This analysis is part of the “Epidemic in a Pandemic” series that looks at what has happened to substance-use treatment access and effectiveness during COVID-19.
In March 2020, as New York State Governor Andrew Cuomo put the state on “pause,” sending employees to work from home and closing non-essential businesses to the public, the state’s substance-use service providers found themselves quickly adapting to a changing regulatory landscape. Federal and state agencies offered new guidelines for substance-use services at the same time service providers had to adopt social distancing measures like other essential industries. What changed, and how did service providers respond?
We spoke to experts and providers from across the state, and they identified three regulatory changes that had the greatest effect on substance-use service provision: telehealth, extended take-home policies for medication-assisted treatment, and social distancing guidelines.
Telehealth
Modified regulations made telehealth more readily available for service providers to use. Prior to the COVID-19 pandemic, physicians could dispense methadone and prescribe buprenorphine only after patients had an in-person physical examination.[1] New regulatory guidance allowed providers to see patients, prescribe medication to existing patients on buprenorphine and methadone, and allow for induction (first-time use) of buprenorphine (but not methadone) all via telehealth. These regulatory changes required waiving in-person or video visits (allowing audio-only appointments), written consent, and HIPAA rules specifying particular kinds of electronic platforms. New York State OASAS waived regulations requiring providers to obtain written authorization and designation from OASAS and in-person patient assessment prior to starting telehealth.
Some organizations enjoyed a head start on telehealth, having already laid the groundwork for the types of regulatory relaxation provided by the state. A provider in New York City, for instance, had already been approved to perform telehealth services in their outpatient clinic, so it was simply a matter of introducing established practices into a broader array of programs, namely their recovery centers and ambulatory care settings. Similarly, a provider in rural, upstate New York was able to adapt quickly because it already had the necessary policies and procedures in place to use telehealth equipment.
… nearly every respondent expressed concern that the pandemic was “generating people with substance use disorders.”
But even with pre-existing policies in place, some organizations were stymied by a lack of technology, including teleconferencing equipment. In the absence of work cell phones, for instance, one rural provider utilized free Caller ID Blocking to avoid giving out counselors’ home phone numbers. The organization later used an online app to conduct group counseling sessions. As of this writing, it is testing video platforms to supplement audio-only services, and a representative noted, “we’re kind of improving as we go along.”
Extended take-home policies for medication-assisted treatments
SAMHSA also allowed states to request blanket exemptions for stable patients to receive up to 28 days of take-home doses of their medication and up to 14 days of take-home doses for patients in earlier stages of recovery.
Organizations, however, have not uniformly increased take-home doses to the maximum levels. Instead, they have chosen to set particular organizational limits for safe dispensing and to allow discretion and flexibility based on patient need. Some patients may do better with lower take-home doses, and organizations developed new and creative ways to administer their medication safely. One upstate provider used its mobile unit to set up a drive-thru methadone dispensary. After signoff from federal officials, it was dispensing medication in the parking lot.
For clients who lack transportation to come to a facility, SAMHSA is allowing trustworthy proxies to pick up methadone or providers to deliver it. Drivers transport medication in lockboxes, call the client on the phone, wait from a distance until they retrieve the box, and leave.
But not all providers operate under the same conditions or have access to the same resources. Drive-thru methadone dispensaries are not as feasible in places like New York City that lack many open-air parking lots. Some urban providers “don’t have any capacity to make deliveries at all.” New York City Health Department started a mobile methadone program in April 2020.
Social Distancing
State social-distancing guidelines ask providers to: post signs about new COVID-19 related policies and procedures, clean and sanitize their facilities routinely, have handwashing and hand sanitizer available, screen staff and clients, provide PPE to staff, ensure six-feet distance between individuals, eliminate large gatherings, and isolate COVID-19 positive individuals. These guidelines had the unintended effect of reducing access for people who need substance-use services across all levels of care, which is especially difficult in residential settings.
Detoxification Services
Prior to the pandemic, access to detoxification services was already limited because, unless prospective patients exhibited the physical symptoms of withdrawal, hospitals generally turned them away. But the risk of contracting COVID-19 made people even more reluctant to go to the emergency department. “[A]lot of people don’t want to go to the hospital because they’re fearful of what they might find,” one provider explained. “A lot of people don’t want to go to a medical facility at all.”
Social distancing requirements seem to have made matters worse, limiting the total number of detoxification beds available. “Even our medically monitored, which is the step up from the emergency room, they had to reduce their census because of social distancing,” this same provider explained. “So if they were able to take 16, they could only take 8. That creates a problem.” Access to some services has become more complex than it already was.
