Disaster Within a Disaster: Ensuring Access to Opioid Use Disorder Treatment During Natural Crises

Hurricane Helene took the mountains of western North Carolina by surprise. As emergency personnel scrambled to mobilize resources, securing medications for patients with opioid use disorder (OUD) was not at the forefront. Yet for “James,” who had been stabilized on buprenorphine, the storm’s destruction became a life-or-death crisis. Trapped behind a flooded creek with no access to his clinic, he faced a stark choice: withdrawal or use of fentanyl. A community health center in western North Carolina scrambled to open a functional telephone line three days after the storm, anticipating calls from patients looking for water, housing, and oxygen. But overwhelmingly, the calls that poured in were from patients taking buprenorphine, desperate to access their medication as they went into withdrawal.

During Hurricane Helene, several opioid treatment programs (OTPs) in western North Carolina closed for days or weeks as a result of flooding, staff displacement, or power loss. Patients faced road closures, collapsed bridges, and fuel shortages that made travel impossible. Nearly a year later, infrastructure damage continued to impede access to care. Communication failures compounded the crisis: cell towers were down, clinics lost access to health records, and pharmacies often lacked buprenorphine because of disrupted supply chains. Amid competing disaster priorities such as housing, food, and infection control, substance use treatment was deprioritized.^1–3

Such scenarios are increasingly common as climate-driven disasters expose systemic weaknesses in addiction treatment. Strict regulations, fragile clinical infrastructure, and inadequate emergency planning jeopardize access to methadone and buprenorphine. Even outside of disaster contexts, access to medications for OUD remains far from ideal, with major gaps in availability, affordability, and equity leaving the most vulnerable individuals unreached.

CLIMATE DISASTERS AS A CATALYST FOR OPIOID VULNERABILITY

Public health disasters, including those resulting from climate change, disrupt health services.⁴ Opioid misuse often increases after disasters, as heightened stress, loss of community resources, and mental health strain can drive increased drug use.^5,6 Individuals with preexisting mental health conditions are especially vulnerable, turning to substances as coping mechanisms. Disasters also disrupt treatment programs and the medical supply chain, limiting access to opioid therapies and pushing individuals toward illicit substances such as fentanyl.^7,8 These supply shocks amplify overdose risks, particularly when health systems are already strained.

In addition, the economic fallout of natural disasters compounds vulnerability. Economic downturns have been linked to rising drug-related deaths, as weakened labor markets and financial instability exacerbate opioid misuse. Intersecting factors of mental health stressors, treatment disruptions, drug market volatility, and economic decline create conditions where climate-related disasters heighten the risk of opioid use and overdose.

SYSTEMIC GAPS AND INEQUITIES IN DISASTER PREPAREDNESS

The United States health care system is poorly prepared for the rising frequency of climate-related events, with most facilities lacking resilience plans to ensure continuity of care for chronic conditions such as OUD.⁹ Unlike insulin or epinephrine, medications for OUD are controlled substances that cannot easily be stockpiled because of existing regulations, rendering those with OUD reliant on a fragile health care delivery system to avoid withdrawal and relapse.

Climate change also magnifies existing inequalities. Low-income communities, rural residents, and people of color are disproportionately exposed to hazards such as flooding and air pollution while lacking adaptive infrastructure such as reliable housing, transportation, and health care access. For people with OUD, these vulnerabilities are compounded by unstable housing, food insecurity, lack of insurance, and stigma within health care systems. Disasters intensify these barriers. Many cannot evacuate safely, end up in shelters unequipped to manage controlled medications, and experience worsening mental health conditions. Stigma and criminalization further contribute to inequitable responses.

POLICY AND SYSTEMIC GAPS

The current regulatory framework governing OUD treatment in the United States remains rigid and ill suited for the realities of climate-fueled disasters. Federal regulations around methadone, in particular, pose significant challenges. Methadone is available only through federally certified OTPs, which require daily, in-person dosing and impose strict limits on take-home doses. Although federal authorities may issue emergency exceptions during disasters (such as temporary take-home flexibility or relaxed counseling requirements), these measures are inconsistently applied and offer little help if patients cannot reach a facility.

