COVID-19 Proves San Francisco’s Housing Crisis Is A Health Emergency

Ako Jacintho remembers when people weren’t living in tents on the streets of San Francisco. Or if there were tents, there weren’t encampments. This was back in the late ‘90s, right at the base of the first tech boom, years before displacement and gentrification, before there were SARS and MERS and the newest novel coronavirus, which causes COVID-19.

The spread of this coronavirus coincides with the greatest number of unsheltered residents living on the streets of San Francisco: about 8,000 adults, 71 percent of whom once had a permanent home in the city. Jacintho, the director of addiction medicine at HealthRight 360, a clinic that has provided comprehensive support to people experiencing homelessness for over 50 years, says health care practitioners who serve those experiencing homelessness are rushing to aid a population that has long been forgotten by the city.

Physicians and other care providers say what’s notable about the city’s response in assisting the most vulnerable San Franciscans is that the strategies deployed during the emergency are exactly the tools city leaders had been dragging their feet on implementing, such as stopping police sweeps, working with hotels to set up housing, and making sure those experiencing homelessness have access to comprehensive preventative health care.

California’s Bay Area was one of the first regions in the country to institute a shelter-in-place order, which drew ire among advocates. At first, those experiencing homelessness were exempt from the order, and later were advised to “seek shelter.” How exactly were the tens of thousands of those suffering from homelessness supposed to follow the order? And, because sheltering in place is the centerpiece of the public health response to the pandemic, how do we provide everyone with the space and security to follow these recommendations?

These are exactly the kinds of questions that Margot Kushel, a physician at Zuckerberg San Francisco General Hospital and Trauma Center, the city’s safety net hospital, thinks about. “There is no medicine as powerful as housing,” she says. “Homelessness is completely incompatible with health.” Housing stability has manifold impacts on those experiencing homelessness, and studies have shown that nearly 90 percent of recipients of organization-supported rehousing or rental assistance are housed in permanent homes a year after their initial transition.

Kushel, who has advised on what model policies should look like to help people make the transition from living on the streets to secure housing, says city medical teams are now conducting direct outreach to those living in unstable housing, like tents. Based on age and other medical vulnerabilities, physicians help those living on the streets understand what their options are for locating temporary shelter. Given that shelter is the first priority of physicians and policy makers, the epidemic has exposed how closely tied housing and health are.

The epidemic has exposed how closely tied housing and health are.

Shelters, which typically offer clients housing for a set number of months, have relaxed some of these requirements and the city is working to make 6,555 hotel rooms available. But it’s work that has to be conducted carefully; the city can’t force someone to live in a room that’s not in their neighborhood or is located away from their community. “That’s a huge thing for the homeless population,” Jacintho says, “the shuffling of them to shelters.” This temporary housing is also the first step in seeking permanent housing solutions, not an ultimate solution.

Educating those seeking aid has made some of the everyday care work more complex. In pre-COVID times, Jacintho says, he would sit face to face with a client to go over their needs, symptoms, progress, and concerns, but now he’s communicating with them via a computer or a phone. Telemedicine might be a natural shift for someone who uses devices every day, but for those experiencing homelessness, Jacintho says it’s “definitely a shift for [his clients] culturally.”

The outbreak has meant a downturn in those coming into clinics, for others. Chuck Cloinger, the chief medical officer at St. James Infirmary, an occupational and health safety clinic for sex workers in the Bay Area, says that their mostly-volunteer team has focused on street support in order to aid clients.

Cloinger and his team are focused on making sure that essential health services that may not appear to be directly related to coronavirus management don’t fall through the cracks. Though they’re no longer conducting health screenings in their mobile clinic, the St. James Infirmary van goes out once a week to facilitate needle exchange and deliver other essential goods like hot foods and groceries.

