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. Author manuscript; available in PMC: 2021 Feb 4.
Published in final edited form as: Hum Organ. 2020 Dec 2;79(4):292–303. doi: 10.17730/1938-3525-79.4.292

Another silver lining?: Anthropological perspectives on the promise and practice of relaxed restrictions for telemedicine and medication-assisted treatment in the context of COVID-19

Emery Eaves 1, Robert Trotter II 2, Julie Baldwin 3
PMCID: PMC7861509  NIHMSID: NIHMS1665986  PMID: 33551465

Abstract

As a response to the COVID-19 pandemic, the United States Drug Enforcement Administration (DEA) has temporarily relaxed restrictions to serve people who are opioid dependent during social distancing mandates. Changes include allowing patients to take home more doses of methadone and buprenorphine rather than coming to the clinic every day (for methadone) or weekly (for buprenorphine) and relaxed restrictions on telehealth delivery. Telemedicine Program representatives have described the relaxing of federal regulations as a “silver lining” to the COVID-19 pandemic. Drawing from medical anthropology approaches to epidemic surveillance and understandings of risk, we critically evaluate media representations of recent changes to telemedicine, prescribing, and opioid treatment delivery. Ethnographic research with providers and stakeholders in Arizona from 2017 to the present add insight to our analysis of media reports on these topics. Our findings demonstrate that media portrayal of access to medication-assisted treatment (MAT) as the key to preventing both COVID-19 and overdose among people who are opioid dependent misses important risks and potential inequities. Applied social science questions raised by the new guidelines include: who receives take-home doses of methadone and buprenorphine and why; and how media representations of risk and benefit rationales shape real-world policy and practice.

Keywords: opioid treatment, telemedicine, medication-assisted treatment (MAT), risk

Introduction

The COVID-19 pandemic, infecting nearly 5 million Americans by June 2020, quickly surpassed estimates of potential deaths to nearly 150,000 by July 2020 (Wamsley 2020). Deaths resulting from opioid use had already been increasing, from 21,088 in 2010 to 46,802 in 2018 (CDC 2020). Although considerable research shows benefit for patients receiving a combination of counseling and medication-assisted treatment (MAT) (Volkow and Boyle 2018; Volkow, Koob, and McLellan 2016), social distancing mandates in response to COVID-19 have resulted in shifts toward prioritizing medication access through telemedicine. This one-size fits all solution may be necessary during the middle of a crisis; however, increasing calls to make the new policies permanent warrant additional research.

Prior to the pandemic, federal regulations required the majority of patients to obtain methadone treatment in daily clinic visits, and methadone could only be dispensed in federally certified opioid treatment programs (Davis and Samuels 2020). Buprenorphine could be prescribed as a take-home medication, but only by physicians who had obtained a federal waiver, and the number of patients each physician could treat were limited (Meinhofer and Witman 2018). In late March, due to increasing demands for reduced contact during COVID-19, the Substance Abuse and Mental Health Service Administration (SAMHSA) and United States Drug Enforcement Administration (DEA) issued new guidance, allowing “stable patients” a 28-day take-home methadone prescription and waiving the requirement for in-person consultation to obtain a prescription for buprenorphine (Alexander et al. 2020; Davis and Samuels 2020).

SAMHSA and DEA policy changes were intended to respond to the risk of using opioids during COVID-19; however, the nature of risks in this situation is complex. Being “at-risk” of something is dependent on the context, the nature of the risk, and the nature of the potential outcomes (Rappaport 1996; Salhi 2015). Boholm and Corvellec (2011) argued that an object can be both a risk object (posing a risk to something else) and an object at risk at the same time, depending on the assumptions of the observer. During the COVID-19 pandemic, as in other crises where scientific understanding is limited, media representations are a key site for the negotiation of which risks to avoid (Beck 1987). In the following sections, we use a relational theory of risk (Boholm and Corvellec 2011) to consider media representations of COVID-19 in relation to known and novel risks associated with opioid use and opioid dependence during a pandemic. Using Boholm and Corvellec’s (2011:180) definition of risk as a “trait that evolves as new dangers are identified and new values are considered at stake,” we incorporate disparate data sources to consider how perceptions and representations of risks, challenges, and needs evolved in relation to COVID-19.

Research has long shown that media representations of people who use drugs are part of the creation and perpetuation of stereotypes that can undermine more complex discussions toward improving drug policy and treatment (Belackova, Stastna, and Miovský 2011; Taylor 2008). News media representations are important as a key way that dominant narratives about drug use are framed (Orsini 2017). In Beck’s (1987:156; emphasis in original) words, “reality can be created and transformed in the shaping of information and information policy.” Medical and criminal models, for example, are often central to media coverage of opioid use, and reports consistently misrepresent harm reduction approaches and remove focus from individual circumstances or alternative voices (Ferguson 2019; Sills 2017). Netherland and Hansen’s (2016) review of news coverage of the opioid epidemic argued that media representations were also involved in racial coding of the epidemic, distinguishing a tragedy of White opioid use from criminalized Black and Brown heroin use a decade earlier. As media reports use the term “harm reduction” to refer to new MAT and telemedicine guidelines in the context of COVID-19, the meaning assigned to harm reduction in this context warrants attention.

