Counselor Louie Ramos of the Opiate Treatment Outpatient Program waits in a parking lot outside of San Francisco General Hospital. Moving some drug treatment services outside allows for more social distancing. (Courtesy of David Beuerman, Opiate Treatment Outpatient Program)
Before the coronavirus pandemic, patients would drop in to Arlene Brown’s clinic to treat their drug addiction whenever it was open.
"If they feel like they're in crisis or they feel like they want to relapse, they know that they have access to our team at any time," said Brown, a recovery support navigator at Northern Inyo Hospital in the Eastern Sierra town of Bishop.
Some patients would go to meet with counselors and get prescription medications like buprenorphine to treat opioid addiction. Others needed harm-reduction supplies like clean needles and naloxon, the drug that reverses opioid overdoses.
There was also a weekly support group, for both “social interaction” and “accountability to other group members," Brown said. A hot lunch was yet another draw, with leftovers usually available to take home.
But since the COVID-19 pandemic upended daily norms, there is no lunch and there is no group. And there is no dropping-in any time you need to.
Across the state, many of these familiar routines have been cut off. Clinics, drug counselors and patients, practiced at facing an overdose epidemic, are now figuring out what confronting that means in the face of a global pandemic.
At the center of this shift is how to maintain a sense of community, which Brown says is key to addressing addiction, at the same time that best practices urge people to keep their distance.
In Bishop, clinic staff aim to mitigate the spread of COVID-19 by minimizing in-person services when possible. They write prescriptions that will last longer so patients don’t have to come in as frequently, and people who are using drugs now take home larger quantities of safety supplies.
Instead of in-person check-ins, Brown says, counselors connect with their clients over the phone.
"Now more than ever, it's important to have more communication with that patient," she said.
While in the past, Brown may have each week connected with a patient once, she now talks to them two or three times.
"Imagine that you're a patient and the only place that you go to get services is the clinic, that's your support," Brown said. "We have social workers. We have nurses. We have myself. We have the doctors. [Patients] have a whole team of people."
But the public health message is to isolate, and this intensifies a problem that already exists for the people she works with.
"Addiction in itself is a very isolating disease,” Brown said. “Then you have social distancing, self-isolation. And so you have this perfect storm brewing for a relapse."
That’s been the case for a lot of new patients lately who have lost their sobriety during the pandemic, she said. Before the coronavirus hit, most new clients were people who'd never been clean in the first place.
'Don't Use Alone' — No Longer the Message
Another concern for Brown is that social distancing will mean more people may use drugs alone.
"It's not safe, because if you overdose, no one's there to save you," she said.
In San Francisco, Dr. Barry Zevin agrees. He’s the medical director of street medicine at the San Francisco Department of Public Health.
"People are really struggling with the basic harm reduction messages that we have been giving … for many years," Zevin said. "Our very key message has consistently been: ‘Don't use alone.’ Now we are doing everything in our power to say to people, ‘Stay alone.’ And it's really hard to have both of those things work."
Though he doesn’t yet have data, Zevin believes the number of people using on their own has increased even if overdoses haven’t.
"And that has made it harder for people to have a reversal of their overdose," he said. "What might have been somebody's life saved, now, potentially, is his life lost because there wasn't somebody around to give them naloxone."
A New Kind of Normal
Kristen Marshall, of the advocacy group Harm Reduction Coalition, says San Francisco has seen a steady rise in drug overdose deaths in the last two years, including during the shelter in place. She traces that increase to availability of the powerful opioid fentanyl in the city's drug supply.
Marshall says it's hard to know whether the continuing rise in deaths is due to the pandemic. But the stress of the pandemic and recent protests "exacerbate people's risk for all sorts of harms related to living in poverty," she said.
San Francisco public health officials reported a spike in the number of homeless people who died this spring, many likely due to overdoses from fentanyl and indirect impacts from the coronavirus pandemic.
"What's happening right now absolutely contributed to those people's deaths," Marshall said.
Despite the isolation born from the pandemic, some clinics and their patients have managed to create a new kind of normal.
That's the case for Ronald, a patient at the Opiate Treatment Outpatient Program at San Francisco General Hospital. We’re not using Ronald’s last name to protect his privacy.
When he first showed up to the clinic 16 years ago, Ronald was addicted to heroin and alcohol. He lived on the street and was often sick.
Ronald speaks about the clinic with admiration. "They saved my life. I'm productive and happy now,” he said.
Sober, and living in a San Francisco apartment, he has a job providing in-home support for a client with disabilities.
For years, he's walked, biked or bused to the clinic every Tuesday to get medication and counseling. While he is stable on his medications, and staff have offered him the option to come in less frequently, he's always decided against it.
"Maybe even part of it is social. I'm really not sure," Ronald said. "But it's a routine I've gotten into and I just like what I'm doing."
Even if Ronald doesn’t want to change, the pandemic means his treatment has to. There are the small changes when Ronald picks up his medications on Tuesdays from the clinic: He wears a face mask, and he socially distances. But the big change is that his and every other patient’s regular counseling now happens mostly by phone.
To make this work, clinic staff have distributed nearly 500 flip phones with unlimited talk and text, a critical donation from an anonymous supporter. Many of the program’s patients are homeless.
The clinic now dispenses daily doses of methadone or buprenorphine from a mobile van in a parking lot outside the hospital. In order to do this, the clinic had to get permission from the hospital, state, federal government and the U.S. Drug Enforcement Administration.
Amid Changes, an Opportunity
Opiate Treatment Outpatient Program social worker David Beuerman says the changes are both good and bad. Like Arlene Brown in Bishop, he worries about the impact of isolation on clients.
"Some of our folks, this is the only thing they have in their life," he said about the clinic. "They feel safe, they're not judged."
But he also sees an opportunity, as the pandemic has forced a loosening of state and federal regulations around how drug treatment happens.
For example, the clinic has given some people small amounts of take-home medication that previously wouldn’t have been allowed, for fear of possible overdose or misuse. There’ve been some surprises.
"We may find that in some cases it's safer to have done these things than we originally thought," Beuerman said.
Some unexpected benefits to counseling over the phone have also been revealed, he said. "Some folks who didn't open up in counseling, per se, have taken to using the phones to really reach out and talk to us and let us know what their experience is like."
Beuerman says upending how drug clinics work could change treatment in a post-pandemic world, spurring less of a one-size-fits-all approach.
While the sign in the San Francisco General Hospital parking lot reads “physical distance, social connection,” the pandemic has forced drug counselors like Beuerman and Brown to reassess just how that connection is made.
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