At first, the spread of COVID-19 among unhoused residents was slower than those with shelter, but as of April 13 at least 90 people at a shelter in the city have tested positive. Unsheltered San Franciscans are already medically vulnerable, and with coronavirus testing still lagging far behind the necessary levels, the true number of impacted unsheltered residents is unknown.

If anything, Kushel hopes the recognition of homelessness as a public health crisis in and of itself — and one that can be remedied or even eradicated through systemic change — is a matter of what she calls “political will.”  Even though San Francisco voters passed Measure C in 2018, which would tax large companies to fund services for those experiencing homelessness, the money is still tied up in court. With early action from the San Francisco Department of Public Health and coordination with hotels to mitigate coronavirus as a public health concern, advocates may be right to wonder when it is that living on the streets without shelter will be seen as an issue of public concern as well.

The San Francisco Homeless Outreach Team was unable to respond to a request for comment.




Food Banks Are Struggling to Meet Demand During the Coronavirus

The Community Action of Napa Valley Food Bank (CANV) stands about 15 miles down the road from the world-class vineyards that made the region famous. It primarily serves workers who keep that industry running: mostly Latinx families, many undocumented, who maintain the vineyards’ landscaping, clean their properties, and perform other kinds of “unskilled” labor that people are now discovering requires, actually, quite a lot of skill.

They are considered “working poor,” a classification that simply means they are not paid enough. Many of these families are regulars at CANV, visiting the market-style food bank once a week. Before the coronavirus crisis began in earnest, the organization served about 30 to 40 of these workers and their families a day, three days a week.

Almost overnight, that number has tripled.

Food banks, like unemployment numbers, act as a weathervane for determining the severity of our current crisis — and the crisis is severe. But they are not built to single-handedly tackle the increased demands these crises create.

As of the first week of April, 17 million Americans have applied for unemployment insurance, shattering a decades-old record and providing a clear look at the unprecedented scale of the current economic and health crisis. According to an early April estimate from the Economic Policy Institute, that number could reach 20 million by summer. Though the President signed a relief bill in late March that bolsters unemployment insurance and will issue direct cash payments to low and middle-income Americans and families with children, it will be months before most people receive that help — and undocumented families will never receive it at all.

The Supplemental Nutrition Assistance Program (SNAP), which could help people immediately, received relatively little additional funding. Food banks will be, as always, left to pick up the slack.

Food banks in Napa, Contra Costa and Solano, and Humboldt counties all report higher demand than they’ve ever seen, topping last year’s record-setting wildfires. Food is harder to track down since hoarding has decimated supply chains and shelter in place orders have constricted the supply of volunteer workers, most of whom, staff say, are over 65 and more vulnerable to complications from the novel coronavirus. As a result, demand is up, supplies are strained, and the labor needed to distribute them is increasingly unavailable.

Already-strained food banks are now left scrambling.

At Humboldt county’s main food bank location, nearby construction crews had to volunteer to help manage crowd control, freeing up the remaining regular volunteers and staff to develop and run a drive-thru model that reduced person-to-person contact. Contra Costa and Solano counties in the Bay Area are moving towards a home delivery-only system, but the labor-intensive delivery strategy is only possible with the support of the National Guard, which started providing 1,000 hours of service per week for the food bank at the end of March. Across the state, an increasing number of food banks were looking to do the same, seeking the Guard’s help with deliveries, crowd control, and assembling supplies.

But for many of the people relying on these resources, the sight of uniformed law enforcement is not necessarily a comforting one. Each food bank, regardless of location, noted the profound anxieties that uniformed law enforcement trigger in their Latinx and undocumented communities. In Napa County, Immigration and Customs Enforcement (ICE) raids have terrorized the close-knit town. In one particularly traumatic instance, ICE apprehended a father at his child’s school after morning drop-off. To many, gathering as a community at a law enforcement-run food drive-thru feels like a bigger risk than their current desperate circumstances.

