COVID-19: Treatment Recommendations from the Urban Survivors Union and signatories
For SUD services providers, recovery services providers, and drug user health advocates
Read and consider this open letter to OUD care providers and government agencies. Email Michael Gallipeau at mikeyg@urbansurvivorsunion.org to add your/agency's signature.
Nation’s Leading Drug Policy Experts Demand Medication Assisted Treatment and COVID-19: Treatment Reforms
During the COVID-19 pandemic, it is critical to remember that we are still in the midst of an overdose crisis. While many regulators have argued that methadone and buprenorphine policies must be deliberately restrictive due to the risk of overdose, adverse medication effects, and medication diversion, the COVID-19 crisis has forced many regulating bodies to re-evaluate these policies in order to comply with the urgent need for communities to practice social distancing and sheltering-in-place. Multiple government agencies including SAMHSA, the DEA, Medicare, and Medicaid have recently announced policy changes to allow for more flexible prescribing and dispensing. While these changes are a step forward, clinics have been either reluctant or resistant to fully implement them to the extent allowable under law. In light of the evolving pandemic and the needs of the community, we must not allow fears of overmedication and diversion to outweigh the health risks caused by patients being forced daily to congregate in large groups, or being driven to an adulterated illicit drug supply.
Close person-to-person contact and group assembly are currently actions deemed hazardous to public health. Unfortunately, “sheltering in place” is unrealistic for many people who use drugs. People who use opioids are either forced to continue to engage with the illicit drug market or must comply with prohibitive and insurmountable requirements to receive medications for Opioid Use Disorder (OUD). Many opioid users are at an increased risk of COVID-19 infection due to being immunocompromised and/or having comorbid health conditions.
In order to reduce the risk of COVID-19 infection, involuntary withdrawal, and drug poisoning, the Urban Survivors Union and the undersigned organizations strongly recommend the following measures be taken immediately:
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The only acceptable standard for discharge of patients from OUD treatment during the COVID-19 outbreak shall be violent behavior that would endanger their own health and safety or that of other patients or staff.
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Administrative detox shall be fully suspended during the pandemic and patients shall be provided the opportunity to request dose increases as needed, given that the illicit drug market will continue to experience fluctuations and patients need access to these life-saving medications. Patient doses shall not be reduced during the transition to take-home care unless they request adjustments to their doses, or documented medical emergencies require it and patients cannot consent due to medical crises, as may be the case with severe respiratory distress resulting from COVID-19 infection.
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Referrals for COVID-19 testing shall be made available at all opioid treatment programs (OTPs), as well as syringe service programs. Staff shall receive training to recognize the symptoms of COVID-19 and be familiarized with protocols to refer patients for further testing. Harm reduction providers can also play an essential role in “flattening the curve” of transmission by identifying cases, making medical attention available to those who test positive, and teaching life-saving harm reduction skills to help people stay safe during this crisis. Plain language and evidence-based public health materials about COVID-19 prevention, symptom identification, and treatment should be available in locally prominent languages at all locations for participants and their communities.
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During the COVID-19 national emergency, healthcare professionals--including doctors, nurse practitioners, physician assistants, and pharmacists--shall not be required to complete the previously- mandated training and waiver to prescribe these medications, thereby making MAT available in all settings. Prescribers shall not have limitations on the number of patients that they can treat. Naloxone and other overdose prevention tools (i.e. fentanyl test strips) shall be prescribed or made available with all dispensed medications in compliance with state law.
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Opioid treatment programs (OTPs), prescribing clinicians, and pharmacies shall actively work to expand access to methadone treatment through the medical maintenance/office-based and pharmacy-delivery methods currently allowed by federal exception/waiver. The existing OTP regulations for the dispensing of MAT shall be temporarily adjusted to require all pharmacies to dispense these medications. This will reduce the risks of transmission associated with daily clinic attendance and person-to-person contact. In accordance with SAMHSA recommendations, lockbox requirements for take-home dispensing shall be suspended. Standard dispensing protocols for other opioid medications are deemed sufficient, since child- and tamper-proof bottles are already in use for methadone and buprenorphine. (Per SAMHSA's TIP 43, Chapter 5: "Some programs require patients to bring a locked container to the OTP when they pick up their take-home medication to hold it while in transit. This policy should be considered carefully because most such containers are large and visible, which might serve more to advertise that a patient is carrying medication than to promote safety.")
