When COVID-19 pandemic hit, opioid treatment changed – but not to patients’ detriment

If you want to begin treatment in Eastern Washington for opioid addiction using methadone, the oldest and most proven medication for such treatment, your options are limited.

A recent Washington State University study found that loosening of the restrictions for patients to take medicine home during the COVID-19 pandemic did not lead to more overdoses.

There are just four programs that offer methadone to treat addiction east of the Cascades, including two sites in Spokane, one in Yakima and one in Richland, according to the federal Substance Abuse and Mental Health Services Administration.

The largest of these four programs is at the Spokane Regional Health District, which treats more than 1,000 patients, some of whom drive hundreds of miles for medication nearly every day.

Patients from as far as Omak, Moses Lake, St. Maries and even Montana at times seek the opioid treatment program at SRHD, the only publicly funded program in Eastern Washington.

Methadone has been around longer than other medications that treat opioid addiction, and its use is tightly regulated. Methadone to treat opioid addictions can only be administered through specific opioid treatment programs, while other medications to treat opioid addiction, like buprenorphine, can be prescribed by physicians in doctor’s offices.

Methadone is a full opioid agonist, which lasts longer than 24 hours to reduce cravings and withdrawals, while buprenorphine is a partial agonist, meaning it produces some similar effects to opioids but at much weaker levels. Both drugs are approved for evidence-based ways to treat opioid addiction and allow a person to participate in normal life, according to the National Institute on Drug Abuse.

Experts and physicians alike emphasize that medication-assisted treatment for opioid addiction is actual treatment, not just swapping one drug for another.

“We are still in the mindset of this is not a medical disorder that could use treatment with an opioid replacement – it’s a moral failing,” Dr. Matt Layton, professor at the Washington State University College of Medicine, said.

The treatment programs, particularly for methadone, are bound by strict rules and protocols at the state and federal level with little room for error.

When you start treatment with methadone at SRHD, you have to physically go get your medication at the center six days a week for the first 90 days. For people who don’t live in Spokane, this is an onerous ask, especially for people admitting they want to seek help for an addiction that might have developed accidentally.

Anyone can become addicted to prescription opioids, which are usually prescribed for pain, according to the Centers for Disease Control and Prevention.

How the pandemic impacted treatment

Opioid treatment programs are subject to federal and state regulations, which dictate at what point a patient can be eligible for more take-home doses.

The pandemic swept much of this regulation away, however, and many patients were sent home with more doses than ever before. Some people who previously might have had to come to the health district every two weeks got to take home a month’s worth of medication.

So, what happened?

A study from researchers at Washington State University looked at outcomes for patients at SRHD both before and after the pandemic. The authors found that sending patients home with more medication did not lead to more overdoses or hospitalizations of patients misusing the methadone than were occurring previously.

“Our results showed that virtually all methadone clients received a substantial increase in the number of take-home doses following the COVID-19 exemption from methadone administration regulations,” the study says. “Importantly, this increase was not associated with poorer treatment outcomes in the post COVID-19 SAMHSA exemption period.”

Dr. Ofer Amram, with the WSU College of Medicine and the lead researcher on the study, said they followed 183 people in their study, including some who were going in daily for their doses before the pandemic hit.

He said the study is one of a handful of others looking at the opportunity the pandemic presented researchers to see if giving patients more doses of methadone would actually lead to more overdoses and adverse outcomes. His findings, along with more studies soon to be published, point to something other countries have figured out.

“The United States is the only country in the Western world that is very restrictive with methadone treatment,” Amram said.

The methadone clinic at SRHD opens to patients each morning at 5:15 a.m. and is open through noon. Patients have to take randomized urine sample drug tests, and progress through the program is determined by regulations at the federal, state and local program level.

Misty Challinor, treatment services division director at SRHD, said the pandemic meant not only more take-home doses for patients but also the implementation of telehealth for patients as well, which enabled some patients to thrive because of the newfound time to be able to coordinate their schedules or stay home with children instead of driving all the way in to the health district.

Previous studies have shown that the farther away a person lives from the health district the higher their likelihood of missing doses.

High demand, workforce in short supply

The opioid crisis nationwide has led to an increased need for treatment, but unlike common prescription treatments for other conditions allowing a person to go through a pharmacy drive-thru, treatment with methadone is laden with requirements.

For example, if a person is going on vacation or out of town and needs more doses to take with them than they are allowed in the program, the district must apply to state and federal agencies for an exemption.

The health district is back to its pre-pandemic programming, which means the highest amount of doses a person can take home with them is for up to two weeks, not a month’s worth.

Challinor said the district has some flexibility under federal regulations with how the program works, and she and her team have looked at other models elsewhere in the country. Some opioid treatment programs are open seven days a week at all hours of the day and night. Expanding their hours or reach would take more staff, she said.

“If we had the staffing capacity, and that was not an issue, we’d expand hours and be open seven days a week, 365 days a year,” Challinor said.

The goal is always to be available and offer treatment when a person is coming in asking for it.

“The biggest issue with behavioral health is getting them in when they’re open to it; when the individual comes up and says I want help, we need to get them in,” Challinor added.

Currently the district is still enrolling patients daily, as the largest opioid treatment program on this side of Washington state.

In October, the district admitted 49 new patients to the program, but Challinor said that figure doesn’t account for the others who came in and couldn’t be seen right away to enroll. Demand has increased, she said, while the workforce has decreased.

For years experts have advocated for a less restrictive and more personalized approach to treatment. For Amram, the results of the most recent study helps point the way.

COVID-19 offered a perhaps once-in-a-lifetime opportunity to evaluate exactly how a more lenient take-home medication policy would affect people. Amram hopes to continue his work in this arena, next examining how much, if at all, common co-occurring substance use is happening in these patients.

Amram’s study also begins to lift the hood on how labor-intensive coming to the clinic every day is for patients.

Clients who had difficulty getting transportation to treatment during the pandemic had higher odds of going to the emergency room for an overdose, and the study found that this group was more likely to be women.

“A possible explanation to this finding may be related to increases in mental health issues and stress in the COVID-19 era among women, partially driven by an increase in childcare labor as a result of school closures,” the study says. “However, more investigation is needed to further unpack this association.”

Ultimately, other factors play a role in patients’ lives when it comes to their desire to seek treatment.

“What we don’t know, which I think is really important, is what does it mean for other aspects of their life if they don’t have to come into the clinic every day?” Amram said. “My gut feeling is that patients actually like it more not coming to the clinic every day, and it allows them to be more productive and have a better quality of life.”