Food banks are not intended to be the first line of defense in the fight against hunger, but a place to turn to when other options like SNAP, WIC, free and reduced school meals, and unemployment insurance aren’t enough. When these programs are properly funded, they work. The last time America was on the brink of economic collapse, in 2009, the most successful policy in Congress’ $800 billion stimulus package was its SNAP expansion. For every $1 in additional funding, $1.74 was generated in economic output.

Because SNAP was mostly sidelined in the COVID-19 response, already-strained food banks are now left scrambling.

Each problem these California food banks face is exacerbated by the coronavirus pandemic, but the problems themselves are not new. Increased demand, dwindling supply, and a lack of capacity to meet their communities’ need has been their daily reality long before this crisis. The overwhelming need they’ve been forced to meet so far definitively shows how catastrophic this crisis already is. The federal government’s plodding and inadequate response to it shows why these communities were so precarious to begin with.



One Way to Fight Coronavirus: End Cash Bail

Recently, I was joking with a homie who also did time that the social distancing directives around the world mean people are getting a snippet of what a prison lockdown is like. I experienced my first lockdown after less than a week inside: Two friends pummeled a third, a former friend. Within seconds of COs breaking up the fight, the rest of us were ordered into our cells until hours later.

During that time some of us did push-ups, others laid on their cots and read, some used the time to write letters or look at their legal work; a few napped, and most of us did a mixture of them all until the jail unilaterally decided that it was safe for us to come back out.

Social isolation is the current fate of most people in this country, and we are all tussling with the dual stressors of our newfound isolation and fear of the virus. But the millions of people in jails throughout the U.S. who can’t afford bail are facing a form of isolation that’s much more severe. If you think it’s hard to share your apartment with your spouse, trying stepping into your bathroom for the next two weeks, along with hundreds of other people, all while a pandemic is preventing your family from being with you during this time of crisis. And that’s just to get your day in court.

Even before the current crisis, states like Alaska, California, and New Jersey had taken the humane position of ending cash bail, so that those awaiting trial no longer have to pay up in order to leave jail while they wait to see if they are proven guilty or innocent. New York followed suit in January, but rolled back key bail reforms last week via a budget package.

Now that the country is battling coronavirus, it’s even more important to end cash bail. Jails are full of public health hazards: A large number of people share a small space, often with limited access to soap, so infectious diseases can spread rapidly. In addition, the prison population is aging quickly — the number of incarcerated people over 55 has ballooned by 400 percent since 1993 — increasing the risk of serious illness. Holding people before trial increases the likelihood that they’re exposed to the novel coronavirus, making them more likely to spread COVID-19 in the prison and after their release.

We’re already seeing this spread take place. As of April 6, more than 600 prisoners and staff members at Rikers Island have tested positive for COVID-19. Four staff members and one incarcerated person have died. Nearly 300 prisoners and staff have tested positive in Cook County, Illinois, and at least two two inmates have died of the virus in Louisiana. And while some cities, like Los Angeles, are responding by releasing, the Federal Bureau of Prisons has opted to place all 167,000 federal prisoners under lockdown. While the world is in search of a vaccine, the commonsense reaction would be to reduce places of contagion.

Humans are not viruses.

Still, some are opposed to bail reform, citing a jump in crime numbers from the first two months after New York ended the practice as evidence of the need to repeal bail legislation. Lawmakers in Alaska attempted to roll back their bail reform legislation after just a couple of months. Law enforcement and the bail bonds industry have mounted claims of an uptick in crime in the brief implementation of the new laws. Their underlying argument is that the world of criminals has been studying new bail laws and conspired to take advantage by committing more crimes while awaiting their day in court. Lies and fear cajole the public into believing that bail reform is criminal justice reform going too far. Even progressive Democrats backpeddled.

Less than six months is not enough to prove ending money bail causes any increase in crime.

New Jersey ended cash bail in 2017 and has seen major crime and pretrial populations fall by double-digit percentages. Offenses like robbery and homicide are down by 30 percent, and there were “6,000 fewer people incarcerated under criminal justice reform on October 3, 2018 compared to the same day in 2012.”