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Take-home exception privileges shall be expanded to the maximum extent possible, limited only by available supply and operations for delivery. Any bottle checks that clinics wish to conduct shall be conducted by tele-medicine. Take-home schedules shall be authorized for individuals in all medical settings, including pharmacies and mobile vans. In light of new SAMHSA guidelines, clinics shall allow 14 to 28 days of take-home privileges to as many patients as possible. Patients testing positive for benzodiazepine or alcohol use shall be allowed the take-home privileges outlined in SAMHSA guidelines, but may be additionally required to check in via telemedicine for the purpose of decreasing the risk of adverse reactions, including overdose. Access to take-home doses is critical to keep patients engaged and retained in treatment.
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Telehealth and service by phone shall replace any and all in-person requirements and appointments as the primary means of service provision until social distancing guidelines change. Toxicology requirements shall be suspended for the duration of telehealth-based services. Telemedicine services shall include waivered platforms, such as telephone intakes and video conferencing, as some patients may have different access needs.
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The regulatory in-person requirements for methadone inductions shall be lifted in order to be consistent with the new policy changes for buprenorphine inductions. Clinic-based in-person appointments shall conform to social distancing requirements and OSHA guidelines for the management of the COVID-19 pandemic.
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DEA restrictions on mobile medication units shall be revised to accommodate delivery of medications to individuals who are sequestered in their homes, are quarantined, or live in rural communities that are 15 miles or more from the nearest opioid treatment program.
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State and federal Medicaid dollars shall be expanded to cover all costs for take-home medications not otherwise covered by insurance for patients experiencing financial hardship due to COVID-19. In states that did not expand Medicaid, the state shall be the payor of last resort.
In the interest of saving lives and adhering to existing public health protocol for management of COVID-19 transmission, it is necessary to make significant revisions to existing regulatory standards. This is a critical time to take decisive action for the protection of patients, providers, their families, and the community. As our healthcare system reaches full capacity and becomes overburdened by COVID-19-related emergencies, as seen in Italy and Spain, providers on the front lines will be forced to make life and death choices. These recommendations outline a plan of primary prevention that will minimize the burden on our healthcare system and save lives during this national emergency.
We, the undersigned, are a coalition of direct service providers, community advocates, public health officials, medical professionals, human rights groups, people in recovery, treatment professionals, members of impacted communities, and many others. We ask SAMHSA, the DEA, and all other federal, state, and local regulatory bodies and health authorities to adopt these recommendations fully and immediately in light of the COVID-19 pandemic.
Urban Survivors Union Louise Vincent, MPH Executive Director
National Harm Reduction Coalition
Monique Tula Executive Director
The National Alliance for Medication-Assisted Recovery
Zachary Talbott, MSW President
Joycelyn S. Woods, MA Executive Director
Faces and Voices of Recovery
Patty McCarthy, M.S. Chief Executive Officer
National Viral Hepatitis Roundtable
Lauren Canary, MPH Director
Law Enforcement Action Partnership
Major Neill Franklin (Ret.) Executive Director
The Levenson Foundation Benjamin A. Levenson Chairman
Foundation for Recovery Dona M. Dmitrovic, MHS Executive Director
National Council for Behavioral Health
Chuck Ingoglia President and CEO
Drug Policy Alliance
Kassandra Frederique
Managing Director, Policy Advocacy & Campaigns
International Certification & Reciprocity Consortium
Crystal Smalldon, CCAC, CIAC, RSSW President
Behavioral Health Association of Providers
Pete Nielsen, MA, LAADC CEO
Center on Addiction / Partnership for Drug- Free Kids
Frederick Muench, Ph.D. President
National Advocates for Pregnant Women
Lynn M. Paltrow, J.D.
