In the last few weeks, I’ve lost two patients of mine at the primary care clinic in Charlestown, Massachusetts, where I work as a physician. But I didn’t lose them to COVID-19. I lost them to drugs.
James had been in remission for months from substance use disorder and was helping to take care of his first grandchild. He had been an ironworker for decades, building our fancy Boston skyscrapers, and was stable enough to undergo surgery for the chronic low back pain stemming from his job.
But after his surgery, his pain worsened. He insisted that the opioid medications his surgeon had prescribed post-op were the only thing that controlled the pain and reminded me that untreated pain is a risk factor for relapse. I switched him to formulations less likely to cause euphoria ― which can increase the risk of abuse ― and made sure he had naloxone, a narcotic reversal agent with him.
But then his oral toxicology started to show irregularities, suggesting cocaine use. He insisted he was safe and still needed the narcotics to control his excruciating pain. I was worried, but renewed his oxycodone prescription along with naloxone. Then methadone showed up on his tox screen, which can be abused just like any other drug and can cause overdoses when mixed with other medications.
When it happened a third time, we diagnosed relapse of his substance abuse disorder and transitioned him to medication-assisted treatment. We recommended buprenorphine, which would help manage his pain and cravings, but James declined, citing his previous bad experience with it ― in his case, he got depressed. Instead, James opted for methadone, which he would have to obtain by visiting a clinic on a daily basis.
The only problem was the coronavirus pandemic; as a lockdown measure, methadone clinics were closing their doors to new patients. At this point, my only option was a riskier one: I tapered his oxycodone and sent more naloxone. Sensing my concern, James was upbeat as usual: “Don’t worry about me, Doc. I’m safe.”
Within a week, my phone alarmed with a message from our nurse. James had been found dead in his single room residence after an unintentional overdose. Nauseated by guilt, I blamed myself for failing him and his family.
According to a 2019 report from the federal Substance Abuse and Mental Health Services Administration, about 20.3 million people aged 12 and older had a substance use disorder related to their use of alcohol or illicit drugs, including 10.3 million who misused opioids.
Although I am a primary care physician, I regularly deal with substance use disorder (SUD). It was not part of the training in my field until recently. Now we’ve got much more support, training and experience with helping this type of patient overcome their challenges.
Our clinic focuses on harm reduction, which involves recommendations to mitigate the worst outcomes of drug use. But substance use recovery and harm reduction are social by nature, and COVID has complicated our work.
Typically, we send people to meetings lead by a peer support specialist where they connect with a sponsor. Our patients have regular appointments with a specialized nurse and myself and get regular saliva toxin screens. For some, we prescribe buprenorphine, a medication that relieves the symptoms of opiate withdrawal. Or if they prefer, we refer them to a methadone clinic.
If they’re not ready to stop using, we urge them to take precautions like cleaning their skin first, obtaining clean needles, and perhaps the most important recommendation of all: not to use alone in case they become unconscious and stop breathing.
In other words, social distancing is uniquely dangerous for this patient population.
I can’t help but wonder if James had not been isolating, could a friend or family member have administered naloxone and saved his life? Or if he had been able to start methadone, would he have overdosed in the first place?
The restrictions imposed by COVID-19 have put the community of substance users under severe duress. Alcoholics Anonymous and Narcotics Anonymous have set up Zoom meetings, but such sessions don’t necessarily provide the same experience as face-to-face group meetings, and not all patients have access to cell phones or computers. As result, patients are going to clandestine in-person meetings because this is the only way they believe they can avoid relapse. In my community, around 30 people are meeting in a nearby field. They try to sit 6 feet apart on bleachers and use sanitizing wipes.
On top of managing their disorder, many of my patients are out of work and can’t meet basic needs like housing and food, which is only partly mitigated by a stimulus check. Many live in overcrowded housing, and some families are allowing loved ones to use drugs at home to keep them off the streets and thus avoid COVID-19 exposure.
Charlestown Coalition has been providing naloxone to as many families as possible to decrease the risk of overdose. Given the times, some doctors have advocated for patients to have methadone “take homes” in an effort to make treatment safer. Still, Sarah Coughlin, the coalition’s executive director, noted, “We cannot minimize the transformative power of the patient/doctor relationship, the lifesaving power of group meetings, and the need to mitigate the risks involved in isolated treatment.”
Her clients are often kicked out of halfway houses and end up on the streets for minor infractions, increasing their risk of relapse and death. Another group at risk are those being released from prison or jail: Substance use disorder patients are 120 times more likely to overdose after release since they are no longer habituated to opioids after their confinement.
For many of Coughlin’s clients, daily face-to-face meetings with sponsors are worth the risk. The chance of dying from COVID-19 is less than that of overdose from social distancing.
Groups like the coalition are having to make their own rules, as national guidance has been lacking. Higher Ground Harm Reduction, a national advocacy organization has created guidelines for safer drug use during the pandemic, stressing the need to minimize the sharing of supplies, wiping mouthpieces with alcohol (still difficult to purchase), and having a breathing mask on hand in case rescue breathing is necessary (it’s not clear how one would find a breathing mask or that a substance user would be able to apply one effectively or safely.) The guidelines also suggest that those doing sex work should “minimize close contact,” (difficult to imagine.)
The same day my team was grieving James’s death, we got tragic news about a patient, Mary, with whom I’d worked for years to get off heroin and regain custody of her three boys.
It took countless meetings with therapists, psychiatrists, supervised visits with her kids, and toxin screens before she got her kids back. Remarkably, Mary stayed sober through weeks of living in a family shelter. We celebrated when she got a job and housing and child care vouchers. Finally, the family rented an apartment; the dad got a job at Home Depot, and the kids enrolled in school and sports. Stability.
Then the pandemic hit. Dad was out of work, Mary became the sole breadwinner as well as the school teacher at home. We had to cancel all in-person follow-up appointments but called her frequently, fearing relapse. She said things were hard, but that she was OK. Then she sent a photo of an infected wound on her arm, asking for antibiotics.
As we move deeper into this crisis, we need to consider our most fragile members.
A week later, Mary and her partner were in detox. Someone had called the child and family services department to report abuse/neglect; the investigator found the children in their underwear at 5 p.m., the house in disarray. Mary has probably lost her children for good.
James and Mary represent an epidemic within the pandemic. While social distancing is critical to flattening the coronavirus curve, for more stigmatized and vulnerable populations like those with substance use disorder, it can also be very dangerous.
As we move deeper into this crisis, we need to consider our most fragile members. We can make a difference to these marginalized people by enhancing social services ― especially child care, improving access to methadone, and considering support meetings an essential service.
Thinking about Mary and James feels so disheartening on many different levels. However, what may be worse is the overwhelming dread that Mary and James represent just a fraction of the crisis repeating itself throughout our communities. I am struggling to imagine what a new normal looks like for these most stigmatized and vulnerable patients.
Carolina Abuelo is a primary care physician at the Charlestown HealthCare Center of the Massachusetts General Hospital and a public voices fellow with The OpEd Project.
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