Disruption of Opioid Treatment Program Services Due to an Extreme Weather Event: an Example of Climate Change Effects on the Health of Persons Who Use Drugs

Abstract

Climate change and the opioid epidemic in combination may pose significant challenges for individuals with opioid use disorder (OUD) due to potential disruptions in access to essential addiction treatment services caused by extreme weather events. Despite concerns over the escalating health impacts of climate change, limited research has documented and explored the vulnerability of patients enrolled in opioid treatment programs (OTP) to disruptions caused by climate change, and particularly extreme cold events. In this commentary, we describe the impact of a catastrophic flooding event during record-setting cold temperatures at an OTP in Seattle, WA. By examining this event, we highlight the potential vulnerabilities the methadone treatment infrastructure faces regarding climate change and future extreme weather events. In doing so, we hope to draw attention to a critical need for research that describes, plans for, and addresses disruptions to OUD treatment resulting from climate change-related weather events.

On January 14, 2024, Seattle experienced an extreme cold event, as did a large swathe of the rest of the United States (US). Temperatures fell below −10 degrees Celsius, which has not been observed in the region since 1989. As a result, the Evergreen Treatment Services’ (ETS) Seattle branch, one of the largest opioid treatment programs (OTP) in Western Washington, experienced a catastrophic flood when a high-pressure valve in the sprinkler system burst due to freezing temperatures. This flood caused extensive damage to more than 80% of the building rendering the building and dispensary unusable, which had immediate and devastating consequences for the 1,100 patients that were primarily receiving methadone delivery.

The organization switched into emergency response: patients were shifted to a smaller ETS site 13 miles south, an ETS mobile methadone unit, and other local OTPs for courtesy dosing. Patient burden increased due to longer travel distances and less accessible public transportation options to the alternate clinic. ETS provided patient transportation via vans that ran all day for about 100 patients to and from the alternate site. As a result, the patient population at the neighboring site more than tripled. Clinic staff were also shifted to this clinic to assist with increased workloads. Despite these efforts the combined service volume across both sites decreased compared to two weeks before the flood. Missed doses at both clinics rose from 16.3% three weeks before to 22.5% three weeks after the flood. Additionally, there was a decrease in patients currently receiving methadone, with the active census combined across both sites dropping from 1,413 patients the week before the flood to 1,297 four weeks after, and 1,290 eight weeks after the flood. Emergency dosing options were available to patients at other OTPs in response to the closure through a centralized registry system. This program helps OTPs to confirm a patient’s enrollment in treatment at other facilities. Following the flood, an average of 34 individuals accessed methadone daily through this system. Despite the heroic efforts of staff, the unexpected patient overflow resulted in wait times for medications that were, in some cases, over two hours long in the days after the flood. Patients were often ill-prepared for the elements and were huddled under propane heaters clothed with only shirts and sweatpants as they had not anticipated waiting outside. About 40% of the patient population at the Seattle site were unstably housed and many suffered from physical disabilities or mobility concerns. Before the flooding, the OTP operations and staffing were just beginning to recover from the impacts the COVID-19 pandemic had on addiction treatment services, which have been previously described.¹

Climate scientists have identified how, in the midst of climate change, the number of extreme cold weather events is generally decreasing in frequency and intensity. However, some climate change researchers have argued that Arctic warming is still driving the intensity of these events through a process called cold air advection, where cold air moves from the polar to lower latitude regions.² These events can occur when the polar vortex, a stream of air moving around the North Pole between the Arctic and more temperate air, becomes disrupted. This disruption can distort the jet stream, pushing it southward.² This phenomenon was observed in January 2024 in various environments across North America and led to the abovementioned crisis. The polar vortex stretched far into the lower stratosphere, nearly splitting due to high-latitude weather in the prior two weeks.² Thus, the paradox of global warming due to carbon emissions is that it may also lead to extremes of cold—and such extreme temperature swings will lead to greater suffering among people who use drugs (PWUD). In such events, patients may experience a lack of access to addiction treatment due to the impact on clinics’ physical infrastructure and due to the damage or utility outages to their own residences, transportation barriers due to road conditions, increased stress and isolation, and displacement from warming centers among those who were unhoused, which were observed for ETS patients in Seattle. Existing research on climate change impacts for PWUD and OTP service disruptions has predominantly focused on extreme heat events, and cold crises may be underrecognized.^3,4 Climate change can affect all environments, including those with relatively mild temperatures and lower risk of extreme weather events like Seattle. Moreover, regions considered less vulnerable to climate change often have infrastructures and emergency response systems that are unequipped to handle such extreme cold events, potentially resulting in greater impact as the frequency of such events increases.⁵

The intersections of climate change and the opioid epidemic pose significant challenges to OUD treatment, particularly for patients treated at OTPs. OTPs face strict regulatory requirements and are the only setting where methadone can only be dispensed for OUD, in contrast to office-based opioid treatment (OBOT) settings that offer more flexibility and have fewer regulations.⁶ OTPs are disproportionately located in neighborhoods in the lowest income quartiles with the highest proportions of minority residents within buildings that are not constructed to withstand extreme temperatures or other impacts of climate change.⁷ Structural racism, stigma, and economic disparities have put patients enrolled in OTPs at higher risk for the impacts of climate-related events than patients receiving buprenorphine. Existing transportation-related barriers faced by patients combined with buildings vulnerable to disruption and damage place this patient population at high risk of treatment interruptions and poor health outcomes.

