During the week of April 6, a sign-on letter circulating in the harm reduction and patient advocacy fields provoked some strong feelings. The letter focuses on mistreatment of opioid treatment program (OTP) patients during the national emergency and the COVID-19 pandemic. Three of the signatories are the National Alliance for Medication Assisted Recovery (NAMA) (a patient advocacy organization), the Urban Survivors Union, and the Drug Policy Alliance. The Urban Survivors Union spearheaded the policy letter.
These seem like odd bedfellows indeed: drug-user groups, many of them in fierce opposition to the OTP system; and the main methadone patient advocacy organization. But the COVID-19 pandemic has brought them together.
The American Association for the Treatment of Opioid Dependence (AATOD) did not sign, because it did not agree with some of the recommendations, saying they threatened patient safety.
Some OTPs Disregard Guidance
There are OTPs that are not requiring social distancing (being 6 feet apart), either in waiting rooms or in line outside the clinic; who are requiring patients who have tested positive for COVID-19 to come to the clinic; and who are not following the guidance from the Substance Abuse and Mental Health Services Administration (SAMHSA).
Under the guidance, SAMHSA has authorized programs to provide up to 14 days of medication to unstable patients and up to 28 days for stable patients. However, SAMHSA cannot direct programs to provide take-homes since the determination of who gets how much medication is up to the treatment program personnel. Liability is a concern. Just as a state cannot indemnify a program, neither can SAMHSA. (https://atforum.com/2020/03/otp-regulations-loosened-due-to-pandemic/).
To be clear, the Drug Policy Alliance (DPA) and the Urban Survivors Union (USU) as well as other groups, want a lot more than these temporary reforms, having called for a complete overhaul or elimination of the OTP system. But the letter doesn’t support that kind of an overhaul; it supports the OTP system.
Risky Take-Homes at Issue
The letter calls for some changes that AATOD agrees with, but some that it doesn’t, as detailed below.
The recommendation that the 14 or 28 days of take-homes be given to all patients, limited only by supply, was firmly opposed by AATOD. “In my judgment, this recommendation poses great risk,” said Mr. Parrino, explaining why the organization cannot sign the letter. “Giving unstable patients more take-home medication when testing positive for benzodiazepine or other drugs does pose a great danger.” (The policy letter’s recommendations also include suspending urine testing.)
The leading cause of methadone-related overdoses is drinking alcohol or using benzodiazepines at the same time,, continued Mr. Parrino. And he noted the only responsibility—ethically and in terms of liability—for providing take-home medications rests with the OTP. “They are responsible for any negative outcome,” he said.
There are protocols for curbside medication administration, and for providing take-home medication to family members or friends, in the case of someone who is quarantined, said Mr. Parrino.
AATOD agrees that the only standard for discharge from the OTP during COVID-19 should be “violent behavior” that would endanger patient or staff safety. AATOD agrees that there should be no “administrative detox” (for nonpayment, for example) during the pandemic. In addition, AATOD requested that in self-pay states, SAMHSA fund patients who cannot afford treatment or have lost their jobs.
Keep Buprenorphine Training
AATOD disagrees with the letter’s recommendation that enforcement of DATA training requirements for buprenorphine prescribing be suspended during the national emergency. Instead, AATOD recommends that State Opioid Treatment Authorities (SOTAs) “should be able to monitor if there is increased need for buprenorphine through DATA 2000 practices, and respond to increased demand.” Training is online, Mr. Parrino pointed out, so it can be expanded quickly.
AATOD also disagrees with the recommendation that office-based and pharmacy-delivery methods be used for methadone. This recommendation would be only temporary, according to NAMA, but Mr. Parrino doesn’t think it can be implemented on such short notice. OTPs are already providing increased medication to patients, based on the 14-day order, he said. And he added that pharmacies cannot realistically dispense methadone for opioid use disorder because “they do not have the clinical experience in evaluating patients.” They also do not stock 40-mg tablets.
AATOD doesn’t think urine testing should be suspended for unstable patients, saying this would be “irresponsible.”
