Update on COVID 19 at the Opioid Treatment Program

 

 

 

 

Yeah I’ve got nothing new. Same old stuff. Social distancing, extra take homes for patients, everyone wear masks, wash hands every two minutes, wipe down facility periodically…

We’ve had a few COVID positive patients, but not as many recently as a month or so ago. We car-dose anyone who is medically fragile or who has any symptoms of COVID. Confirmed cases are usually given two weeks of take homes, unless they are terribly unstable.

Financial stress on patients has been worse. Our state grants for treatment that are administrated by area LMEs (local management entities, a frustratingly vague term) dried up at the end of June. More money from the State Opioid Response (SOR) grants has become available, but prospective grant recipients must qualify for them. In order to qualify for this grant money that pays for treatment, the patients must first apply for, and be turned down for, Medicaid coverage.

In the past, patients could go to our local department of social services, be interviewed, and get a letter saying they didn’t qualify for Medicaid within a day or two. Now, for some reason, our local department of social services says it will take at least a month to process applications for Medicaid.

I hate red tape.

Many of our patients, out of work due to COVID, have no money to pay for treatment. They have great difficulty hanging on for a week, let alone for a month. As a result, we’ve had a higher-than-normal number of patients drop out of treatment last month, mostly because their grant that paid for treatment ended. Our OTP, owned by a for-profit company, has allowed people to charge, especially for extra take home doses, for the last four months and that’s been great. But there’s an end to all charity in such companies, and now our clerical personnel have been instructed to ask for payment on balances.

Lest any person think our for-profit company is unfeeling for asking to be paid, allow me to remind readers that in our country, healthcare is not a right. It is a privilege. People with no money and no insurance are denied medical care every day of the week, in all areas of medicine. If you don’t like that arrangement, be sure you vote this fall. I know I will.

Some readers will surely point out that prospective patients spend more each day for illicit drugs than they would for treatment, but it’s different. When using drugs, people often resort to illegal activities to finance their addiction, and in treatment of course we don’t want them to do this.

Overall, I sense a downward slide in the overall wellness of our patients. More patients have tested positive for benzodiazepines, and judging from my conversation with these patients, it appears driven by the stress and uncertainly of present-day life.

Patients with school-age children must decide how to manage the every-other-day schedule our local school system announced. The schools are doing this to reduce the number of children in school at the same time, to promote distancing. But parents, if they work, have to find child care on the off days from school, adding to their anxiety burden.

Many more patients are testing positive for methamphetamines. From what I hear from other doctors, this seems to be a statewide trend. It’s a cheap and widely available drug, with effects that last for days.

At first, this liking for methamphetamine puzzled me. If a patient prefers sedating effects of opioids, why would he like the speedy effects of methamphetamine? But I was thinking too simplistically. Some patients with opioid use disorder say they like the energy it temporarily brings, or they enjoy feeling different for a short time, to forget about their problems.

We have no medication that’s been proven to help treat stimulant use disorder, so counseling is the mainstay of treatment. Often it must be provided in an inpatient setting, where the patient is removed from the source of methamphetamine, before patients make progress in recovery.

I used to taper patients on methadone or buprenorphine out of treatment for intractable methamphetamine use. Now, with overdose deaths from fentanyl rising in our state, I keep these patients in treatment while we try to increase their “dose” of counseling, either with us or to go to inpatient treatment at a facility where they can stay on their methadone or buprenorphine.

Overall, it feels like our opioid treatment program is in limbo, waiting for the end of COVID, waiting for more grant money for patients with no means to pay for treatment.

Yet some patients have thrived over the past months. Unexpectedly, some patients are making progress in their recovery despite difficult and stressful times. Some people are like that – fires that burn brighter against the wind. Watching those patients, I remember how resilient people can be. Many, if not most of our patients are survivors of one disaster or another: suboptimal parenting, physical/sexual/emotional trauma, terrible auto accidents, major health issues at a young age, or other calamities.

These are the people who inspire me to remain positive. It’s easy to give in to pessimism and cynicism, but watching these patients reminds me there’s another way, a better way to conduct myself in the world. I lean on these people for inspiration and hope I can reflect it back to others.

 

7 responses to this post.

  1. Posted by Mark Wulff on August 6, 2020 at 6:24 am

    It is such senseless false economy making funding so difficult to access.

    I would actually go so far as to say ‘inhumane’ even more so in these extraordinary times.

    The bureaucrats obviously don’t realize, or don’t care, that one month in the life of an addict is an eternity and can even mean the difference between life and death.

    Either a human life isn’t worth very much these days or maybe its because the persons currency is devalued because of the stigma of drug addiction?

    I can only begin to imagine the personal frustration and angst you must be feeling virtually being left powerless to help or continue to help people knowing full well the possible ramifications.

    “Research repeatedly finds that when access to maintenance is reduced or eliminated, deaths from drug overdose rise, as do rates of infection with HIV, hepatitis C and other blood-borne diseases.
    In fact, patients on maintenance treatment have a death rate three to four times lower than those who leave it.
    It is clear that maintenance saves lives.”

    Reply

  2. Posted by Mary Anne Hughes on August 6, 2020 at 2:30 pm

    What an inspiring read! Yes to the same challenges at out clinic and agree with methampetamine use uptick and often used when nothing else around to stave off w/d. I had a light-bulb moment myself, when I remembered patients said were “energized” by their use. Makes perfect sense! What doesn’t make sense, is the “business” side of this. And yes, it is disheartening and traumatizing for staff at our ” for profit” clinic also . And yes to the previous comment about treatment saving lives and stigmatization ramifications.
    Jana, you ARE a power of example to all of us and our patients too. You do us all proud.Thank you for all you do and for reminding me that the resilience of our patients holds us to a higher bar. Stay well, Jana and keep shining that little light. It is more reflective than you could ever imagine!

    Reply

  3. Posted by Alan Wartenberg MD on August 9, 2020 at 3:01 am

    There are now a couple of articles of small series using mirtazepine (Remeron®) for methamphetamine abuse with some modest results. I am going to start trying it. I have started working a brand new OTP, currently with methadone only, and we admitted our first patient on Thursday. Nice to be back in the saddle.

    Reply

    • Posted by Mark Wulff on August 9, 2020 at 10:53 am

      Meth is wreaking havoc here in Australia.

      One of our capital cities (Adelaide SA) has the highest methamphetamine use in the world and our regional areas usage ranks third overall in the world.

      Currently our country is trialing the ADHD drug lisdexamfetamine in the hope it will reduce the withdrawal symptoms and cravings.

      I really hope you have great success with Remeron, I could think of no greater hell than withdrawing without some kind of medication assistance, I certainly could not have.

      Reply

    • I’m delighted to hear you’re back in the saddle. Those are some very fortunate patients!
      THanks for the tip about mirtazepine.

      Reply

  4. Posted by Kirsten B on August 9, 2020 at 12:34 pm

    Thank you for your ever inspiring messages. We are living in strange times. I pray for you, the physicians, for us, the recovering addicts,and for those have haven’t found their path yet. I am beyond grateful for over 6 years clean before Covid. I simply cannot imagine dealing with the stress of daily life now, with active addiction or new found recovery. When we are active in addiction, we constantly look for ‘our place’ our direction, which path to follow, and with so much information being passed out by media and networks, it pulls even the healthiest mind into dark and confusing places….the “what ifs” are endless. Thank you for continuing to be a light for your patients and even for your readers like me!

    Reply

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