A major barrier is the absence of a standardized interstate system for verifying or transferring treatment records. Pharmacy shortages and prescriber inaccessibility further compound the problem. Preparedness protocols rarely include OUD treatment continuity. Few OTPs maintain disaster-ready infrastructure such as backup power, mobile dosing, or evacuation support, and most public health emergency frameworks omit substance use treatment entirely.

PROMISING PRACTICES AND INNOVATIONS

The COVID-19 pandemic served as an unexpected proving ground for how regulatory flexibility can sustain continuity of care for individuals with OUD during crises.¹⁰ Federal waivers allowing extended take-home methadone doses and buprenorphine initiation via telehealth, including audio-only visits, reduced daily clinic burdens, expanded access in underserved areas, and showed no increase in adverse events, prompting calls for permanent policy adoption (Box 1).¹¹

BOX 1—

Policy Recommendations to Support Medications for Opiate Use Disorder in Disasters

Level	Domain	Strategy
Federal level	Codify emergency flexibilities	Enable automatic expansion of take-home doses and emergency dosing at alternative sites without requiring federal waivers. Develop preapproved emergency exemptions for disaster-prone states.
	Develop interoperable treatment registries	Establish cross-state systems so that OTPs and providers can verify patient status and transfer care quickly. Link with prescription drug monitoring programs for real-time updates.
	Mandate disaster planning at OTPs	Require federally funded programs to test and maintain emergency continuity protocols, triage protocols (virtually and in-person), and communication drills.
	Integrate MOUD into emergency management systems	Include MOUD logistics and triage alignment within FEMA, DHHS, state, and local emergency operations frameworks.
	Develop MOUD-capable Medical Reserve Corps	Embed MOUD continuity into Medical Reserve Corps preparedness plans, ensuring that trained volunteers can be rapidly deployed to support medication access and patient care when local providers are unable to respond.
	Emergency communications infrastructure	Support OTPs and emergency departments with satellite phones or Starlink connectivity to enable prescribing and record verification when local networks fail.
State level	Centralized MOUD emergency protocols	Create standardized statewide protocols including rapid waiver activation and preapproved take-home dosing.
	Stock disaster kits with MOUD	Just as vaccines and insulin are prioritized, preposition buprenorphine and naloxone in regional emergency stockpiles and make available to shelters, harm reduction teams, and mobile units to serve displaced individuals.
	Create statewide patient registry	Maintain interoperable patient verification databases to allow displaced individuals to access care across counties or states.
	Integrate with emergency operations centers	Embed MOUD continuity into state disaster response plans and coordinate with Medical Reserve Corps, OTPs, hospitals, and harm reduction programs.
Community level	Establish mobile MAT units and pop-up clinics	Deploy mobile MOUD units and medical tents equipped with refrigeration, secure storage, and DEA-compliant protocols.
	Advance planning for helicopter medication drop sites and drone recovery protocols	Identify and preapprove helicopter landing zones for medication dropoffs in rural, mountainous, and flood-prone regions, such as school fields, hospital rooftops, or fire department lots, mapped in coordination with local emergency management agencies and vetted for DEA-compliant storage and handoff procedures. Deployment of drones could support delivering medication to isolated communities but requires advance planning for designated, secure areas where drones can safely land or be retrieved after delivery. Local community health centers or OTP satellites can serve as drone docking stations, equipped with trained staff and secure storage to manage inbound supplies and confirm patient identities.
	Create community outreach network	Train peer navigators, community health workers, and mutual-aid groups to perform patient check-ins and distribute harm reduction supplies during disasters.
	Integrate in shelter protocols	Require shelters to provide secure, private spaces for dosing and storage; coordinate with OTPs for continuity of care.
	Local communication hubs	Equip community health centers with satellite phones or radios to maintain connectivity with OTPs and emergency offices.
Health system level	Emergency communication and data access	Maintain electronic health record connectivity through satellite systems; ensure ability to verify prescriptions and enable telehealth.
	High-risk patient database	Identify patients dependent on time-sensitive treatments (e.g., dialysis, MOUD, ventilators) for proactive outreach.
	Patient communication protocols	Develop automated alerts and scripts to inform patients of weather threats, clinic closures, and alternate dosing sites.
	Occupational and staffing resilience	Stockpile supplies (food, water, fuel) for staff; create flexible staffing models for rapid role reassignment.
Practice level	Provider preparedness and training	Implement training on disaster readiness and MOUD continuity, including telehealth prescribing rules.
	Weather resilience lead	Assign a clinic lead to coordinate emergency planning with local/state agencies and maintain updated staff protocols.
	Continuity drills	Incorporate MOUD continuity into annual emergency drills.
	Patient preparedness education	Counsel patients to maintain naloxone, backup contacts, and awareness of alternate treatment locations.