Outpatient Treatment
Though the number of detoxification beds diminished, providers sought new ways to provide outpatient services consistent with social distancing guidelines—conducting temperature checks, screening for symptoms, and moving around staff to limit exposure. One provider described the executive order directing businesses to keep 50 percent of the workforce at home as “exceptional” because “it freed up offices. It allowed some of our shared workspaces to be spread out.” This same provider kept group therapy sessions “very, very small for social distancing in highly ventilated areas.” Yet others, particularly those in rural areas, considered holding individual and group counseling sessions outdoors.
Residential Care
Social distancing posed unique challenges in congregate care settings, where clients typically share bedrooms and live in close quarters. Social distancing guidelines suggested significant changes in the way residential facilities operate from the number of people sleeping in a single room to the number of people picking up medication at the same time. In the words of one provider, “the residential system … is not set up for social distancing.”
You have programs that are open but having to safely distance people from each other means that if you have 20 beds maybe you’re down to 10 or 12 because you can’t have people that close to each other. If you have bunk beds or two beds in one room you can’t have both beds full at the same time. So how do you manage through this enormous disruption?
One approach was to reduce the overall census density by refusing new admissions or moving people to different locations. As one provider noted, “social distancing cut capacity down significantly.” Still others sought to restructure their facilities – adopting staggered lunch times and spaced-out seating and warning residents about longer elevator wait times. “We had to change everything,” said one provider:
We had to change rooms; we had to change offices; we had to put markers on the floor to identify six feet distances; we had to stop having groups in case managers’ and social workers’ offices. We had to stop doing individual sessions because most of the social workers’ offices don’t allow for appropriate social distancing.
If a social worker wanted to meet with a client in this setting, the client was placed in an office several doors down and they had a conversation over the phone. “The logistical managing of the situation became a full-time job … [I]t’s really been tough.”
“Creating New Addicted People”
Despite the loosening of some constraints, most people we spoke to are worried substance use is getting worse, evidenced by “some troubling signs of overdoses.” In fact, nearly every respondent expressed concern that the pandemic was “generating people with substance use disorders.” Though the number of overdose deaths declined in 2018, many predicted “we’re going to have problems with overdoses again in a way that we haven’t had for a while.”
COVID-19 has not displaced the opioid epidemic, it has intensified it.
Part of the issue is that traumatic events related to the pandemic can trigger substance use. “Loss of housing, jobs, loved ones,” noted a provider, “these are often the precursors that lead to mental health and substance-use disorders.” Also, many people with substance-use disorders already “suffer from post-traumatic stress disorder because of circumstances that have happened in their life. Sheltering in place and being in confined quarters is not a solution for people with those types of disorders.”
Beyond increased risk of substance use, providers worry that it is becoming more difficult to access treatment, changes in the rules and regulations notwithstanding. According to one provider, “we’re actively saying to people No, no, no, don’t. Don’t come into our clinic. You can’t come to our programs. You can’t get on the subway and go to appointment in the clinic. You can’t go into many residential programs because they’ve got limited number of beds and they have to observe social distancing.”
Because social distancing requires reduced capacity, residential providers found themselves in the unenviable position of having to pick and choose between clients. For some, it is a matter of life and death. “I have to keep people as safe as possible in my program,” noted one provider, “but there are people out there who could die if I don’t admit into the program. How many of them will die?” It’s a “morbid exercise” of the mind. At the same time, it is also a matter of keeping the doors open. “How am I going to pay my bills? Serving less people, less revenue, and state saying that they are going to cut funds.”
Preliminary numbers from Rensselaer, Sullivan, and Queens Counties reflect stories similar to what has been reported by counties across the nation: overdoses and overdose deaths have increased, sometimes doubling during COVID-19. COVID-19 has not displaced the opioid epidemic, it has intensified it. Even as public attention to the pandemic has overshadowed attention to substance use, it is important to remember, as one provider explained, “addiction doesn’t take a day off.”
ABOUT THE AUTHORS
Patricia Strach is a fellow at the Rockefeller Institute of Government
Elizabeth Pérez-Chiqués is a fellow at the Rockefeller Institute of Government
Katie Zuber is a fellow at the Rockefeller Institute of Government
Trevor Craft is a graduate research assistant at the Rockefeller Institute of Government
Serita Lewis is an undergraduate research assistant at the Rockefeller Institute of Government
[1] Medication-assisted treatment is tightly regulated, in part, because the medication used falls under the federal Controlled Substances Act (methadone is a Schedule II drug while buprenorphine is a Schedule III drug).