to more drug overdose deaths. Paired with that, the powerful synthetic opioid fentanyl has continued to supplant heroin in more of the illicit market — and in part because it’s so potent, it’s more likely to cause overdoses and deaths.

“While our attention has gone to Covid, and rightly so, our overdose deaths have skyrocketed,” Clark said. “We have to keep overdose deaths on the map.”

One of the key contributors to this crisis all along has been lack of access to evidence-based treatment. Good treatment remains very difficult to get in the US — it can cost tens of thousands of dollars out of pocket, and despite those high costs, it’s still frequently of bad to mediocre quality. One family I spoke to last year told me that they spent $200,000 on treatment before they found something that worked. That’s an extreme example, but it’s not rare, based on the thousands of responses to Vox’s survey about the issue, for people to spend an exorbitant amount on treatment and end up with little to nothing to show for it.

That’s not because evidence-based treatment doesn’t exist. For opioid addiction, the medications are truly proven to work well. Studies show buprenorphine and methadone reduce all-cause mortality among opioid addiction patients by half or more, and they do a far better job of keeping people in treatment than non-medication approaches. There are all sorts of other good treatment modalities for other kinds of addiction, including medications and paying people to stay in treatment (known as contingency management).

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But these evidence-based approaches are dramatically underutilized. According to federal data, only 42 percent of the nearly 15,000 facilities tracked by the Substance Abuse and Mental Health Services Administration (SAMHSA) provide any type of medication for opioid addiction. This is largely driven by stigma — the faulty notion that medications replace one drug for another, even though the medications are proven to improve outcomes compared to continuing to use illicit drugs.

So there’s a dearth of providers for evidence-based treatment. When those providers are available, they might not be covered by insurance, and cost thousands out of pocket. If someone has gone to a treatment facility before and ended up with a bad experience due to shoddy, evidence-less care, they also might be skeptical that there’s good help out there at all. That all makes treatment less accessible, and people less receptive to it.

That’s why much of the work to combat the opioid epidemic, from legislation passed by Congress to state efforts to more localized approaches to lawsuits, has gone to expanding access to treatment: If truly effective treatment exists, then it’s just a matter of making sure it’s available to the public.

Along those lines, activists had pushed for more access to telemedicine for years. Of particular concern were underserved areas with few providers — like rural West Virginia, which has a massive overdose crisis and not enough addiction treatment providers to handle demand from patients. Telemedicine can make it easier for existing providers to serve other areas in the state, or even people in other states entirely.

It’s also about expanding the spectrum of care. Every person dealing with addiction is different. Some people are fine with being on medications; some people aren’t. Some will like treatment through Zoom or phone; some won’t. Some have a car; some have no reliable transportation. By offering a variety of options for what care is delivered and how, the hope is fewer people won’t get into treatment because there’s not an option for them.

“It’s not to say everybody should get telehealth, or everybody should get in-person [treatment],” Lin said. “It was just that, before, everybody was in person because that was the only option available.”

Covid-19 has made a lot of things worse, including the opioid crisis. A silver lining to all of this is it’s also given us a big, ongoing experiment to see if a telemedicine model can work for addiction care.

Some providers are now hoping that the eventual end of the pandemic isn’t the end of that experiment — given that it may be helping stave off what’s already the worst drug overdose crisis in American history.

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