Founder and Executive Director
Recovery Advocacy Project
Ryan Hampton Organizing Director
Open Society Foundations
Sarah Evans
Unit Manager, Public Health Program Kasia Malinowska-Sempruch Director, Global Drug Policy Program
305 Psychotherapy Group Mark Houston, LCSW Owner and Psychotherapist
Addiction Professionals of North Carolina
Sarah Potter, MPA Executive Director
AIDS United
Drew Gibson, MSW
Policy Manager for HIV & Drug User Health
Alcohol & Drug Abuse Certification Board of Georgia
Amanda Finley Executive Director
Alliance for Positive Health
Diana Aguglia Regional Director
The BALM Training Institute for Family Recovery Services/Family Recovery Resources Beverly A Buncher, MA, CBFRLC, PCC
Chief Executive Officer
Bay Area Workers Support
Maxine Holloway, MPH Co-Founder
Benevolence Farm
Kristen Powers
Interim Executive Director
Better Life in Recovery/Springfield Recovery Community Center
David Stoecker, LCSW Executive Director
BioMed Behavioral Healthcare, Inc Brian A McCarroll DO. MS. ABAM CEO, President
Brave Technology Coop
Gordon Casey
Chief Executive Officer
Broken No More Tamara Olt, M.D. Executive Director
CADA of Northwest Louisiana
Bill Rose, LAC, CCS, CCGC
Executive Director
C4 Recovery Foundation, Inc. Ricard Ohrstrom, Chairman Jack O'Donnell, CEO
Center for Optimal Living Andrew Tatarsky, Ph.D. Executive Director
Center for Popular Democracy/ Opioid Network
Jennifer Flynn Walker
Senior Director of Advocacy and Mobilization
Central Texas Harm Reduction
Richard Bradshaw Community Outreach Leader
CheckUpandChoices.com Reid K Hester, Ph.D. Director, Research Division
Chicago Drug Users Union
Peter Moinichen, CADC, CODP, MAATP Co-Founder
Chicago Recovery Alliance
Brandie Wilson Executive Director
Choices Recovery Trainings Ginger Ross, CRSW, NCPRSS Owner/Trainer
Church of Safe Injection
Kari Morissette Director
Circle for Justice Innovations Aleah Bacqui Vaughn Executive Director
City of Revere - Substance Use Disorder Initiatives Office
Julia Newhall, BSW, CPS Director
Coastal Holistic Care
Jessi Ross Founder
Connecticut Certification Board
Jeff Quamme, MSW Executive Director
DanceSafe Mitchell Gomez Executive Director
Desiree Alliance
Cristine Sardina, BWS, MSJ Director
društvo AREAL Janko Belin President
ekiM For Change Diannee Carden Glenn Director
Exponents, Inc. Joseph Turner, J.D. President and CEO
Faith In Public Life
Blyth Barnow, MDiv
Harm Reduction Faith Manager
Families for Sensible Drug Policy
Carol Katz-Beyer President
Florida Opiate Coalition- Block by Block
Bonny Batchelor Director
Foundation for Recovery Dona M. Dmitrovic, MHS Executive Director
Full Circle Recovery Center, LLC Stephanie Almeida, CDAC Founder
Georgia Overdose Prevention
Laurie Fuggitt, RN and Robin Elliott, RN Co-Founder
GoodWorks: North Alabama Harm Reduction
Morgan Farrington Founder
The Grand Rapids Red Project
Stephen Alsum Executive Director
Grayken Center for Addiction, Boston Medical Center
Michael Botticelli, MEd Executive Director
Greater Hartford Harm Reduction Coalition Inc.
Mark A. Jenkins Executive Director
Guilford County Solution to the Opioid Problem
Chase Holleman, LCSW, LCAS Program Director
Harm Reduction Action Center
Lisa Raville Executive Director
Harm Reduction Ohio Dennis Cauchon President
Harm Reduction Therapy Center
Jeannie Little, LCSW Executive Director
Health in Justice Action Lab Leo Beletsky, JD MPH Director
Health Professionals in Recovery William C. Kinkle, RN, EMT-P, CRS Co-Owner
Health Services Center, Inc.
Melissa Parker
Prevention Projects Director
Healthy Streets / Health Innovations
Mary Wheeler Program Manager
HIPS
Tamika Spellman
Policy and Advocacy Associate
HIV/HCV Resource Center Laura Byrne, MA Executive Director
Hope Recovery Resources
Beth Fisher Sanders, LCSW, LCAS, MAC, CCS, MATS
Chief Executive Officer
HRH413
Albert Park, MSW Co-Founder
International Network of People Who Use Drugs
Judy Chang Executive Director
Illinois Association of Behavioral Health
Sara Howe, MDA Executive Director
Inclusion Recovery Dan Ronken, LPC, LAC Founder
Indiana Recovery Alliance
Kass Botts Executive Director
Innovative Health Systems Ross Fishman, Ph.D. President
Instituto RIA Zara Snapp Co-Founder
Iowa Harm Reduction Coalition
Sarah Ziegenhorn Executive Director
Katal Center for Health, Equity, and Justice
Gabriel Sayegh, MPH Co-Executive Director The Lemire Group LLC Dean Lemire
Owner
Lifespan Counseling