But now those statistics are backed with something: The tiniest shred of experience. The country has gone through self-imposed quarantines, governmental prohibitions on gatherings of groups larger than 10, and containment zones that could make it easier to understand the experience of incarceration even without studying those numbers.

Should innocent until proven guilty people, like you, be isolated in a cage?

Have we forgotten the motivation behind bail reform in America? A 16-year old child, Kalief Browder, committed suicide because of the trauma associated with his indigence. He spent two years in jail because he could not afford bail. Prison beat his soul physically and emotionally. The country was horrified. Jay-Z made a documentary about him. There was a collective awakening that the concept of money bail was an arcane law that penalized poor people who came into contact with the criminal legal system. Elected officials were championing the cause for bail reform. And yet for some reason, we stopped.

The inhumanity of the notion that bail reform will be rescinded, especially in the era of COVID-9, should compel us to question our civil society. We should want fewer people contained in the petri dish of incarceration in order to prevent the spread of the disease, and in order to prevent people who literally cannot escape their surroundings from being infected. There’s simply no reason to be holding people in cells where they could contract the disease simply because they are too poor to get out.

Humans are not viruses. And no segment of humanity should be considered dispensable, convicted or not. Ending money bail is efficient and humane and should be allowed more than a just a few months to prove its overall success.



Everything You Need to Know About Today’s Instacart Strike

On March 25, the U.S. became the leading country in the world for coronavirus cases. As of March 30, there were more than 140,000 confirmed cases and 2,400 deaths, according to a Johns Hopkins University database.

Cities have all but shut down in response to public health advisories. Millions of people are working from home or other non-office locations in order to honor “social distancing,” leading to a surge in home deliveries for app-based workers like Instacart’s Shoppers, who are tasked with shopping and delivering customers’ groceries. Instacart itself reported that Shoppers have seen on average a 15 percent increase in basket sizes.

However, despite the heightened risk that Shoppers are facing by doing the work that is considered too dangerous for the general public, Shoppers say Instacart hasn’t made much of an effort to protect them from potential transmission or incentivized them to cease working despite the risks it poses.

Instacart initially said it would give two weeks’ paid leave through April 8 to any Shopper who tested positive for the coronavirus, despite the fact that tests are rarely accessible . However, one Shopper TalkPoverty spoke to said that they didn’t know a single person who had received paid sick leave.

In response, Instacart Shoppers nationwide walked off the job March 30, their second strike in four months, and are refusing to return until their demands are met. Because gig workers like Instacart Shoppers work alone, they rarely have face-to-face contact with one another, highlighting how extraordinarily prepared they must be to conduct a large-scale labor action such as this.

In a Medium post announcing the strike, Instacart Shoppers working with labor organization Gig Workers Collective wrote that they were demanding an added $5 of hazard pay per order as well as provision of complimentary sanitation supplies such as cleansing wipes and hand sanitizer, paid time off for Shoppers with preexisting conditions that put them at high risk if they contracted coronavirus or whose doctors advised them to self-isolate, and an extension of these benefits beyond April 8.

“Instacart has turned this pandemic into a PR campaign, portraying itself the hero of families that are sheltered-in-place, isolated, or quarantined,” Gig Workers Collective wrote.

“Instacart has refused to act proactively in the interests of its Shoppers, customers, and public health, so we are forced to take matters into our own hands. We will not continue to work under these conditions. We will not risk our safety, our health, or our lives for a company that fails to adequately protect us, fails to adequately pay us, and fails to provide us with accessible benefits should we become sick.”

Instacart Shoppers can make as little as $7 for up to three orders or $5 for up to five deliveries only, due to the company’s opaque algorithm structure for compensation, and aren’t automatically entitled to employment benefits such as sick leave or health care due to their independent contractor status. Some have argued that they are being misclassified and should be termed employees. In a historic first, the CARES Act, which President Trump signed into law March 27, extended unemployment benefits to gig workers. However, because these benefits are taxpayer-subsidized, they relieve gig companies like Instacart of any legal obligation to provide employee benefits.

