When Mayor London Breed announced a strict shelter-in-place order on March 16 in response to the COVID-19 outbreak, health facilities scrambled to identify ways to safely see patients. For addiction medicine doctors, this presented a particularly difficult challenge: Patients engaged in medication-assisted treatment for opioid addiction must be seen frequently, often every few days. Regular doctor visits are not just helpful for people’s recovery but until that point had been required by the federal government for the dispensing of certain opioid addiction medications.
As doctors across San Francisco switched to telehealth visits — talking to patients over the phone or through video chat — an unexpected shift took place. Missed appointments, a norm before the shelter-in-place order, became rare. A lower barrier to care combined with a relaxation of federal regulations around prescriptions means that accessing drug treatment has, in many ways, become easier than ever before.
Dr. Keith Loring, an addiction medicine specialist at the community health center HealthRIGHT 360, said the shift from in-person visits with patients to those that take place over the phone or online happened swiftly.
“We adapted immediately,” Loring said. “Our biggest concern was trying to keep as many people out of the clinic as possible, both staff and patients.” By the beginning of April, Loring was working full time from home.
The transition has come with a few challenges. Many of HealthRIGHT 360’s patients are low-income or unhoused, and some don’t have access to a phone or computer. To remedy this, the clinic set up laptops for people who come off the street for care. They are also available for patients who don’t have access to a phone.
Benefits of meeting remotely
The benefit of seeing patients who didn’t have to physically show up quickly became apparent. Before the pandemic, no-shows were common at HealthRIGHT 360. Patients would lose track of time, have difficulty finding transportation to the clinic or not be able to leave their belongings on the street. Telehealth has made reaching their physicians easier. As long as you have a phone, you can make your appointment, whether you’re on the streets or in a hotel.
“I was seeing eight to 10 patients a day” before COVID-19, Loring said. “Now we’re able to fill our schedules, and I’m seeing 14 patients, and more sometimes. They built up the operations where if there’s a no-show they can backfill with another patient.”
At the same time as the switch to telehealth was happening, the federal government loosened the requirements to access several opioid addiction treatment drugs, and enabled doctors to write prescriptions for lengthier periods of time.
Historically, California regulations have required patients accessing methadone — a pill that reduces both opioid cravings and withdrawals while blunting the effects of a high — to visit a clinic daily to pick up their dose. But the seven methadone clinics in San Francisco were a perfect scenario for contracting COVID-19.
“The state regulations required that somebody be at that window every day, which is a lot of exposure,” said Dr. Judith Martin, the medical director of substance use services at the San Francisco Department of Public Health. “People came in and hung around and got their dose until they left, and sometimes they were standing in line with 20 other people, because they wanted to be there right when it opened.”
That one-pill-at-a-time rule has been loosened for now.
“If deemed appropriate by a physician — imagine that, we’re allowed to make clinical decisions! — you could decide to give up to two weeks at a time to somebody who’s brand new, or a month to someone who’s stable,” Martin said.
Prescription extensions have also been put in place for buprenorphine, a popular alternative to methadone with fewer side effects. Efforts have been made to get these drugs delivered to people who need them as well. Residents of shelter-in-place or quarantine hotels run by the city can have their prescriptions delivered to them by case managers.
“We knew from people living in SROs that being isolated in your room when you use is problematic,” Martin said. “If you use alone, you’re more at risk for overdose. We were really concerned that the shelter-in-place hotels might lead to more overdoses, so it was important to offer buprenorphine to that group.”
The shift to telehealth and looser prescription guidelines have helped many patients access care with fewer barriers. But the move away from in-person visits raises new questions.
Not being able to see patients one-on-one, particularly when they’re working through trauma and addiction, is tricky. Trusting one’s doctor often results in more honesty about drug use and can inform better care.
“We’ve lowered the barrier from our side as best we can,” Loring said. “Then the question becomes: what can we do with the access we’ve created to make it as safe and nurturing and compassionate and welcoming as possible? Now that we’ve increased capacity and volume, how do we increase the quality?”