Dene Berman, Ph.D., MPH, ABPP, MAC Director
Lysistrata Mutual Care and Collective Fund
Cora Colt
Co-Founder and Treasurer
MEDPEARL LLC
Deanna Dunn, PharmD Owner/Pharmacist
The Middle East and North African Network of/for People who use Drugs
Hasan Taraif Executive Director
Minnesota Recovery Connection
Wendy Jones Executive Director
Movement for Family Power
Lisa Sangoi and Erin Coud
Co-Founders and Co-Directors
NCADD- NJ
Heather Ogden, CPRS, CRSP, CADC Intern Advocacy Coordinator
New England Users Union
Jess Tilley Executive Director
New Jersey Harm Reduction Coalition
Jenna Mellor Executive Director
A New PATH, Parents for Addiction Treatment & Healing
Gretchen Burns Bergman Executive Director
New View Addiction Recovery Educational Center
Jennifer A. Burns, MA Executive Director
New York Center for Living
Audrey Freshman, Ph.D., LCSW, CASAC Executive Director/Chief Clinical Officer
New York State Harm Reduction Association
Joseph Turner, J.D. Co-Chairperson
North American Syringe Exchange Network/ Tacoma Needle Exchange
Paul A. LaKosky, Ph.D. Executive Director
North Carolina Harm Reduction Shelisa Howard-Martinez Executive Director
North Carolina Survivors Union
Louise Vincent, MPH Executive Director
Northern Berkshire EMS Stephen Murray, BBA, NRP Paramedic Supervisor
ONESTOP Harm Reduction Center, North Shore Health Project
Mary Doneski, MA Program Manager
PeerNUPS/Athens/Greece Christos Anastasiou Coordinator
Pennsylvania Alliance of Recovery Residences
Fred Way, MA Executive Director
Pennsylvania Harm Reduction Coalition
Devin Reaves, MSW Executive Director
People’s Action Sondra Youdelman Campaigns Director
The People’s Harm Reduction Alliance
Shilo Jama Executive Director
The Perfectly Flawed Foundation
Luke Tomsha Executive Director
Philadelphia Drug Users Union
David Tomlinson, BA Founder
Project Point Pittsburgh
Alice Bell, LCSW
Overdose Prevention Project Coordinator
Protect Families First Annajane Yolken Executive Director
Provenance Counseling
Lisa S Musarra, MSW, LCSW, LCADC, ICADV
Owner
The Reach Project, Inc and Reach Medical, PLLC
Justine Waldman, MD, FACEP Chief Executive Officer
Reframe Health and Justice
Sasanka Jinadasa Partner
Rights & Democracy NH, Rights & Democracy VT, Rights & Democracy Institute
Kate Logan, MA/ABD
Director of Programming & Policy
R Street Institute
Carrie Wade, Ph.D., MPH
Director of Harm Reduction Policy Chelsea Boyd, MS
Research Associate Harm Reduction Policy
San Francisco AIDS Foundation Laura Thomas, MPH, MPP Director of Harm Reduction Policy
The Seven Challenges LLC
Robert Schwebel, Ph.D.
Author and Program Developer
Sex Worker Advocacy Coaltion
Tamika Spellman Lead Organizer
Sex Workers Outreach Project Behind Bars
Jill McCracken, Ph.D. Co-Director
Sex Workers Organizing Project- USA
Christa Daring Executive Director
The Southern Tier AIDS Program
John Barry, LMSW Executive Director
Students for Sensible Drug Policy
Betty Aldrich Executive Director
Students For Sensible Drug Policy Africa
Ewelle Sylvester Williams, SW Vice Chairman
Substance Use, Policy, Education and Recovery PAC
Haley McKee Co-Chair
Suncoast Harm Reduction Project
Julia Negron, CAS
Founder and Lead Organizer
Tennessee Recovery Alliance
Sara Alese Executive Director
Texas Drug User Health Alliance
Mark Kinzly Executive Director
Texas Harm Reduction Alliance
Joy Rucker Executive Director
Texas Harm Reduction Conference
Emily Gray Co-Founder
Texas Overdose Naloxone Initiative
Mark Kinzly Executive Director
Truth Pharm Alexis Pleus Executive Director
Ukrainian Network of People who Use Drugs
Anton Basenko, ME Chair of the Board
University of Missouri, St. Louis Missouri Institute of Mental Health Claire Wood, Ph.D.
Rachel Winograd, Ph.D. Addiction Science Faculty
Urban Survivors Union, Greensboro Chapter
Derek McCray Miller Member
Dr. Vando Medical Services
Leonardo Vando, MD Chief Executive Officer
Vantage Clinical Consulting LLC Jamelia Hand, MHS, CADC, CODP Chief Executive Officer
Vermonters for Criminal Justice Reform Thomas Dalton, J.D., MA, LADC Executive Director
VICTA
Lisa Peterson, LMHC, LCDP, LCDS, MAC Chief Operating Officer
Voices of Community Activists and Leaders- New York
Jeremy Saunders Executive Director
Whose Corner is it Anyway
Caty Simon
Founding Co-Organizer
Women With A Vision
Christine Breland Lobre, MHS, MPH, LPC Program Director
Zanzibar Network of People Who Use Drugs
Kassim Nyuni Executive Director