Nichter (2003) argued that studies of harm reduction should be attentive to social relations of risk and vulnerability. Harm reduction, in his definition, can be an expression of agency or a form of manipulation. “As an expression of agency, harm reduction practices are undertaken to reduce a sense of vulnerability and enhance a sense of self-control. As a form of manipulation, harm-reduction practices are fostered at the site of the individual body by parties who wish to deflect attention away from risk factors affecting a population’s health” (Nichter 2003:13). Harm reduction in the context of opioid use involves both agency and manipulation and targets multiple areas of risk, including: risk of contracting a virus (usually HIV); risk of relapse and overdose; risk of social isolation and stress; risk of criminality, incarceration, and recidivism; and risk of deadly potential side effects of the treatment medications themselves. In Spring 2020, COVID-19 added the risk of infection and led to a subsequent reorganization in the hierarchy of risks surrounding people who are opioid dependent. This reorganization presents an opportunity for applied anthropological influence in a situation of rapid policy change.

While news articles emphasize great breakthroughs in opioid treatment resulting from COVID-19, anthropologists cannot ignore that pharmaceutical “best-practice” treatments are produced by the pharmaceutical industry. Anthropologists have described MAT, including methadone and buprenorphine, as forms of governance prior to the pandemic (Bartoszko 2019; Bourgois 2000; Harris 2015). MAT has been increasingly central to defining what is considered a normal recovery (McElrath 2018; Ostrach and Leiner 2019). The growing popularity of MAT as a long-term solution not only continues to feed into the pharmaceutical market but also further neutralizes what Garcia (2013) referred to as the failure of institutionalized treatment programs to care for marginalized substance users. These well-documented concerns over MAT as a form of governance have been shelved in the current crisis in order to offer “safe” treatment through telemedicine. Briggs and Nichter (2009) called social scientists to document the ways knowledge production in the context of an epidemic can solidify some forms of governance. For people who are dependent on opioids, media representations of shifts toward telemedicine and access to MAT, while other forms of harm reduction such as needle exchanges close their doors, are important to consider as they shape public and political understandings of the issues at hand.

Telemedicine as a treatment modality eliminates the need for in-person interaction through the use of electronic devices for communication between providers and patients. Telemedicine as a form of care has been a topic of anthropological interest, as a high-tech manifestation of Foucault’s medical “gaze,” allowing providers to see not only patients but also their homes and life circumstances (Milligan, Roberts, and Mort 2011; Sinha 2000). Although telemedicine has been touted as a solution to problems of distance and cost in providing access to care, Sinha (2000) called attention also to the potential for telemedicine to further isolate some individuals. Lupton and Maslen (2017) add that most public health research on telemedicine emphasizes cost-cutting potential or acceptability and often fails to take the lived experiences, social contexts, and power relationships between providers and patients into account.

In this paper, we describe applied anthropological approaches to assessing guideline changes resulting from COVID-19 and point to the need for comprehensive evaluation of online forms of care for people who are opioid dependent. Informed by medical anthropology approaches to epidemic surveillance and understandings of risk (Briggs and Nichter 2009), we critically evaluate the potential for recent changes to methadone and buprenorphine prescribing and online substance use treatment delivery to increase access to care and reduce risk for people who are dependent on opioids. Drawing insight from ethnographic interviews with providers and stakeholders from 2017 to the present, we consider media representations of risk and harm reduction at the intersections of opioid use, opioid treatment, and COVID-19.

Methods

Content Analysis of Media Portrayal

We collected news articles and blog posts reporting on guideline changes, needs for policy changes, and impacts of COVID-19 on opioid treatment. Using keyword searches in google, including “opioid, drug, and COVID-19” as keywords in multiple searches from April 2020 to June 2020, we located media articles, including national news, blog posts, and local media, published between March and June 2020 that focused on the intersections of opioid use and COVID-19. We coded articles using ATLASti Qualitative Data Analysis software, guided by constant comparative analysis methodologies (Namey and Trotter 2015; Strauss and Corbin 1990) to identify emergent themes shared among news sources. Using emergent themes to guide keyword searches, we conducted additional searches in google and on prominent news websites such as The New York Times (nytimes.com), The Washington Post (washingtonpost.com), Fox News (foxnews.com), and National Public Radio (npr.org) to locate additional national news articles that did not appear in our google searches and ensure a balanced representation of media perspectives.

