As the balancing act between maintaining essential addiction treatment and protecting public health during the COVID-19 crisis tilts more toward slowing transmission of the virus, opioid treatment programs (OTPs) that have daily contact with highly vulnerable patients face some of the toughest choices in the field.
Even when given broader authority to dispense take-home doses of methadone so patients can reduce in-person visits to a clinic, OTPs must rely on sound clinical judgment to determine the risk-benefit equation for each individual patient.
“People simply cannot give 30 days of methadone to a patient who is not stable. They'll die of that before they die of the virus,” Allegra Schorr, president of the Coalition of Medication Assisted Treatment Providers and Advocates and co-owner of a New York City OTP, tells Addiction Professional.
At the same time, OTPs in coronavirus hotspot areas such as New York City and surrounding communities are facing a major organizational challenge. For providers that already have reduced patient capacity by upwards of half, in accordance with social distancing guidance, that will mean major declines in revenue over a yet-undetermined period.
“For smaller organizations, like those where the OTP is the main revenue source, they're not going to be able to do this very long,” Schorr says.
The situation could be particularly dire in New York, where providers are trying to initiate discussions with state officials about a temporary change to the unbundled Medicaid payment system under which they operate.
“We need some sort of bundled payment,” says Schorr, vice president of the West Midtown Medical Group. “We don't want to see a cascading effect—we have to keep these programs going.”
Missteps, she says, could result in more patients with substance use disorders ending up in hospital emergency rooms that already are in danger of becoming overwhelmed because of the COVID-19 outbreak. “We're looking at the same news everyone else is,” Schorr says.
Guidance from SAMHSA
On Monday, the Substance Abuse and Mental Health Services Administration (SAMHSA) released updated guidance to the highly regulated OTPs. States and OTPs now have more flexibility to receive blanket exceptions allowing stable patients to receive 28 days of take-home medication and somewhat less stable patients to receive a 14-day supply.
In states that have declared a state of emergency, the state may request the blanket exceptions, according to SAMHSA, while in other states the OTPs themselves must make the request. In all cases, the blanket exception process eliminates the need to request exceptions on an individual patient basis, a process that under normal circumstances is fairly routine but would be highly cumbersome during a public health crisis.
The guidance statement from SAMHSA reads, “Programs and states should use appropriate clinical judgment and existing procedures to identify stable patients. Please note an increased medication supply will accompany these requests. Therefore OTPs and states must ensure that there is enough medication ordered and on hand to meet patient needs.”
Authorizations for providers mainly run through each state's opioid treatment authority. In Rhode Island, that function is housed at the state Department of Behavioral Health, Developmental Disabilities and Hospitals. The president and CEO of CODAC Behavioral Healthcare, which serves 3,000 patients at eight OTP sites across Rhode Island, credits state officials and the governor's office for taking aggressive steps to limit possible exposure to COVID-19.
“We knew what was coming, so we put together a 15-point waiver request,” Linda Hurley tells Addiction Professional. The number of items reflects the layers of regulation to which OTPs are subject, in areas ranging from what Hurley calls “critical issues” to “anachronistic stuff.”
Knowing that more medication supply would be needed to cover an increase in take-home dosing, CODAC began ordering additional quantities of methadone a couple of weeks ago. One of its two suppliers has been able to fulfill the request, but the other informed CODAC that it could not because the Drug Enforcement Administration (DEA) was requiring it to keep a certain amount in stock.
Hurley says this demonstrates why it is so important at this time for government agencies to communicate effectively with one another. “It's ridiculous that one entity can provide what we need and the other can't because of what the DEA is requiring,” she says.
CODAC has altered its shift patterns so that one group that arrives to work at midnight can prepare that morning's doses, allowing clinic patients to receive their medication quickly when they start arriving at 5:30 or 6 am. “The last thing we need is a bottleneck when we're doing social distancing,” Hurley says.
All arriving patients are being asked the same three screening questions regarding fever, cough and shortness of breath, Hurley says.
CODAC and other treatment organizations must take several factors into account when assessing risk and benefit around in-person visits or take-home dosing for the individual patient. These include length of time in treatment (“a true demonstration of stability,” Hurley says) and patient-specific factors such as co-occurring mental illness or cognitive impairment.
In these individual cases, “What is more risky: coming in and being in contact with others or misusing the medication?” Hurley says.
Patients' own anxieties about the virus also are a factor. “Today as I was walking in I overheard somebody saying to security, 'Hey, how crowded is it in there?'” Schorr says.
Hurley adds that at one CODAC program site this week, staff had to initiate eight patient admissions, a clear sign that many patients with opioid use disorders (OUDs) are struggling in this time of crisis.
She believes that in the OTP community as a whole, there inevitably will be some adverse outcomes, because methadone has street value. “If we see an increase in diversion, it could set ourselves back years with stigma,” she said. “We can't let that be a variable in our decision-making, but it's just something that may happen.”
In terms of the counseling these patients need along with their OUD medication, Schorr says many of her agency's patients wouldn't be able to access telehealth services for that purpose, due to limited access to technology.
At CODAC, Hurley says the organization is moving forward with telephone counseling, one-on-one support enabled through a smartphone. Government agencies need to work through all the details of reimbursement, she says, or a treatment community that is critical to combating the ongoing opioid epidemic will be dealing with serious cash flow problems.