The key balance is between harm reduction and clinical judgement, said Mr. Parrino. There is more than one harm here.
In-Person Inductions and Coverage for Non-Insured
SAMHSA and the DEA already lifted the requirement for in-person inductions for buprenorphine, even allowing these to be done by telephone (with even video no longer required). Why not for methadone, asks the letter. AATOD agrees, and has requested this, but SAMHSA said no.
There is a proposed rule on mobile methadone that AATOD has been working on for several years; the comment period ends April 27 (https://atforum.com/2020/02/lawmakers-urge-dea-to-move-on-mobile-vans-telemedicine/). The USU letter wants these vans to be used for patients who are isolated in their homes or are 15 miles or more away from the nearest OTP. Mr. Parrino agrees with the recommendations, but in fact there are very few mobile vans available.
Finally, AATOD agrees with the recommendation that state and federal Medicaid money cover all costs for take-home medications not otherwise covered by insurance.
Other Voices: Support From Faces & Voices, But Not From SOTAs
Other voices in the field support the letter, including Faces & Voices of Recovery CEO Patty McCarthy Metcalf. She told AT Forum that the organization does not support eliminating the X waiver for buprenorphine, as many of the signatories do.
Significantly, the organization representing the SOTAs did not sign the letter. Robert I. L. Morrison, executive director and director of legislative and regulatory affairs at the National Association of State Alcohol and Drug Abuse Directors (NASADAD), told AT Forum that the organization is communicating with a variety of stakeholders, including Mr. Parrino.
“The COVID-19 crisis is having a devastating impact across all health sectors—including the substance use disorder service system,” he said. “In particular, there are challenges pertaining to opioid treatment programs (OTPs), which are overseen by State Opioid Treatment Authorities [SOTAs], that require attention. As the umbrella group that houses the SOTAs, NASADAD is coordinating with SAMHSA and the DEA to facilitate communication.” Noting that SAMHSA has already released guidance related to these issues and is having regular conference calls, Mr. Morrison highlighted the fact that SAMHSA designated OTPs as essential medical facilities.
“It is also important to express our appreciation for the staff providing care in OTPs and other settings around the country,” said Mr. Morrison. “They are working tirelessly to help those in need under difficult circumstances.”
“We signed on because the recommendations are incredibly appropriate, based on what’s going on with COVID-19,” Jeffrey Quamme, MS, CNE, executive director of the Connecticut Certification Board, told AT Forum. The Connecticut Certification Board certifies addiction counselors. “We also say there is overregulation of OTPs. As we move forward as a treatment system, we have to look at being more flexible, because there are many things that come into play. Individuals who can’t come to work. Patients who may not have access to employment, because they have to go to an OTP every day. We don’t have any flexibility. Do I want OTPs eliminated? No. But I would like flexibility, having the ability to meet clients where they’re at. Dosing should be left to the doctors.”
Mr. Quamme says there is harm reduction in everything done by treatment. “The minute somebody enters treatment is an opportunity to meet them where they’re at, address the needs that they’re presenting immediately,” he said. He cited the Hartford area syringe-exchange program, which helps drug users. “It’s not just a syringe swap,” he said. “There are relationships being formed. Somebody may not want to go to treatment today, it may take time, but a therapeutic relationship with a provider is forming.”
Yet Some Opposition Continues
The signatories include many people, including physicians, and organizations that advocate for getting rid of the OTP system entirely, by making methadone available in primary care, or directly from pharmacies, or both. Many of these same people also advocate for getting rid of the X-waiver for buprenorphine.
However, advocates are now balancing the need to prevent the spread of the virus against the possibility that some diversion may occur. The only ones with liability if someone dies from a take-home, however, are the OTPs. Already, relapses are being reported by providers (http://www.methadone.us/doctor-jana-burson/).
For the policy letter, including signatories, go to the Urban Survivors Union website: http://ncurbansurvivorunion.org/2020/04/09/mat-treatment-recommendations/