We identified thirty-five media sources focused on opioid use and COVID-19. Codes used to characterize media articles included: comments about change to telemedicine; harm reduction barriers; negative outcomes of COVID-19; positive outcomes of COVID-19; calls for additional policy change; comments by providers about guidelines prior to COVID-19; concerns about guidelines; unequal access and uneven implementation of guidelines; impacts of added stress and social isolation on patients; and comments about take-home MAT prescriptions and barriers to MAT access.

News articles are cited with the author’s last name and the date of publication. Full citations are provided in Table 1 after the conclusion to distinguish them from scholarly citations.

Table 1.

Media sources included in content analysis

Author(s) Source Article Title Date URL
Levandar and Wakeman STAT Covid-19 will worsen the opioid overdose crisis if we don’t prepare now 3/17/2020 https://www.statnews.com/2020/03/17/covid-19-will-worsen-the-opioid-overdose-crisis-if-we-dont-prepare-now/
Banta-Green et al. The Hill Nation’s opioid addiction treat system during COVID-19 needs reform 3/17/2020 https://thehill.com/opinion/healthcare/488112-nations-opioid-addiction-treatment-system-during-covid-19-needs-reform
Rohrich, Z PBS News Hour Amid COVID-19, a new push for telehealth to treat opioid use disorder 3/23/2020 https://www.pbs.org/newshour/health/amid-covid-19-a-new-push-for-telehealth-to-treat-opioid-use-disorder
Brico, E Talk Poverty Blog Addiction Treatment Clinics Struggle to Keep Up with COVID-19 3/25/2020 https://talkpoverty.org/2020/03/25/methadone-covid-19-addiction-treatment/
Sganga, N CBS News How the coronavirus is hurting drug and alcohol recovery 4/3/2020 https://www.cbsnews.com/news/how-the-coronavirus-is-hurting-drug-and-alcohol-recovery/
Sternlicht, A Forbes The Opioid Epidemic Meets The Coronavirus Pandemic—With Potentially Deadly Results 4/5/2020 https://www.forbes.com/sites/alexandrasternlicht/2020/04/05/the-opioid-epidemic-meets-the-coronavirus-pandemic-with-potentially-deadly-results/#2731be3c15bd
Bono, M USA Today Job loss, anxiety, isolation: Coronavirus is a prescription for more opioid use 4/16/2020 https://www.usatoday.com/story/opinion/2020/04/16/coronavirus-threatens-progress-against-opioid-addiction-column/2982966001/
Parshley, L National Geographic The pandemic may fuel the next wave of the opioid crisis 4/21/2020 https://www.nationalgeographic.com/science/2020/04/coronavirus-pandemic-may-fuel-the-next-wave-of-the-opioid-crisis/
Galewitz, P Kaiser Health News Coronavirus crisis opens access to online opioid addiction treatment 4/24/2020 https://www.fiercebiotech.com/medtech/coronavirus-crisis-opens-access-to-online-opioid-addiction-treatment
Hoffman, J The New York Times With Meetings Banned, Millions Struggle to Stay Sober on their Own 4/26/2020 https://www.nytimes.com/2020/03/26/health/coronavirus-alcoholics-drugs-online.html?searchResultPosition=1
Quinones, S The New York Times (opinion) What the World Needs Now Is Grace 4/27/2020 https://www.nytimes.com/2020/03/27/opinion/coronavirus-opiate-epidemic.html?searchResultPosition=2
Rowe, N AZ Telemed Program Blog Pandemic Silver Lining: Federal Telehealth Regulations Relaxed – At Least for Now 4/30/2020 https://telemedicine.arizona.edu/blog/pandemic-silver-lining-federal-telehealth-regulations-relaxed-least-now
Sklar, T AZ Telemed Program Blog Law and Telemedicine in the Time of Covid-19 5/7/2929 https://telemedicine.arizona.edu/blog/law-and-telemedicine-time-covid-19
Siegel, Z UnDark Opinion: Amid a Pandemic, An Overdue Change in Opioid Addiction Treatment 5/7/2020 https://undark.org/2020/05/07/covid-19-opioid-methadone/
Kaur, H CNN Health The opioid epidemic was already a national crisis. Covid-19 could be making things worse 5/7/2020 https://www.cnn.com/2020/05/07/health/opioid-epidemic-covid19-pandemic-trnd/index.html
Harveston, K Physician’s Weekly How COVID-19 Has Impacted the Opioid Crisis 5/7/2020 https://www.physiciansweekly.com/how-covid-19-has-impacted-the-opioid-crisis/
Simon, M CNN Health 75,000 Americans at risk of dying from overdose or suicide due to coronavirus despair, group warns 5/8/2020 https://www.cnn.com/2020/05/08/health/coronavirus-deaths-of-despair/index.html
Schwartzapfel, B USA Today No strings attached: More opioid addicts get meds without talk therapy 5/9/2020 https://www.usatoday.com/story/news/investigations/2019/05/09/opioid-crisis-drugs-no-therapy/1131110001/
