Gateway Treatment Centers in Ellijay, Georgia, opened January 7—just a few weeks before the pandemic hit. But it was prepared.
The program currently has over 50 patients; 20% of the initial intakes were transfer patients. They were living in this county but having to drive close to an hour to get to treatment. The majority are new patients—new to treatment.
OTP Initiatives: Stepped-up Take-Homes, Social Distancing
The two main initiatives OTPs have been told to implement due to the pandemic are stepped-up take-homes—every stable patient can get up to 28 days, and even patients who are less than stable can get up to 14 days, under the new rules (see https://atforum.com/2020/03/otp-regulations-loosened-due-to-pandemic/) —and social distancing for patients who must come in. The American Association for the Treatment of Opioid Dependence (AATOD) has issued its own guidelines (see http://www.aatod.org/advocacy/policy-statements/covid-19-aatods-guidance-for-otps/). All of Gateway’s new patients are less than stable, said Chip Fuller, Gateway’s administrative director and program sponsor.
Take-Homes: Up, But Not 28-Day for Everyone
The State Opioid Treatment Authorities (SOTAs) have been assisting OTPs with these changes. In Georgia, providers met on a conference call with the SOTA. And in Georgia, the 28-day provision for everyone met some tough going from the SOTA.
At the time of the conference call, a 28-day exception was not going to be approved based upon the current situation in Georgia. “I did not put through an exception for more than 2 weeks” Mr. Fuller told AT Forum. The upshot was that all patients at Gateway were given extra doses through the exception process except for a few that were just recently admitted—something many other Georgia programs did as well.
Georgia’s rules for take-homes are not progressive. Under the pre-pandemic rules, once a patient was in treatment for 30 days and had good results on a drug screen, he or she was entitled to one take-home a week. After COVID-19, however, any patient who had at least 1 take-home a week could get up to 6 take-homes. Another change after COVID-19 applied to all patients whose only reason for being required to come in daily was that they had tested positive for THC, the main active ingredient in cannabis; these patients went to weekly take-homes.
Nobody is required to have daily dosing, except those who had just been admitted to treatment.
Very stable patients—those already getting 28 days of take-homes—continued on that schedule; they were the only ones on a 28-day schedule (we have an interview with one of them in a separate story).
All take home exceptions were approved by the medical director based upon a patient’s stability.
The Gateway building was already equipped with a foyer that can accommodate four people. There are blue lines on the floor inside, 6 feet apart. The waiting room can handle 10 people maintaining that same distance. “Every morning we’re sanitizing all the door handles,” said Mr. Fuller. Signs have been up since mid-February instructing patients not to come in the building if they had a cough, fever, or didn’t feel well, and to call instead from the parking lot. There are extra boxes of every size gloves; masks for patients and staff. “We’re washing our hands after any patient contact,” he added.
The dosing windows already had plexiglass installed down to a small opening at the counter.
Gateway Has Room to Grow
The original growth plan was to admit three new patients a week, Mr. Fuller told AT Forum. “That way we weren’t growing too big too fast to offer patients with the counseling and services they deserve.” But the program can get bigger— “we have the building space to accommodate more than 250 patients,” he said. And the landlord said the building could expand to be big enough for 500.
So far, the clinical director and Mr. Fuller, who are both certified counselors have been managing the caseloads and providing clinical services, which includes an hour of counseling per month. “We agreed that we’re going to manage the first 60-75 patients,” he said. Gateway also has a pharmacist, a registered nurse, and a medical director.
Some Free Testing; Curbside Dosing
There is a statewide initiative offering free hepatitis testing through the county health departments, and the OTP itself does HIV and hepatitis testing, said Mr. Fuller. “We are doing extra counseling and taking extra precautions for anyone who has a weakened immune system.”
Anyone considered high-risk for contracting the COVID-19 along with HIV, hepatitis C, or any condition that weakens the immune system gets curbside dosing, said Mr. Fuller. “We make sure when they arrive that they are not required to go into the waiting room at all.” And he stressed that these patients are reassured that this is to protect them from getting the virus. “They (the patients) recognize that we are looking out for their best interests.”
More Take-Homes / Better Drug-Test Results
Interestingly, during the time when patients have been getting more take-homes, the results of their drug tests have been improving. Mr. Fuller thinks that’s because they are “able to get to a therapeutic dose.” Some of the transfer patients had been coming every day, because their drug screens weren’t favorable. Often times having to miss days due to the long drive and time away from morning family routines and work did not allow for them to achieve stability. “When we got some of them to a stable dose, they started feeling good about themselves,” he said.
When the pandemic—and the restrictions—hit the headlines, the biggest anxiety among patients was that they would lose their treatment. “’Are you guys going to shut down?’” they worried. Now that they’d found a treatment program that worked for them, they didn’t want it to disappear. Nothing is more frightening to a methadone patient than that.
Adequate Dosing vs. Possible Exposures
There are still patients coming in every week who have never been in treatment, and it’s essential that they get enough medication, explained Mr. Fuller. “Do we want patients on the street looking for medication? Do we want patients dropping out of treatment and getting exposed, or exposing people?” And Mr. Fuller noted that the area of Georgia where Gateway is located doesn’t have a hospital. “They shut it down and Piedmont opened an emergency room for the community.”
One patient did think she had been exposed (she was tested, but results had not come back yet). “She drives herself to the clinic and gets curbside dosing, doesn’t get out of the car,” said Mr. Fuller. Interestingly, she was told that the program would give her two weeks of take-homes, but she would only take one week. She wanted to come once a week. She was isolated at home the rest of the time.
“Patients who used to come every day, and now come once a week, they miss this place,” said Mr. Fuller. “This was a safe place. We didn’t judge them. Just to have that positive interaction every morning, that’s something they want.”
Indeed. Isolation is not good for mental health, and certainly not good for early recovery. So everything that can be done to make such patients feel more secure is helpful. In the case of the diseases of opioid use disorder and COVID-19, methadone and social support can treat one. For the other, the best we can do now is stop the spread.
Georgia was due to open some public facilities, such as hair salons, tattoo parlors, and bowling alleys, on April 24. At Gateway, social distancing will still be required, to protect patients and staff. Perhaps even more protection will be required now.