For the first time, the city of New York is facilitating delivery of methadone to patients who would otherwise be required to go pick up their medication at a clinic, a move designed to slow the spread of COVID-19 among high-risk populations.
The new NYC Opioid Treatment Program Methadone Delivery System is a collaboration between the city’s Department of Health and Mental Hygiene and the New York State Offices of Addiction Services and Supports (OASAS), the agency that oversees use of methadone to treat addiction to opioids, such as heroin and prescription painkillers like oxycodone.
Around 28,500 people are enrolled in methadone clinics, or Opioid Treatment Programs (OTPs), in NYC. Under normal circumstances, most of them must report to their OTP each morning and take that day’s dose under supervision, a notoriously high level of regulation that has been relaxed amid concerns over social distancing.
The program first rolled out to the city’s five Department of Homeless Services (DHS) Covid isolation hotels last month; the converted hotels are being used to quarantine people experiencing homelessness who are positive or at-risk for coronavirus. Deliveries are now available to patients from isolation hotels operated by NYC Health + Hospitals, NYC Emergency Management, and the Mayor’s Office of Criminal Justice. As more isolation hotels become operational, deliveries will likely expand to those facilities as well.
“Getting this delivery program has been all-consuming,” said Allegra Schorr, President of the Coalition of Medication Assisted Treatment Providers and Advocates. “Getting medication outside the [OTPs], they’re not built for that, it wasn’t ever contemplated. Most programs, people were just begging, ‘Nurse, could you please just stop on your way home.’ It’s all just been volunteer. So this has been an enormous lift. We’re really grateful the city has put the resources in.”
As of May 19, the city has made 40 deliveries to isolation hotels (31 run by DHS and nine run by NYCHH) and 16 to participants’ homes. The program could reach an estimated 900 patients for home delivery, according to Schorr.
“We’ll continue to do as many referrals as we get from the isolation shelters, and then we’re hoping [OTPs] will really step up the number that they refer to us for home delivery,” said Denise Paone, the senior director of research and surveillance for the city’s Health Department. “We’re prepared. We’re ready.”
In March, the city’s public hospital system also rolled out a virtual clinic for buprenorphine— another medication federally approved for the treatment of Opioid Use Disorder—so that patients with the means to do so can refill their prescriptions via telehealth appointments rather than having to meet their doctor in person.
As the coronavirus pandemic throws the drug supply chain into chaos, expanded access to these medications is crucial in reducing risk of both overdose and of COVID-19. It will also help mitigate the spike in HIV and Hepatitis C that the city faces as people with reduced access to harm reduction facilities inevitably re-use and share syringes—the greater the access to methadone and buprenorphine, the more people will be able to hold out until they can access new syringes.
The national overdose crisis is often misrepresented as a crisis synonymous with opioids, but rates of opioid overdose have in many places been surpassed by overdoses from stimulants, such as crystal methamphetamine, which are often used in conjunction with opioids. Around half of all overdose deaths in NYC involve cocaine. Many chronic users of stimulants have underlying cardiac and/or respiratory conditions, meaning they’re a high-risk population for COVID-19 as well. While there are no medications approved for treating stimulant addiction, harm reduction centers have compiled resource guides for those affected.
New York State has also pre-empted risk of alcohol withdrawal by keeping liquor stores open. Meanwhile, telehealth meetings for groups like Alcoholics Anonymous and Narcotics Anonymous have ballooned in popularity since early March, including some that help maintain a sense of community by re-creating local chapter meetings online.
The Health Department has so far trained 10 teams of drivers and couriers to carry out the methadone deliveries. Couriers enter the isolation hotels with specially ordered lockboxes containing a seven- to 28-day supply of methadone, at which point patients are called down for a contactless delivery. Couriers and drivers are provided masks, gloves, hand sanitizer, and sterilizing wipes.
Each delivery also comes with a kit containing naloxone, the medication used to rapidly reverse opioid overdose. Naloxone cannot be self-administered, which is one reason the pandemic is disproportionately dangerous for people who use opioids -- in addition to already being an at-risk group for COVID-19 (chronic opioid use can compromise respiratory function) social isolation is a worst-case scenario for a population whose best, and often only, safeguard against overdose is to never use alone.
“It’s a great opportunity for us to just get naloxone in their hands,” Paone said.
OASAS is responsible for notifying the city’s 68 OTP providers about the new delivery system, and the individual providers are in turn responsible for referring patients to the program. Anyone with a methadone prescription who has tested positive or is showing symptoms for COVID-19, or is over 50 with one or more underlying health conditions, is eligible for deliveries.
The program in its current form will not serve methadone patients who are street homeless, and it’s likely that many patients with chronic mental illnesses won’t be deemed stable enough to receive deliveries either.
Participants are also now able to designate family members or roommates to pick up their medication for them, though Paone says the DOH is encouraging OTPs to make as many referrals for home delivery as possible.
“We had one member in a hotel who was COVID-positive and only had enough [methadone] for four days of his stay,” said Jasmine Budnella, Drug Policy Coordinator for social services nonprofit VOCAL-NY. “With no delivery infrastructure and the emphasis put on the methadone clinics to figure it out, he ended up having to get on the train to go get his methadone, which is one way we were able to escalate this issue to the city … people were already facing one public health crisis, and now that’s compounded by COVID.”
Drug-related death (a term that encompasses both accidental overdose death and death resulting from underlying causes related to chronic drug use) is the leading cause of death among people in the DHS system by a large margin, and has been since 2016.
The methadone delivery program will remain in place for the foreseeable future; activists and patients who have long advocated for methadone regulation reform hope it will continue after the Covid-19 threat has dissipated. While program participants could not be reached for comment, Budnella said VOCAL-NY will fight to make methadone delivery in the city permanent.
“Lots of people are invested in the possibility that this could lead to change post-COVID,” Paone said. “That’s a decision to be made by the feds. I do think data that can show that this was successful and that people did really well will help the argument ... so we’re hoping to be able to contribute to that conversation.”