Cunningham, PW The Washington Post The Health 202: Coronavirus could worsen the opioid abuse epidemic 5/11/2020 https://wellbeingtrust.org/news/washington-post-the-health-202-coronavirus-could-worsen-the-opioid-abuse-epidemic/
Polansky, R WKYC A tale of two epidemics: When coronavirus and opioid addiction collide 5/12/2020 https://www.wkyc.com/article/news/investigations/a-tale-of-two-epidemics-when-coronavirus-and-opioid-addiction-collide/95–077c0c9c-2c57–4abf-b5d6–6b2666e43e39
Facher, L STAT Covid-19 has streamlined addiction medicine. Will the changes stick? 5/12/2020 https://www.statnews.com/2020/05/12/coronavirus-addiction-medicine-reforms-future/
Link, D USA Today Fact check: San Francisco providing drugs, alcohol to quarantining homeless but not on taxpayers’ dime 5/13/2020 https://www.usatoday.com/story/news/factcheck/2020/05/13/fact-check-san-francisco-project-room-key-provides-alcohol-tobacco/3111155001/
Alfonso, F CNN Health The pandemic is triggering opioid relapses across Appalachia 5/14/2020 https://www.cnn.com/2020/05/14/health/opioids-addiction-appalachia-coronavirus-trnd/index.html
Holman, K UMSL Daily (blog) Rachel Winograd and Claire Wood address the impact of COVID-19 on opioid addiction and treatment 5/18/2020 https://blogs.umsl.edu/news/2020/05/18/opioid-webinar/
Marsh et al. New York Post NYC delivering methadone to addicts with coronavirus 5/19/2020 https://www.foxnews.com/health/nyc-methadone-addicts-coronavirus
McKay, H Fox News Mental health crisis spawned by coronavirus fears and lockdown could be next pandemic 5/22/2020 https://www.foxnews.com/health/next-pandemic-mental-health-crisis-spawned-coronavirus-fears-ock-down
Marshall, T et al MedPage Today Addressing the Opioid Crisis During COVID-19 — Two health emergencies collide 5/23/2020 https://www.medpagetoday.com/publichealthpolicy/opioids/86655
Erdman, S CNN Health Opioid drug overdose deaths are down in US, study finds, but Covid-19 could change that 5/25/2020 https://www.cnn.com/2020/05/21/health/drug-overdose-deaths-covid-19-trnd/index.html
Medrano, K Gothamist Methadone Deliveries Now Part Of NYC’s Public Health Mission 5/26/2020 https://gothamist.com/news/methadone-deliveries-now-part-nycs-public-health-mission
  GlobalData Healthcare Covid-19 pandemic changing how opioid use disorder can be treated for the better 5/27/2020 https://www.pharmaceutical-technology.com/comment/opioid-use-disorder-covid-19/
Editorial Board Bloomberg The Response to Covid-19 Will Help to Defeat Opioid Abuse 5/27/2020 https://www.reformer.com/stories/another-view-the-response-to-covid-19-will-help-to-defeat-opioid-abuse,605642
Baicker et al. USA Today The coronavirus and efforts to fight it could be fueling opioid deaths 5/27/2020 https://www.usatoday.com/story/opinion/2020/05/27/coronavirus-drug-reforms-could-fueling-opioid-deaths-despair-column/5257218002/
Trad et al. HealthAffairs Blog COVID-19 Pandemic Provides Opportunity To Realign Self-Help Groups With Medications For People With Opioid Use Disorder 5/28/2020 https://atforum.com/2020/06/pandemic-opportunity-self-help-groups-medications/
AMA Leaders AMA News COVID-19 daily video update: Experts discuss the pandemic’s impact on the opioid epidemic 5/29/2020 https://www.ama-assn.org/delivering-care/opioids/ama-covid-19-daily-video-update-experts-discuss-pandemic-s-impact-opioid
O’Donnell, J USA Today As suicide, addiction death projections soar amid COVID-19, treatment centers struggle to stay alive too 6/21/2020 https://www.usatoday.com/story/news/health/2020/06/21/covid-spurs-mental-health-needs-treatment-centers-go-underfunded/3191251001/
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Sources of Local Ethnographic Insight

In addition to review of the media portrayal of the new guidelines, we conducted a qualitative meta-analysis of semi-structured interviews collected as part of multiple projects in the past five years. We wanted to understand what providers said prior to COVID-19 since many providers in the past months have described the new guidelines as being needed long before the pandemic. We draw from interviews with substance use providers and stakeholders in northern Arizona that were coded previously. This focused ethnographic meta-analysis, using data from available sources, allowed us to conduct rapid assessment of an emergent issue using existing data from multiple research projects.