Matthew Telles, a veteran Shopper in the Chicago suburbs, said that while he makes himself available on the Instacart app to work for as many as 77 hours a week, the amount of time he actually spends working for Instacart has dwindled since fewer and fewer batches can actually cover his expenses.

“I work anywhere from about zero to eight hours a week for Instacart, and that’s [only] when they pay enough to obtain my secured services,” he said, adding that the pandemic has driven down wages even more.

He explained that since authorities began encouraging people to stay home, Instacart has essentially begun bundling three orders into one by combining multiple “orders” into one batch. That allows the company to elide per-order pricing, leading Shoppers to accept batches that may promise a large amount of money that decreases when they reach the actual register to check.

If a customer asks for, say, 20 unique items, Shoppers are guaranteed a base pay plus tip that’s a particular percentage of the entire order. However, because grocers are now limiting the quantity of particular items one can buy, such as toilet paper and wipes, Shoppers are forced to buy less of a particular item, allowing Instacart to pare down the guaranteed wage and tip for every item a Shopper can’t secure for a customer.

On top of that, Telles added, Instacart is capitalizing upon laid off workers’ desperate need to pay the bills by ramping up their operations. On March 23, Instacart CEO Apoorva Mehta announced plans to hire 300,000 new Shoppers in response to anticipated customer demand over the next few months.

“They’re not vetting who’s a Shopper now,” Telles said. “It’s pretty much — if you’re alive, you can be a Shopper.”

Vanessa Bain, a Silicon Valley-based Shopper and founder of Gig Workers Collective, agreed.

“It’s going to be a disaster if [Instacart] is successful in hiring 300,000 people,” she said. “Veteran Shoppers are breaking down. The last time I shopped, I had an anxiety attack. And that’s just speaking about veteran Shoppers who are used to the general stress of the job. I can’t imagine what it’s like for new people just getting their footing. It’s really uncharted territory, shopping during the middle of a pandemic. People aren’t respecting social distancing in grocery stores.”

Bain added that because she lives with multiple elderly people who are at high risk of contracting coronavirus, she hasn’t shopped since March 13.

We’re out here risking our lives.

Sarah Clarke, another Gig Workers Collective organizer, said Instacart was capitalizing upon the divide between its corporate employees, who are guaranteed benefits such as health insurance and remote work, and that of Shoppers, whom many cities and local governments consider “essential workers” but aren’t treating as such.

“Instacart knows there are workers who can afford to stay at home and shelter in place, and then there are workers who absolutely need the money and who will work under any conditions because they have to,” Clarke said. “But you can’t really fault someone who’s working while they’re sick if they absolutely need to [to pay their bills].”

Above all else, however, all three organizers TalkPoverty spoke to said that the strike was being conducted out of concern for Shoppers’ customers, who bear the brunt of the risks they say Instacart is forcing them to shoulder by not guaranteeing basic sick leave and protective equipment.

“If [Shoppers] get the virus, most likely we will pass it on to customers,” Clarke said. “Lots of Shoppers are living in fear because they’re terrified they’ll pass it on to customers.”

“We’re the people customers interface with,” Bain said. “Most people who have ordered [from Instacart] are doing so to comply with the shelter in place, and to mitigate the risk of spreading disease. It’s literally now a matter of public health and safety.”

“It’s reckless,” Telles stated, speaking for himself, not the strike organizers. “We’re out here risking our lives. If I were a state official, I’d bar Instacart from my state.”