Note. DEA = Drug Enforcement Administration; DHHS = Department of Health and Human Services; FEMA = Federal Emergency Management Agency; MAT = Medication-Assisted Treatment; MOUD = medications for opiate use disorder; OTP = opioid treatment program.

Future preparedness strategies should build on these lessons by improving data sharing and operational flexibility. Expanding prescription drug monitoring programs (PDMPs) to include treatment plans and not just prescriptions could facilitate continuity of care across disrupted systems. In the absence of fully interoperable health records, parallel information-sharing platforms can help clinicians verify treatment history, reduce inequities, and coordinate services more effectively.

Operational innovations also demonstrate promise. Mobile medications for opiate use disorder (MOUD) units deployed after hurricanes and wildfires have provided on-site dosing, reassessments, and harm reduction services such as naloxone and syringe exchange. After Hurricane Helene, such units, paired with peer outreach workers, filled critical gaps when OTPs were inaccessible for weeks. Some health departments now stockpile MOUD alongside traditional emergency supplies, reflecting its essential role (Box 1).

Interdisciplinary collaboration is equally vital.¹¹ Coordination between emergency medicine teams, addiction specialists, and primary care ensures safe medication transitions, such as transitioning from daily methadone to extended release. Social workers, case managers, and community health workers can help sustain adherence and psychosocial stability, although their own vulnerabilities during disasters highlight the need for supplemental support. To help address this gap, a well-prepared Medical Reserve Corps mobilizing trained volunteers including clinicians, pharmacists, and behavioral health specialists could reinforce continuity of care when local capacity is strained. Interagency communication protocols that enable real-time data sharing and shared care plans are critical for maintaining continuity of care during disasters.

RECOMMENDATIONS

To prevent a “disaster within a disaster,” continuity of OUD treatment must be recognized as essential in emergency preparedness. Our recommendations span federal, state, community, health system, and clinical levels. They include codifying emergency flexibilities, developing interoperable registries, mandating disaster planning at OTPs, and embedding MOUD into emergency operations. Innovations such as mobile units, harm reduction partnerships, and resilient communication systems further strengthen continuity of care.

If these recommendations are to be operationalized, responsibilities must be defined across all levels of governance and care. Federal agencies including the Substance Abuse and Mental Health Services Administration (SAMHSA), the Drug Enforcement Administration (DEA), and the Department of Health and Human Services (DHHS) should codify emergency flexibilities including preapproved take-home methadone dosing and telehealth buprenorphine initiation, eliminating reliance on ad hoc waivers during disasters. These agencies, which already oversee OTP licensing and security, are well positioned to enforce such standards and allocate funding through mechanisms such as SAMHSA block grants, Federal Emergency Management Agency preparedness funds, and state resilience programs. Medicaid and Medicare could further incentivize compliance by linking reimbursement to verified continuity-of-care plans.

State governments should maintain centralized treatment registries, standardized emergency protocols, and stockpiles of buprenorphine and naloxone alongside other essential medications. Health systems and OTPs must develop, test, and regularly update disaster continuity plans with designated resilience leads. Local agencies, shelters, and community partners should integrate MOUD into shelter operations, ensuring secure storage, dosing, and outreach through peer navigators. Clinicians need training and decision support tools to manage continuity of care in resource-limited settings.

By explicitly delineating these responsibilities from federal policymakers to frontline clinicians, our recommendations outline a coordinated, multilayered approach that could be tailored at the local level. Embedding MOUD into disaster planning requires leadership, accountability, and action across all tiers of the health care and emergency response systems, ensuring that patients with OUD are not left behind during climate-driven crises.