Ethnographic data are drawn from: (1) a regional health equity assessment project conducted in 2017 that involved all authors, funded by the NARBHA Foundation with support from Northern Arizona Healthcare Foundation (Eaves et al. 2020); (2) ethnographic interviews in an ongoing project with providers who work with women in methadone programs in urban Arizona; and (3) meetings with providers and stakeholders involved in substance use policy and programming as part of multiple projects focused on substance use among women in rural and urban regions in Arizona, funded by the Southwest Health Equity Research Center (NIH/NIMHD U54MD012388–01 Baldwin/Stearns). Although several of the projects listed were focused primarily on women, providers interviewed were not treating only women in their practice. Table 2 provides detailed descriptions of participants, activities, and analysis for each project. The lead author has also participated in project ECHO sessions, attended stakeholder meetings, and collaborated with substance use providers to understand barriers to care and needs for provider and patient support for the past three years.

Table 2.

Ethnographic Data Collection and Analysis

Participants Activities Analysis
Northern Arizona Regional Health Equity Assessment (2017)
N=62 community stakeholders and providers Qualitative Interviews and Focus Groups NVivo, thematic content analysis 3 coders met regularly to reach agreement and discuss discrepancies in coding (see AUTHORS 2020)
Urban clinic providers who work with women in recovery (2018–2020)
N= 10 providers Ethnographic interviews ATLASti, thematic content analysis and phenomenological analysis First author and two students met regularly to discuss codes and address discrepancies and identify emergent themes
Urban and Rural community stakeholders and providers (2018–2019)
N=29 community stakeholders and providers Community-engaged planning and dissemination meetings on statewide substance use research, programming, and policy needs ATLASti, Analysis of field notes to identify key themes and areas identified as greatest need for substance use intervention First author coded field notes with targeted codes to identify comments about MAT prescribing and telemedicine concerns
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We identified codes in those datasets related to telemedicine and MAT access guidelines and used code reports to determine sentiments within the data. Ethnographic data have been merged below to protect participant confidentiality commitments. All interviews were conducted with approval from the Northern Arizona University Human Subjects Protection Program, and all interviewees provided informed consent.

Results

Providers and stakeholders in Arizona have advocated for more leeway in implementing alternative strategies, such as telemedicine, to reach patients. In a regional health equity assessment of northern Arizona in 2017, one of the most commonly noted direct barriers to accessing any type of health care was distance:

Distance to provider is a huge issue—if people can go see a doctor and pick up their food box at the same time, it’s doable. If they have to make two trips, not doable. (AZ Interview Participant, 2017)

For patients in rural Arizona, many of whom live on tribal lands, telemedicine and mobile health apps were becoming popular for providing a range of services prior to COVID-19, but restrictions prevented many forms of care. Even in urban areas, daily visits to methadone clinics, sometimes across town, place a heavy burden on people who are opioid dependent, particularly women, who often have childcare and department of child safety demands to consider as well (Fiddian-Green 2019). As a measure to increase access, one local provider recently described changes to prescribing as “something we’ve been wanting to see for a long time.”

In March, as the pandemic ramped up, national news articles emphasized the need to focus on the opioid crisis amidst COVID-19. By May, journalists reported serious negative consequences of COVID-19 for opioid treatment programs and people who depend on them. An article in USA Today explained, “The COVID-19 pandemic tragically fuels the root causes of the opioid crisis, including depression, unemployment, poverty, social alienation, and many other ‘conditions of despair’” (Baicker, Simborg, and Thangaraj 2020:para. 3). Academic experts cautioned that heightened stress levels due to economic hardship, reduced social contact, and limited access to other stress relieving activities could lead to increased reliance on substances as a coping mechanism and subsequent increases in overdose (Alexander et al. 2020; Knopf 2020a, 2020b; Slat, Thomas, and Lagisetty 2020). Further, border closures and travel restrictions during the pandemic impacted supply chains for synthetic drugs, leading to concerns about increased risk of overdose or complications from ingesting adulterated substances (Chiappini et al. 2020).

Mitigating Risk: MAT and Telemedicine as Harm Reduction during COVID-19

People who are opioid dependent are particularly vulnerable to COVID-19 complications due to effects on respiratory and pulmonary health and increased likelihood of experiencing homelessness, incarceration, and co-morbid mental health conditions than the general population (Akiyama, Spaulding, and Rich 2020; Volkow 2020). COVID-19 introduced the additional risk of virus transmission during in-person clinic visits, prompting changes that allowed for more take-home doses of medications to avoid frequent contact.

