New Yorkers have been asked to stay home during the coronavirus pandemic. But throughout the lockdown, Ralphie has been waking up before 4 a.m. to catch a bus to the Staten Island Ferry, where he crosses the harbor and then boards two subway trains to arrive at a methadone clinic in Red Hook by 6 a.m. He makes the journey five or six days a week—most days except Sunday, when the clinic is closed and all patients are given an extra bottle.
The federal government in March lifted ordinarily strict rules to allow clinics to dispense take-home doses of methadone, an effective but tightly regulated treatment for opioid use disorder. To mitigate Covid-19 risk, federal rule changes allowed clinics to dispense up to four weeks of the medication, rather than requiring patients to make daily trips.
But months later, as temperatures drop and coronavirus cases rise to levels not seen since spring, long lines still snake around methadone clinics. Instead of being given the recommended two-to-four week supply, many patients must still travel to clinics multiple days each week.
“I had a heart attack a month ago. They made me come in the next day—the next fucking day, when the doctor told me to go home and rest,” said Alonzo, a wiry 66-year-old Black man who said he pressed for more take-home bottles after his heart attack but is still required to come in three times a week.
Alonzo was waiting in line at 5 a.m. in below-freezing weather to enter Carlos Pagan Recovery Center, an opioid treatment provider housed in a nondescript brick building in Red Hook. Witty, popular with other patients, Alonzo stood at the center of a cluster of older men, some leaning on canes.
“People are disabled. We’ve got to get out of bed at three o’clock in the morning and get here by five, to get on line, to be in by six,” one man waiting in line said. “I’m disabled, too. I got two artificial hips. And I gotta stand out here in the cold. They don’t give a shit about nobody.”
“This guy can hardly walk. And he’s got to stand on line? That’s ridiculous,” he added, gesturing to a quiet man to his right, who was hunched over against the cold. That man, who identified himself as 82 years old and Puerto Rican, said he makes the trip five days a week.
“I’ve got nerve damage in my back, I’m diabetic—I shouldn’t have to come two hours, riding on the train from Queens, every other day,” another man added. Several worried about putting themselves at risk for coronavirus, while in transit and once at the treatment facility.
“It depends on the luck of the draw of your clinic”
Around 30,000 people were enrolled in daily methadone treatment in New York City alone in 2016, the most recent year for which city health department data is available. More than 70% of those patients are Latino or Black, and more than half are over 45 years old.
The skew towards populations more vulnerable to the coronavirus sits atop another concern: Individuals with a substance use disorder are more likely to be hospitalized or die from Covid-19, a recent study found.
Public health experts say that a small number of patients, such as pregnant women, may need to come in for frequent monitoring while using medication-assisted treatment. Some acknowledge risks around illicit sale of take-home bottles, but maintain that these risks are often exaggerated—and methadone is stigmatized—to avoid increasing access to the medication, which has been shown to lower risk of opioid-related death.
“Most methadone patients would benefit from wider take home privileges,” said Pedro Mateu-Gelabert, an opioid researcher at CUNY’s Graduate School of Public Health. “Our national problem is not over-distribution of medications for opioid use disorder—rather, we need to see more, wider, easier availability.”
Drug policy advocates say clinics have differing attitudes toward dispensing take-homes, leading to significant disparities between providers.
“The mass variation is unacceptable, because it depends on the luck of the draw of your clinic,” said Jasmine Budnella, drug policy coordinator at VOCAL-NY.
In March, the state addiction services agency, OASAS, issued guidance echoing federal rules. “The expectation is that as much as practicable and clinically permitted, patients will be seen face-to-face only once every 28 days,” the agency instructed providers.
But advocates say OASAS has not enforced that guidance. “It was toothless, there was no carrot and no stick,” Budnella said. “Clinics need to be evaluated on why they aren’t giving enough takehomes. Before COVID, they were evaluated if they were giving too many takehomes—this needs to be turned on its head.”
Budnella suggested that OASAS implement an accountability mechanism—such as issuing citations—for clinics that are underutilizing take-home doses.
