Will feds shut down addiction treatment experiment post-pandemic?

WASHINGTON (Gray DC) - As the pandemic makes addiction deadlier than ever, loosened regulations are making it easier for many to get, and stay, in treatment. But, it’s unclear whether that shift will outlast the COVID crisis, and the experiment is over in at least one state.

In idyllic towns and bustling cities, Fentanyl, 20 times as potent as heroin, is driving a spike in fatal overdoses nationally and in Massachusetts. Federal data suggest most users do not seek treatment.

“We want to be there at the moment you decide you want care,” said Addiction Medicine Physician Dr. Ruth Potee.

Potee said she sees more patients than ever before taking that first step into the clinic she runs in Springfield, Mass.

She attributes that to two factors:

- Black market opiates are more powerful and deadly than ever, scaring users straight

- And, it’s easier to get help thanks to relaxed federal treatment standards

“It’s been a game-changer for patients,” she said of the latter.

Before the pandemic, those with less-than-perfect sobriety and treatment attendance records could spend hours in the car and clinic waiting rooms every day just to get one dose of methadone.

Now, most can return home from a visit with a multi-week supply of medication. Potee said that dramatically increases the odds a patient will stick with treatment.

“To free methadone from the confines of these regulations is the most practical way to get people’s lives saved and back on track,” said Potee.

Like Heroin methadone is an opiate. But, it’s weaker and takes longer to wear off. Used as directed, it relieves agonizing withdrawal symptoms and powerful cravings without a high.

“If a patient comes in and says, ‘my goal is not to quit, but to be more safe,’ is that enough for you?,” we asked of Potee.

“Yeah, it is,” came her reply.

“When I have a patient come in here and they’ve gone from 50 bags a day to two bags a few times a week, I pat them on the back and say, ‘you’re amazing, you’re doing great, let’s talk about ways we can maybe improve you more’,” she said.

“That is a person who is participating in society, they’re taking care of their grandmother, they’re taking care of their kid, they’re going to work,” Potee added, “and they’re less likely to cost the American health care system a lot of money.”

That cost can be substantial, experts with the C.D.C. said it’s estimated that 3 million Americans suffer from Opioid Use Disorder, with an associated financial cost of $1.2 trillion. That’s a nearly $4,000 bill for every citizen.

Data from the Federal Substance Abuse and Mental Health Services Administration suggest approximately just more than 400,000 patients received methadone treatment in 2019, the last year for which data is available.

Caty Simon is one of those patients. “I have used opioids, on and off, for most of my adult life,” she said, without providing too many details about past or current use.

Navigating the highs and lows of addiction led her into academic research and advocacy work supporting fellow users, work she said she couldn’t do if she had to constantly chase the next fix.

“Methadone takes me outside the desperate cycle of dependency,” Simon said, “it means I can functionally focus on the rest of my life.”

Simon’s not looking for a drug-free life but said she started every day of the past decade in line for methadone, never once able to sleep in for fear of missing a daily dose.

The treatment reduces cravings and relieves crippling withdrawal. It can be abused but can also provide a level of chemical protection against overdose.

“I probably wouldn’t be alive today if I was not on a clinic,” Simon said of what it’s meant for her personally, “methadone is a life or death treatment.”

Simon and clinicians like Potee argue all patients, regardless of disease, deserve evidence-based care, even if they don’t always follow doctor’s orders.

Access to methadone remains uneven across the country. As of March 2021, SAMHSA reported 1,816 methadone clinics operating in the U.S.

Clinics don’t exist in some areas, many shutdown due to the pandemic or shutout new patients, and some stuck to old limits on take-home medication despite the federal waiver.

The State of Ohio largely re-implemented the old rule this spring when the country looked to be emerging from the pandemic. We connected with Lori Criss, director of the state’s Department of Mental Health and Addiction Services to find out why.

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Dir. Lori Criss - Ohio Department of Mental Health and Addiction Services:

“We were one of the first states out of the gate to make sure that we had flexible take home policies... in fact, our federal partners held our plan up as one for other states to look at.”

“And the implementation of it went really well.”

“It was more anecdotally that we heard that there were some concerns not just in Ohio, but in other states, around diversion and potential relapse issues”

“and that’s when we started... thinking about how we needed to monitor our practices.”

Kyle Midura - Washington Bureau Reporter:

“I think it’s doctors who are most fond of telling me that, ‘the plural of anecdote isn’t data’. So, talk to me about weighing that decision, because it sounds like this was a success, so why go back?”

Criss:

“The waiver was issued as part of a pandemic response, not just a new way of doing business.”

“Each individual provider can still seek a waiver for any patient that needs a specialized circumstance.”

“That built a lot of confidence... in saying that that statewide nature wasn’t something that we necessarily needed to do.”

Kyle:

What do you say to those who say, ‘it’s also an opportunity to maybe shift how we have been doing things’?

“The pandemic definitely taught us how we can advance practice in behavioral health... there are a variety of harm-reduction strategies that we put forward in addition to those take-home opportunities.”

“If there is a provider and a patient that believe there is a risk for overdose without a take-home opportunity, that opportunity still exists for them on an individualized basis.”

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Data provided by officials at the Ohio Department of Mental Health and Addiction Services indicate clinicians are continuing to apply for waivers but far fewer patients are covered than last year.

Patients who did well under expanded eligibility may have earned the right to keep take-home methadone. But generally, unless a patient can document a case of COVID, those who continued using illegal substances, do not seek counseling, or have behavioral issues would not qualify for a waiver.

While addiction treatment professionals differ on whether all positive drug tests should bar a patient from take home medication, every medical expert consulted for this story agreed screenings are not purely punitive.

Those who test positive for fentanyl and benzodiazepines are at an increased risk of overdose if the substances are used with methadone. Potee added that she would not prescribe take homes to those with alcohol dependency issues as mixing the two substances can be a deadly cocktail.

Congress does appear poised to make another drug prescribed for opiate addiction, buprenorphine, more available permanently. More than one hundred lawmakers, from both sides of the aisle, have added their names to proposals to do so.

But, there’s no proposal on Capitol Hill to do the same for take-home methadone. A handful of lawmakers have asked federal regulators with the Biden administration to make that change on their own.

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