On the other hand, take-home doses are associated with their own set of risks. Concerns about potential toxicity complications due to underlying health conditions (Davis and Samuels 2020; Yancy 2020), diversion for illicit use, and potential for overdose from methadone and buprenorphine (Tjagvad et al. 2016) were all compounded by COVID-19. COVID-19 has disproportionately impacted minority and underserved communities due to higher burdens of co-morbidities including hypertension, obesity, housing insecurity, mental illness, substance use disorders (SUDs), and many others, combined with reduced access to telecommuting and physical distancing options (Yancy 2020). Take-home doses of methadone and buprenorphine remove the in-person, structured support that many providers see as crucial pieces of treatment programming. Further, implementation of these options has been uneven and may further disadvantage patients that don’t meet prescribing physician’s notions of a “stable” patient.

Media reports during COVID-19 depict MAT and telemedicine as a combined solution that can replace other forms of harm reduction, other treatment options, and even prevent some of the risks imposed by COVID-19. In a story published in the Gothamist, for example, Medrano (2020:para. 9) wrote, “As the coronavirus pandemic throws the drug supply chain into chaos, expanded access to these medications is crucial in reducing risk of both overdose and of COVID-19.” Medrano goes on to suggest that MAT can replace harm reduction programs, saying, “It will also help mitigate the spike in HIV and Hepatitis C…. people with reduced access to harm reduction facilities inevitably re-use and share syringes—the greater the access to methadone and buprenorphine, the more people will be able to hold out until they can access new syringes.” Medrano (2020:para. 9).

“A Natural Proving Ground”: Potential Benefits of Access to MAT and Telemedicine

In recent blog posts, Telemedicine Program representatives in Arizona described the relaxing of federal telehealth regulations as a “silver lining” to the COVID-19 pandemic, arguing that “many of these policy changes are just a step or two beyond what was already in the works” and saying, “I hope that by the end of the public health emergency, they’ll have evidence that using telemedicine to prescribe controlled substances does not add to the opioid epidemic” (Rowe 2020:para. 13). Another argued that “the long-awaited promise of telemedicine may finally be realized as a response to COVID-19” (Sklar 2020:para. 1).

National news outlets similarly portray the pandemic as a tipping point for changes that providers have been working toward for a long time. Lev Facher’s (2020:para. 14) commentary in STAT news, for example, quoted the vice president of an addiction advocacy group saying, “We’re seeing changes in the last six weeks that, in some cases, we’ve been advocating for a really long time, and in others, that we didn’t even really think were possible.” Facher (2020:para. 15) points to the weighing of risks amidst the pandemic, saying, “The steps represent a stark acknowledgment from physicians and drug enforcement officials: That even for many vulnerable patients with opioid addiction, coming to the clinic could be more dangerous than staying home alone.” Facher (2020:para. 10) further described COVID-19 as “a natural proving ground for policies that many addiction treatment advocates have been pushing for years.”

Media outlets focus on positive outcomes of telemedicine, in terms of reducing transportation barriers, reducing contact with the virus, and increasing access to care overall. Stories like the one below, describing Godinez, a women who was able to access treatment because providers “wield unprecedented freedom,” however, suggest that policy advocates may be forging ahead toward permanent change with little understanding of potential long-term impacts of the changes:

Godinez’s process was almost impossibly simple: She texted her doctor and a drug counselor, who briefly evaluated her via FaceTime and wrote a prescription that she filled at a Walgreens around the corner from her Hendersonville, Tenn., home—a process that, until March, would have been largely illegal. “The first thing one thinks is, ‘Oh, my God, am I going to be able to get my medicine?’” Godinez, 33, said. “If I couldn’t get it through text, then I wouldn’t get it. I wasn’t going to leave my baby.” Now, as they wield unprecedented freedom to prescribe addiction drugs by telemedicine and evaluate patients by phone, many doctors and advocates say they’re unwilling to relinquish that flexibility without a fight. (Facher 2000:para. 5)

In the digital magazine Undark, Zachary Siegel (2020:para. 6) described how COVID-19 tipped the balance of risk away from concerns about diversion and misuse toward access to a needed form of care:

Entrenched fears that patients will misuse the medications or exchange them on the illicit market have long governed how, when, and where patients can receive these life-saving medications—and which doctors can prescribe them. But the coronavirus pandemic is proving those age-old fears and stigmas to be unfounded, while revealing new and better ways to treat hard to reach patients.