There is limited but growing research exploring the vulnerability of substance use disorder (SUD) service disruption during severe weather events and subsequent adverse outcomes. Prior examples include Hurricanes Sandy and Katrina in the US and a tropical cyclone in Australia. The COVID-19 pandemic also highlighted the existing vulnerabilities of OTP programs. OTPs rapidly adapted to implementing telehealth services and federal regulations to maintain continuity of care, similar to the adjustments that would have to be made during future climate emergencies.⁸ During and after disasters, most deaths are attributable to indirect sequelae from the disaster, such as disruptions to care and deterioration of vital infrastructure.⁹ Additionally, the risk of opioid overdose increases during extreme weather events due to colder temperatures and opioids both promoting respiratory depression.¹⁰ Interruption of treatment can also lead to missed doses, heightened travel barriers, and delayed emergency services that can increase the risk of overdose. Across these natural disasters, the largest challenge for OTPs has been to provide continuity of care with surging demand for addiction treatment while practicing within regulatory requirements for methadone imposed nationally.¹¹ Clinics in these contexts were trying to provide care while addressing physical damage to facilities and patient records, staffing shortages, rapid merging of patient populations after the closure of clinics, and communication disruptions for timely coordinated responses.¹¹ These resulted in patients being lost to treatment, faced with increased transportation burdens, long wait times, delays in the extension of take-home dosing, and reduction of dosing verification in the midst of treatment disruption.¹¹ Research has documented the negative impacts of climate change-related events on dialysis treatment, which are similarly used for a patient population requiring frequent in-person treatment. However, these patients generally face less stigma and marginalization than patients with SUDs.¹² This commentary contributes to the existing body of literature about climate disruptions by documenting an example of OTP treatment disruption resulting from an extreme cold weather event due to a phenomenon likely related to climate change.¹⁰

There is a need for greater attention to and research regarding the impacts of climate change on patients with SUDs. Acknowledging the stresses that climate change-related extreme weather events are having on already-fragile systems for delivering potentially-lifesaving and sustaining medications for persons with OUD is an important first step in advocating for policies that can address and halt these crises. Some progress has been made to increase access to methadone, with the DEA amending registration requirements for mobile methadone units, which supported a partial response during this emergency.¹³ Another congressional bill, the Modernizing Opioid Treatment Access Act (MOTA), has been introduced that could offer some opportunity to broaden access to methadone beyond OTP settings. This bill may help limit disruptions to treatment caused by future climate emergencies.¹⁴ However, MOTA might also restrict “back-up” strategies for patients by removing the option to guest dose at other OTPs.

Additionally, OTPs and other sites of addiction treatment service delivery need resources, ideally funded by state or federal programs, that can help them prepare for disruptions that will inevitably happen due to extreme weather events and move to more flexible models of treatment that minimize travel to “brick-and-mortar” clinics. OTPs have historically experienced stigma, marginalization, and underinvestment, and been placed in neglected industrial areas that are difficult to access. This combination has resulted in infrastructural deficiencies that may require urgent attention. Existing clinics will likely need resources for updates and renovations to ensure they are safe and “climate resilient” to extremes of heat and cold and allow for potential surges in clientele. Similar to preparations during heat crises, treatment facilities should prepare for the possibility of cold events disrupting treatment. Though recommendations for preparing for cold crises likely differ from those for preparing for extreme heat in terms of infrastructure resilience and emergency response measures, both scenarios require preparing to extend take-home doses to reduce travel, allowing more options to receive medication at alternative locations (“guest dosing”), offering emergency transportation options and cross-training to staff to ensure staff can play multiple roles, and developing robust communication plans. Additionally, preparing for extreme cold weather events should include ensuring appropriate insulation and reliable heating systems to prevent pipe bursts and maintain safe temperatures for patients and staff, offering patients warm layers, and shelter from the cold (whereas adequate cooling systems and shaded and well-ventilated waiting areas are needed during heat waves).⁴ Regardless of the climate event, educational efforts are needed to support PWUDs to understand the synergistic effects and safe ways of drug use during extreme weather events.³ During previous climate change disasters, recommendations included ensuring that patient records and ventilation are maintained during emergencies by backing up databases and installing backup generators in OTPs.¹¹ It is important to create emergency guidelines for future disasters, including the rapid extension of unobserved “take-home” doses and the development of remote observation systems to confirm doses outside of OTPs, such as in homes, mobile units, or shelters.¹⁵

Finally, addiction medicine providers can become “champions” of interventions to address climate change within their institutions and professional societies. Climate change is affecting all regions of the world, and adaptation and emergency preparation is needed to protect health and well-being, particularly for populations affected by the opioid epidemic. Recent calls have been growing to study the interplay between climate change and substance use, alongside the development of prevention programs and interventions for populations at high risk from both climate-change-related impacts and the opioid epidemic.¹⁶ The Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) recently developed a “Climate Task Force” to improve their environmental impact, with an emphasis on learning about and publicizing the impacts of climate emergencies on PWUD.¹⁷ Other organizations may wish to follow this example.

In conclusion, a recent extreme cold event leading to the flooding and closure of a Seattle OTP highlights the vulnerability of our addiction treatment systems to climate change and emphasizes the need for adaptive strategies to safeguard time-sensitive healthcare services for persons with SUDs. Future research should explore the broader impacts of climate change events on MOUD access and identify innovative solutions to address climate-related challenges in methadone treatment. Ultimately, a wider range of immediate responses is needed on a personal and professional level to address these national crises.