For more than a decade, I led a double life, fueled by heroin and mental illness. There was nothing recreational about my use — no dinner parties with pairings of Dilaudid (hydromorphone) and Chilean sea bass, no afternoons of shooting up and playing Ultimate Frisbee. I lost a lot of friends to overdoses and tried many times to stop before I finally got sober 12 years ago.
Depression was my gateway and relapse trigger. If my addiction was a compulsion to kill emotional pain with heroin, recovery was a process of healing the wounds that led me to dope in the first place. For me and many others, such healing has required buprenorphine and intensive therapy. Both sources of treatment are complicated by closures intended to inhibit the spread of the coronavirus.
When social-distancing measures were implemented this spring, doctors and officials urged patients to stock up on prescribed medications. This was impossible for people on methadone, who must go to a clinic every day for disbursements, and next to impossible for those of us on buprenorphine, the other drug proved to reduce the risk of overdose and relapse. Although pharmacists in most states have legal discretion to dispense controlled substances early, many don’t. (In 12 years, I have yet to encounter one who has.)
Without medication, people in recovery are effectively forced to choose between the excruciating physiological agony of withdrawal, or relapse. Tragic outcomes were obvious even before overdose fatalities began to surge in Ohio, New York, Pennsylvania, South Carolina, Florida and elsewhere.
Restrictions on medically assisted treatment involving methadone and medications containing buprenorphine were eased in mid-March — after the first wave of deaths was reported.
Allowing physicians to prescribe over the phone or by videoconference is a good step; as of 2016, 60 percent of rural U.S. counties had no physicians licensed to prescribe buprenorphine. About half of all U.S. counties lacked a publicly available licensed provider of medication for opioid use disorder in 2017.
Having a prescription, however, doesn’t eliminate all problems. Although restrictions have been eased to allow stable patients in opioid treatment programs to receive as many as 28 days’ worth of doses to be taken home, many clinics refuse to dispense more than one dose at a time. Crowded conditions and long lines have been reported across the country, precisely the risky type of situation that social-distancing measures seek to avoid.
Users motivated to seek treatment or to minimize risks related to their addiction have limited options. Although drug overdose fatalities declined 5.1 percent from 2017 to 2018, opioid overdoses are still at crisis levels. Using alone increases the odds of fatality if the person overdoses. Pandemic measures have limited access to resources that might reduce risk, such as needle-exchange and safe-injection sites, or the overdose-reversing drug Narcan (naloxone).
In Texas and Indiana, first responders recently stopped carrying naloxone and have been instructed to maintain a distance of six feet from overdose victims, reportedly to reduce potential exposure to the coronavirus. A recent Indiana policy change considers treatment of an overdose with naloxone probable cause for a police investigation. This practice is likely to deter addicts from seeking medical treatment in an emergency or carrying something that could save their life.
Historically, mental health and substance-abuse issues have surged after disasters. The viral outbreak and self-isolation trigger stress and fear that could be particularly difficult for recovering addicts. Support groups, though helpful, do not have the proven efficacy of medication, and many people prefer in-person contact to remote connections.
Just 11 percent of the more than 21 million Americans struggling with substance abuse received needed treatment in 2018, the Association of American Medical Colleges reported in December, and only 1,883 physicians are certified in addiction medicine. Most care is provided by counselors without medical qualifications and no standard training or requirements. Medically assisted treatment is offered in only about a third of rehabs.
The opioid crisis cannot be resolved by restricting and stigmatizing the antidote. A 2019 Journal of the American Medical Association article predicted 82,000 annual opioid overdose deaths from 2016 through 2025, or about 700,000 such fatalities, barring substantial changes to policies for treatment and harm reduction.
Access to a coronavirus vaccine or a cure for covid-19 would not be limited. Why are the most effective remedies to another national health emergency being restricted?