“We Need a More Nuanced Conversation”: Potential Risks in Media Representations of Reducing Harm

Taylor (2008:379) pointed out that in media coverage of drug use, “Whether the media is driving policy or vice versa is unclear …, yet the media are allowed (or even encouraged) to focus upon convenient caricatures rather than wider and possibly more pressing issues.” Hallin and Briggs (2015) argue that news media goes beyond communication to play a key role in co-producing meanings and understandings of health and disease. As the media joins calls to make MAT and telemedicine guideline changes permanent, anthropological perspectives should continue to question the role of the media in shaping opioid treatment policy in the wake of COVID-19. Bloomberg’s editors (2020:para. 7), below, offer a troubling depiction of MAT as a stand-alone treatment and even as a potentially manipulative replacement for attention to issues that contribute to drug use in the first place:

States can and should do more. They all should eliminate requirements that Medicaid beneficiaries be preauthorized for addiction medications and waive requirements that medications must always be accompanied by counseling. Although it’s ideal for patients to receive both medication and counseling, there’s good evidence that medications alone are a powerful treatment. …[S]tates and the federal government alike should ensure that addiction treatment with medications is always available when people who need it enter hospitals, jails or prisons, and that these patients receive further treatment when they leave.

In our ethnographic work with providers in Arizona, some express strong commitment to getting patients access to methadone or buprenorphine. Others, such as the two quoted below, were more critical of the increasing emphasis on MAT as a long-term strategy for people in recovery even prior to COVID-19:

With MAT being so popular right now, we can’t make a big deal about them getting off of it. Now we have to bring peers in to encourage them to taper…clinics are discouraging them from lowering the dose. (AZ Provider 2019)

There has been as strong push to de-stigmatize MAT, which is very important and an incredible tool, but it needs to be done more cautiously. There has been a swing to the “you are probably going to need to be on this for life”… There’s a catastrophizing of titration, and we need to have a more nuanced conversation about this. (AZ Provider 2019)

Providers and stakeholders in our ethnographic research, although also advocating for more attention to practice-based knowledge, cautioned that what works for some may not work for others, saying, “When you want to create change and innovation, you don’t look in the literature, you talk to the people in the field… [A good model] recognizes that some people will receive services well and do well in that model and some won’t.” More recently, in the context of stay-at-home orders implemented to counter COVID-19, providers raised concerns that lack of structure and daily interaction is a source of risk that can’t be entirely mitigated by telemedicine:

We always tell people in recovery, “never use alone.” Humans naturally use drugs and alcohol to cope, and this is even harder now. People need more structure for the day with being home all the time. Online support programs are just not as connecting as in-person groups. (Meeting Attendee, April 2020)

Harm reduction as agency in the context of opioid use is typically associated with strategies, such as needle exchanges or safe use sites, designed to reduce potential harms associated with choosing to use heroin or other illicit opioids. Media coverage of new guidelines, however, may add momentum to understandings of MAT and telemedicine as silver bullet solutions for risks associated with opioid use and further distract from issues of social context and individual agency in harm reduction.

Silver Lining or Further Failure of Institutionalized Care?

Media sources describe guideline changes as allowing new insights into patients’ life circumstances. Providers, they explain, have experienced a new level of insight into treatment for people who are opioid dependent, including family and housing situations. In a New York Times report, for example, Hoffman described a doctor who “is new to online platforms and sees silver linings.” A bonus, Hoffman explained, is that “By seeing patients in their homes, she is getting more information about how they live. ‘I’ve told a few of my patients to clean their rooms,’ she said.” (Hoffman 2020:para. 31). Similarly, in USA Today, O’Donnell describes a provider who “actually prefers doing her therapy remotely” and another who is “definitely in favor of continuing telemedicine for those who have trouble getting into the clinic” (O’Donnell 2020:para. 36).

On the other hand, providers’ comments about telemedicine as a harm reduction strategy in these reports raise the possibility of increased surveillance and more opportunity to extend the medical gaze into patients’ homes and personal lives. In Kaiser Health News, Phil Galewicz (2020:para. 26), for example, quoted a provider, saying, “‘I can pick up an awful lot on the video,’ particularly a patient’s body language, she said. ‘I think people open up to me more because they are sitting in their homes and in their place of comfort.’” In a CBS News report, Nicole Sganga (2020:para. 32) quoted a provider, saying, “They’re absolutely enjoying sitting on their couch comfortably, talking to their therapist or counselor. They’re sharing more.”

Surprisingly few media sources we reviewed mentioned concerns about the new guidelines (4 of 35). Providers, however, are more responsible than ever for evaluating risk among their patients. Sganga’s (2020:para. 13) CBS report also highlighted concerns about liability and limited guidance, such as the quote below from the president of a State Coalition of Medication- Assisted Treatment (MAT) Providers and Advocates:

The only guidance we’ve had from federal governments and state governments across the country is to gauge how “clinically stable” your patient is, then give them take-homes. And that leaves you wide open…. Without clear guidelines, as providers, we have a huge vulnerability. We’re accepting it because we have to, but we know it is there.