While leaders & officials are surely warm and INSIDE w/ their families this holiday, vulnerable NYers at Carlos Pagan are being forced to crowd together & wait in the cold for their medication— all while #COVID19 cases continue to climb in NYC.
— Biz Berthy (@BizBerthy) November 25, 2020
Gregory James, an addiction medicine advisor at OASAS, declined to say how many more patients are now able to access take-home medication. But he said that clinics have made more medication available by reducing the amount of time patients are required to be in treatment before they receive take-homes.
“You have to have a certain amount of time in treatment to be eligible for a certain amount of take-home medication. All of that was relaxed. And, as a result, more people are getting take-home medication,” James said.
But patients say that clinics still frequently deny requests for take-homes on the basis of time in treatment. “If you haven’t been here a while, you gotta come here every day,” one patient at a Staten Island University Hospital clinic said. “I seen it with my eyes – I seen other people get denied because they don’t have seniority.”
She began coming to the clinic in February and is allowed to come to the clinic every other day, instead of every day. She still worries she might get sick, since she takes a bus to reach the clinic and lives with her 60-year-old father.
Allegra Schorr, President of the Coalition of Medication-Assisted Treatment Providers and Advocates, said that new patients, who would normally be seen six days per week, are able to come in slightly less frequently. “Most programs have moved those people to every other day,” Schorr said. “So they’re still coming in multiple times during the week, but a lot of them are not coming in as frequently as they would.”
Even coming in a few times a week makes many patients anxious about coronavirus exposure. At the Vincent P. Dole facility in Red Hook, clients arrive early and wait in a parking lot adjacent to a Lowe’s home improvement center. The building is shared with a Retro Fitness facility, and flows of patients sometimes crowd the hall along with sweaty gymgoers.
One patient, a bearded young man who works at a lumberyard mill, said that the clinic was more willing to dispense 14 day methadone take-home supplies at the start of the pandemic. Now, he said, things have largely gone back to normal restrictions, with a couple days’ maximum supply.
“I think they should give us what they gave us at the beginning – every two weeks. That way, we wouldn’t have crowds here in the morning.”
Meanwhile, harm-reduction advocates wonder whether what little progress was made on liberalizing take-home provision during the coronavirus crisis will continue after lockdowns end.
“During the height of the first wave, programs were very cooperative with their patients,” said Roberto Gonzalez, director of a syringe exchange program in central New York. In recent months, programs in places like Schenectady and Utica have reeled in pandemic-era policies on dispensing take-home methadone, he said. “They scaled back on their leniency, and became more restrictive, the way they were prior to the outbreak.”
“If I didn’t have to deal with this, I could most likely find myself a job”
Ernesto, 50, has been coming to a clinic run by Staten Island University Hospital five years. At the beginning of the pandemic, in late March, he was happy to be bumped up on take home doses – he went from having to come in six days a week to three.
But he still worries about the Monday, Wednesday and Friday trips he continues to make. In the small space, it’s hard to socially distance. Sometimes, Ernesto said, “it’s cluttered up with people, and some people don’t have their mask on.”
The frequent visits amid the unfolding economic crisis have also cost him financially, Ernesto said. He is sometimes able to find off-the-books work in construction and demolition—but only on the days when he does not need to attend the clinic.
On Thanksgiving this year, he and his sister decided to skip the cost of a turkey, he said. “I ate oatmeal.”
Even in normal times, clients like Ralphie found the daily trips to clinics disruptive to daily life.
“If I didn’t have to deal with this, I could most likely find myself a job,” he said. “But I can’t work. By the time I get out of here, and position myself to go to any place, it would be too late.”
Ralphie was enrolled in an introductory computer course, but his morning trips to the clinic made it impossible for him to complete the class, which ran from 8 am to noon. “By the time I made it all the way back, it would be 11 o’clock,” he said. “So the teacher would just tell me, ‘Sit on the side, we only got like an hour left.’ There was no sense in me even being there.”