Key inequities in addiction care could be managed by correcting shortcomings uncovered in a recent qualitative study.
The study was published in Journal of Substance Abuse Treatment, and was conducted by researchers at Boston University and Boston Medical Center. It was drawn from a parent study, REpeated dose Behavioral intervention to reduce Opioid Overdose (REBOOTs).
The authors of the new study recruited 20 opioid-overdose survivors for in-depth individual interviews focusing on experiences using drugs and accessing addiction services during the COVID-19 pandemic. Each interview lasted 45 to 60 minutes, conducted by phone or in person between August 24th and October 31st, 2020. Interviewers were conducted by the study team.
The 20 subjects were asked about their experiences with the following during the COVID-19 pandemic:
- Methadone treatment
- Buprenorphine treatment
- Behavioral health service treatment
- Harm reduction services utilization (eg, syringe service programs)
The study team found that participants broadly described experiences with addiction service access during the pandemic as:
“Liberating” – 7
“Destabilizing” – 8
“Unjust” – 5
Some readers may be surprised by these responses, given the well-known advantages of COVID-driven changes—methadone take-homes, relaxed outpatient prescribing regulations for buprenorphine, required counseling delivered virtually, and less frequent toxicity testing.
To examine the differences in responses, the authors broke down the responses by group—and listened to what patients had to say about their experiences during treatment.
As the authors noted: “Patients’ perceptives can provide a critical content for observed outcomes (eg, efficacy of changes, impact on overdose deaths) and have the potential to guide and inform future research.”
The “Liberating” Group
All seven “Liberating” patients had stable housing and strong supports. All found the COVID-related changes easy to access and flexible to work with.
Jayla transitioned from a sober home to her own apartment with her husband early in the pandemic. The couple accessed methadone by car.
When the coronavirus came, me and my husband had never missed group…we [never] gave [the methadone clinic] a dirty urine. So me and my husband, apiece, we have six bottles. So we only go to the clinic once a week…
I like it because I can do anything [with] my time. I go and I stay in bed, or I can get up. I can make coffee, drink my coffee, go back to bed. Lay down. When you got to go to the clinic, you got to go to the clinic.
Jeremy, after release from court-ordered methadone treatment:
Well, my uncle let me stay at his house, thank God, when I got out [from jail]… He brought me to a clinic and everything…My buddy has been driving me, thank God. So he’s been helping me a lot too.
If it wasn’t for methadone, I probably would’ve died…It’s actually nice that they give out take-homes. So I only go in twice a week…I go in, they give me bottles. I bring a lockbox, and they give me bottles. I go home.
The “Destabilizing” Group
The eight in “Destabilizing” were homeless or only recently housed. Many lacked access to telemedicine. Some reported thefts of methadone or buprenorphine; others had their doses reduced or temporarily stopped. Still others lost access to sterile supplies and detox referrals—services previously available through syringe service programs.
Their views of take-homes differed from those of the “Liberating” group.
Viviana, stable on methadone, felt that weekly instead of daily clinic visits reduced her connection to “positive people” and disrupted her treatment goals:
When you’re on the clinic, you go every single day, which means you got to get up and leave the house, and just go. Now, they were giving people take-homes … I ended up getting six bottles so I could stay home. In a way, it helped me, but then in a way it hurts too because I started that feeling again of not leaving the house…I think I probably shouldn’t have got any take-homes and just continued going daily, and seeing the nurses and the counselors…
Edison, stable on methadone, also found take-homes difficult:
I would drink a little extra on day four, and it would leave me running on empty…So I basically told on myself … so they stopped giving them to me…I like it better because [going to the clinic] gets me up and ready for the day. I get up early, so I’m not sleeping all day. So it gets me motivated.
I got so used to living, last 10 years I’ve been homeless and staying at shelters and stuff like that, that once I finally got the place, I’m so used to someone always being there…I’m just so used to community living that now that I got my own spot and stuff like that, it’s uncomfortable. I get anxiety really easy.
Edison’s time was cut short:
I would see [my counselor] every Friday for like an hour… When I go to meetings I like to see people. I like to associate, not over the phone.
But after the pandemic hit, Edison’s counselor had only 10 or 15 minutes to talk with him.
Not surprisingly, Edison and Viviana asked to return to daily dosing.
Viviana’s reaction to housing placement:
I was lonely and I was scared. You live in a shelter with 222 women a day and then you go and you move into your own apartment, which believe me, I love now that I’m used to it. It was like, oh my God. It was quiet and I thought I was going crazy. I did. I thought I was losing my mind.