From the perspective of relative risk, it is important to consider how media sources portray and negotiate what risks are deemed most pressing. Salhi (2015) argued that medical risk is contingent on what is at stake and whether it is the patients or the providers themselves who face the most salient risk. Garcia’s (2013) description of the chronic brain disease model of addiction as a failure of institutionalized care is important here, as media reports describe access to MAT via telemedicine as, in one example, “a permanent boon especially to rural Americans,” (Bloomberg Editorial Board 2020:para. 6). At the same time that media reports describe the changes as overcoming a great barrier to accessing care, many people who use opioids have found their options for harm reduction increasingly limited.

Sam Quinones (2020:22) author of Dreamland, wrote recently, “Perhaps we’ll come out on the other side of this [pandemic] with the insight recovering addicts gain, and glimpse the addict in all of us. For the pandemic will make us live for a while with the kind of anguished and deadening isolation they feel.” As applied social scientists and addiction researchers striving to understand the impacts of COVID-19 on people who are opioid dependent, and on opioid treatment in the future, we are cautious about media representations of COVID-19 as a mostly positive situation for people in opioid treatment. We argue that there is a pressing need for more critical assessment of media attention to MAT access and more research to understand the impacts of changing guidelines on people who are dependent on opioids in relation to several questions. For example, how might accepting MAT and telemedicine as key to harm reduction further isolate people who are opioid dependent at the same time as they are increasingly open to monitoring? How can a critical perspective enhance access to care for people that want it while still keeping focus on other definitions and strategies for reducing harm? And how might ethnographic perspectives counter and complicate media caricatures to refocus the discussion on contextual factors that drive drug use and limit access to care in the first place.

Conclusions

Media attention to MAT and telemedicine for people in opioid treatment warrants caution as it draws attention away from the drivers of drug use and away from other harm reduction strategies that have been struggling to survive amidst closures and loss of funding. As COVID-19 is increasingly portrayed as a great tipping point toward access to care for people who are opioid dependent, anthropological insights raise questions such as: Access for whom and to what type of care? Which risks are privileged in risk-benefit assessments of the impacts of guideline changes? How does conflation of MAT with mitigation of a range of risks further disadvantage people who choose not to engage in medicalized treatment programs?

Analysis of media representations of telemedicine and MAT for people who are opioid dependent in the context of COVID-19 is compelling as a place to consider issues of relative risk because treatment providers have long advocated for the guideline changes implemented during COVID-19. Many providers and scholars, however, are cautious about the increasingly central role of MAT in opioid treatment. We analyzed news articles between March and June 2020 and conducted a meta-analysis of ethnographic observations from the past five years to consider how the relative risk of COVID-19 tipped the balance away from concerns about the risks associated with MAT toward arguments for increased access to MAT as central to opioid treatment. Media outlets portray guideline changes as allowing new forms of connection with patients, increasing access to care, and reducing stress and burden on some patients.

Anthropological approaches are particularly well-suited to understanding drug users’ local worlds, challenges, and areas for intervention (Page and Singer 2016). Reducing harm associated with opioid dependence is a major area of progress in drug policy; however, public health measures to avoid COVID-19 contradict social solidarity practices that are central to harm reduction (Schlosser and Harris 2020). Critical perspectives on the ways harm reduction, risk, and vulnerability are framed in media representations of opioid use in the context of a pandemic are important for engaged anthropology and research toward equitable policy and practice.

As other forms of harm reduction have been adversely impacted by the COVID-19 pandemic, Nichter’s (2003) two-pronged definition of harm reduction is a useful framework to consider how the combination of telemedicine and MAT as harm reduction during the pandemic can be both an assertion of agency and a manipulative strategy. Using media representations and earlier ethnographic research with providers and stakeholders, we considered media portrayal of guideline changes resulting from COVID-19. We call for additional research to assess which of the changes benefit patients and which warrant more caution. Drawing from Rappaport (1996), Boholm (2003:174) argued that perceptions of risk and safety depend on “social relationships, power relations and hierarchies, cultural beliefs, trust in institutions and science, knowledge, experience, discourses, practices, and collective memories.” Future applied social science research should consider policy and program impacts of MAT and telemedicine guideline changes during and after COVID-19 and document how media representations have not only reported but shaped rapid policy change during the pandemic.

Acknowledgements

The authors would like to thank the providers and stakeholders who participated in focus groups, meetings, and interviews. The authors would also like to thank Kristin Hedges and two anonymous reviewers who provided valuable feedback on earlier drafts.

Contributor Information

Emery Eaves, Department of Anthropology, Northern Arizona University, Flagstaff, AZ.

Robert Trotter, II, Department of Anthropology, Northern Arizona University, Flagstaff, AZ.

Julie Baldwin, Department of Health Sciences Director, Center for Health Equity Research (CHER) Northern Arizona University, Flagstaff, AZ.

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