Update (4/2/20): The state has deemed drug and alcohol treatment centers to be "essential businesses" and they are allowed to continue to operate during the coronavirus emergency. Gov. Tom Wolf's office is encouraging individuals struggling with alcohol or drug abuse disorders to call a hotline, 1-800-662-HELP, to get connected to recovery resources.
The number of calls from people seeking help for both alcohol and opioid use disorders has dropped since the arrival of the new coronavirus, but the number of calls from people seeking help for cocaine and methamphetamine abuse has increased, according to Jenn Smith, director of the Department of Drug and Alcohol Programs. She recommended that people in recovery use video call services to keep in touch with family and friends during this trying time.
The novel coronavirus is changing the way that providers in Allegheny County and across the nation treat people with drug and alcohol use disorders, particularly those who use medications like methadone and Suboxone to maintain their recovery.
“This is such a tumultuous time for everyone, especially those with substance abuse disorders,” said Daniel Garrighan, facilities director at Jade Wellness Center, an outpatient treatment center with locations on the South Side, Wexford and Monroeville, that offers services including Suboxone, Vivitrol and ReVia.
Those treatments, plus methadone — all commonly referred to as medication-assisted treatment or MAT — stave off cravings and help people stay off of illegal opioids. Vivitrol and ReVia can also be taken for alcohol use disorder. But they are typically provided at regular office visits, sometimes daily in the case of methadone. The coronavirus crisis has made such visits much more difficult, if not impossible.
“We have already faced our own epidemic with this subgroup of folks with the opiate crisis,” said Garrighan. “We saw such outrageous fatalities over the past 10 years and we just started to get a grip on it and then something like this happens. We have this social responsibility and we don't want to neglect [patients] but we also need to take necessary precautions with the spread of COVID-19.”
After a record-breaking high of 737 overdose deaths in Allegheny County in 2017, fatal overdoses in the county dropped by more than 40% in 2018.
Some worry that progress could be at risk. “What’s happening right now with coronavirus,” said Lauren Ballew, a harm reduction specialist with Bridge to the Mountains, “is limiting resources for everyone: for the homeless, for average users, for service providers, and for people on medication for opiate use disorders.”
Less frequent visits
Under normal, non-emergency circumstances, methadone is dispensed on a daily basis in person at a licensed clinic. Suboxone is dispensed on either a weekly or biweekly basis, depending on the patient.
The Substance Abuse and Mental Health Services Administration (SAMHSA) recently released new guidelines for dispensing these maintenance medications amid COVID-19. According to the memorandum, doctors and clinics prescribing these medications in areas where a state of emergency has officially been declared are authorized to dispense up to 14 days worth of medications to patients considered “less stable” and up to 28 days worth to patients considered “stable.”
Garrighan said he thought the guidelines were “very responsible.”
Some recovery professionals, though, are concerned about the possible misuse of medications. Methadone misuse can result in overdoses, and it can take several doses of naloxone (also known as Narcan) to reverse that.
“A single daily dose of methadone that is taken in the morning is meant to last all day. If someone takes two doses and decides they want to get high then they are taking a significant risk,” said Alexis, a drug and alcohol outreach and case worker in Allegheny County who is in long-term recovery from drug and alcohol addiction, and asked that her last name be withheld.
Ballew said that a lot of the concern surrounding the abuse of maintenance medications is due to the stigma attached to patients who take methadone and Suboxone to support their recovery.
“People think that if folks are given more than what they need then they will use more than what they are supposed to,” she said. She speculated that fears of misuse could be “an extension of general panic that is more concerned with the stigma around various forms of MAT than what is actually happening with the individuals that use these medications to maintain their recovery.”
“Recovery means a lot of different things,” she said. “It’s not a one-size-fits-all and we need to give people the choice to define what recovery means for them.”
Virtual visits, stalled goals
Jade Wellness Center and other outpatient and MAT clinics in Allegheny County are responding to coronavirus by moving toward virtual doctor and therapist appointments using the online platform Telehealth. “We are promoting the option and about half of our visits right now are virtual,” said Garrighan.
“Some insurances won't cover virtual visits,” he added. “Medicaid providers will, but some private plans won’t. Also, not everyone has access to the internet.”
Other changes taking place at Jade Wellness Center include a no-waiting-room option in which the clinic messages people when practitioners are ready to see them. Jade is also reducing urine analyses out of concern that COVID-19 may be transmissible through urine.
While engaging in virtual or phone appointments has clear benefits in terms of preventing the spread of COVID-19, some service providers feel that important information regarding their most vulnerable clients may get lost in the technology.
“When you see someone face to face, there is an unspoken language of what is going on that is so much more important than what’s being said,” Alexis said.
That’s true in cases in which clients are still using, but also for those who are sober and pursuing life goals.
“If sobriety is being maintained and we are [working] on employment or housing goals then there isn’t much we can do right now,” Alexis said. “Every single one of those things is on hold for them, like it is for everyone else.”
The trend toward virtual visits also affects distribution of naloxone, which reverses opioid overdoses.
“I normally give [naloxone] to clients during appointments or leave it with EMS, police or even at restaurants. But due to social distancing we can't do this as much,” Alexis said.
Prevention Point Pittsburgh is still distributing naloxone and clean syringes from its van. “They are going to have a big presence, with what’s going on,” Alexis said. “I have driven folks to their sites to get clean needles because they have HIV and hepatitis C.”
For users, increased risk — but also hope
COVID-19 is changing life for individuals that are still using and in active addiction.
“It seems like it could be easier to use now because police aren’t pulling people over unless absolutely necessary,” Alexis said.
There is no official data yet for overdoses since the onset of COVID-19, but she speculated that we might be looking at a rise in overdoses due to closure of some outpatient facilities. She also worried that people in active addiction who contract COVID-19 could be at increased risk for overdose. “Overdoses attack the respiratory system for opiate, benzodiazepine and alcohol users,” and coronavirus affects the same system, she noted.
Ballew added that the panic around COVID-19 and resulting 911 calls could clog dispatch and slow EMS response time. “With less dispatch, overdose calls might not be attended to as quickly,” she said.
“This is a really critical time to be aware of how you are using or how someone else is using to help prevent a fatal overdose,” Ballew said. She stressed the importance of making sure people have naloxone and know where it is.
“We encourage people not to use alone and encourage those who are using alone to use the buddy system,” she said. With the buddy system, the person who is using texts someone else when they are about to get high, and then follows up 10 to 15 minutes later. If the person who is supposed to receive the follow-up text fails to hear from the active user, they can reach out to EMS for help or go check on that person themselves.
“What’s happening with COVID-19 is so similar to what happened to those in recovery in Florida during Hurricane Irma: everyone either left or hunkered down and stayed at home,” Alexis said.
When Hurricane Irma hit in 2017, Alexis was in early recovery, living in Florida, with around six months of sobriety, when she had to evacuate. Formalized meetings and treatment stopped because of the emergency. She moved to North Carolina, went to meetings and stayed in recovery. She moved in with her then-partner, who was in long-term recovery and who helped her to avoid relapse during that trying time.
“I fear for those in early recovery who don’t have a support group or a sponsor yet,” she said, “because having that during the hurricane was what helped me stay clean.”
Joanna Bernstein is a writer in Pittsburgh. She can be reached at firstname.lastname@example.org.
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