I got a really short attention span, so [meetings] got to be in the moment kind of thing. I got to be in the room … My mind wanders…
I liked [Zoom recovery meetings]…I was still kind of using, but people don’t judge … I told them, “Hi, I’m an addict and I’m struggling right now. I’m having a hard time. I’m living alone and I’m scared.” It was just so nice to be able to see other people. [laughs] Because the world was like gone, it was empty. It was horrible at that time.
The ”Unjust” Group
Most “Unjusts” lacked social supports and were sleeping in the street or living in shelters.
Unable to benefit from COVID-related changes, the people in this group considered those changes “inadequate to make up for the inequities that burden unhoused people who use drugs,” the authors noted.
Group members considered it especially galling that they had to risk COVID exposure to access medications and shelter services.
Aiden, unhoused, on methadone, was using non-prescribed opioids:
I ended up getting COVID, and … in a quarantine in a hotel for two weeks. So I had a hard time getting my dose, ‘cause I couldn’t get there daily. I need to have the dose brought to me… And since then I had to go to the clinic daily … I didn’t qualify for take-homes.
I don’t have a home to take [methadone] to. I didn’t qualify for a lockbox full of meds that I could give to anybody that was in a position of being able to watch me. Because nobody’s in that position over me, I’m homeless.
These are the roads and the bumps and the twists and turns that people don’t understand that addicts, we deal with a lot of b*llsh*t because we’re the black sheep of the community.
Aiden, after COVID-19 stay-at-home orders:
I still had to get up and go every day. They weren’t running trains. They weren’t running the buses…I’m five miles away from [the] inner city. And here I am having to f*ck*ng ride the bike down the highway…We couldn’t do anything, but it’s okay to send the drug addicts out. The homeless guys out, so that they can go get their food stamps and f*ck*ng methadone.
Maurice, “sleeping out” at the start of the pandemic, regularly attended the local syringe service program until it closed. He missed having a place that is “safe, warm, and dry.”
The needle exchange … had a social aspect to it. People who knew each other, and we were all friends with the employees … it was a very nice area. Especially for homeless people to have a place to hang out…
It’s been very difficult trying to see my family, with me being as sick as I was, I needed to just stay away from everybody… I’m trying to deal with my low immune system, getting COVID, dealing with hepatitis C … addiction issues … the stress of parenting from afar…the stress of being a son from afar.
Unfortunately, with “just too much” on his shoulders, feeling like he “earned a break or something,” Aiden ended up escalating his substance use.
Some cited “unjust increases in attention from police”:
… they would come around and kicking us out everywhere that we would be trying to sleep. We’d run out of options… And then it was just like everywhere a homeless group would gather the cops would come tell us to leave.
People in the “Unjust” group also encountered challenges in meeting their daily needs.
“there were no bathrooms available…water became difficult to get …
Despite everything, some in the “Unjust” group remained committed to their goals.
I give a lot of the credit also to the therapy and the medication because when I get up in the morning, I go get my medicine. I’m not sick. I talk to somebody on the way in, so I’m getting therapy on my way to get my meds…I’ve already done therapy for the day, so I don’t have to worry too heavily about something weighing on my conscience and sh*t. And I can get on with my day.
In their final comment, the authors make a key point: addiction care inequities “will persist if drivers of marginalization, specifically a lack of housing, remain unaddressed.”
Additional points from this study:
People with an opioid use disorder can be greatly damaged if they lack support networks, and damage can be further exacerbated if changes to services disrupt community and supports.
Some participants in all the groups pointed to isolation and boredom as disrupting their substance-use goals.
Housing, access to safe public space, and community connections were important or essential factors for all three groups.
“Take-homes” can be fine—unless you don’t have a home to take “take-homes” to.
Harris MTH, Lambert AM, Maschke AD, Bagley SM, Walley AY, Gunn CM. “No home to take methadone to”: Experiences with addiction services during the COVID-19 pandemic among survivors of opioid overdose in Boston [published online ahead of print, 2021 Nov 4]. J Subst Abuse Treat. 2021;108655. doi:10.1016/j.jsat.2021.108655
For Additional Reading
Repeated dose Behavioral intervention to reduce Opioid Overdose: A two-site randomized controlled efficacy Trial (REBOOT) (Coffin, 2019, Clinicaltrials.gov: NCT03838510).