Following the strike announcement, Instacart almost immediately updated its policies. In an email to TalkPoverty, the company said it had extended its paid leave through May 6 to anyone who had been ordered by a state, local, or public health official to self-isolate or quarantine, but made no mention of Shoppers’ demands for personal protective equipment (PPE) or added hazard pay. Instacart added on Sunday that it would allow customers to set their own default tip payment, but workers said it’s not enough: The company is still refusing hazard pay and expanded sick pay.

But it’s too little too late, Bain said.

“We all have the potential of becoming vectors. Everyone’s a stakeholder. The stakes are very different from normal working conditions. Nobody should be against the idea of workers having safety measures to keep their customers alive and themselves safe.”

Editor’s note: This post has been updated to clarify Instacart’s compensation structure for batch orders. 



Addiction Treatment Clinics Struggle to Keep Up with COVID-19

I just watched my husband run out the door. Not straight to his job as a cook, since his restaurant is shut down during the pandemic, but to his opioid treatment provider—a facility legally allowed to dispense methadone for the treatment of opioid addiction—so he can get his daily dose before the doors close for the day.

He still has to go every single day to get his medication, without which he would go into weeks of painful opioid withdrawal. My husband is one of hundreds of thousands of people across the country who rely on medications like methadone and buprenorphine to curb addiction to opioids and stay out of withdrawal, and who are now wondering whether they are going to continue to have access during the novel coronavirus pandemic, or risk being exposed to the virus by visiting facilities daily.

The short answer is yes, facilities that prescribe and dispense these medications are continuing to run, and patients should not lose access to medications for opioid use disorder during this crisis. Methadone and buprenorphine are classified by the World Health Organization as essential medicines, which means continued access to them should be a priority. Various government agencies have issued guidelines and legal exceptions to a number of rules and regulations that usually limit access to these medications, in the hope of reducing visits to clinics.

But, of course, there’s a longer and far more complex answer as well.

Although methadone and buprenorphine treat the same disorder in relatively similar ways, they are governed by vastly different sets of rules and regulations. “On the [buprenorphine] side, the minimum you tend to see prescribed is a week. It would be easy in that case to give those patients a two-week prescription or call in an extra script with a refill. On the [methadone] side, that’s where it gets hairy,” said Zac Talbott, president of the National Alliance for Medication Assisted Recovery (NAMA-R), who also has direct experience as a patient and running facilities that provide these medicines.

Buprenorphine can be prescribed by any doctor or advanced practice registered nurse who has taken an eight-hour waiver course. That means patients can access it in a number of settings including primary care, psychiatry, gynecology, or addiction treatment facilities. Methadone, on the other hand, can only be dispensed for addiction treatment from a licensed opioid treatment provider (OTP), commonly referred to as a methadone clinic. It is governed by a complex web of rules, regulations, and policies that come from federal agencies, state authorities, and individual clinic directors. Since methadone is a better option for people with higher tolerances to opioids, and doesn’t require patients to go into withdrawal before starting it, it’s essential that both medicines are available.

“There’s going to be a broad variety in the way OTPs respond,” said Talbott. “Patients need to realize this could vary from state to state because of state authorities.”

The response is as varied as opinions on addiction.

Across the nation, State Opioid Treatment Authorities, who make state-level decisions about medications for opioid use disorder, have been looking to the federal Substance Abuse and Mental Health Services Administration (SAMHSA), for guidance on how they can respond to the novel coronavirus outbreak. This agency governs the rules around making medication available to be taken at home, instead of in a clinic (colloquially called “takehomes”), and many other methadone regulations at the federal level. Elinore F. McCance-Katz, the head of SAMHSA and the assistant secretary for mental health and substance use, told TalkPoverty by email that “SAMHSA/HHS are working in an ongoing manner with states and communities facing these issues. We have provided flexibilities to the states to help to assure that those on medications for opioid use disorders continue to get their medication. We have also been working to expand the ability to provide services by telehealth modalities wherever possible.”

Washington state, where the first confirmed cases of COVID-19 appeared in the United States, was the first state to receive the ability to dispense extended takehomes, lasting up to 14 days, to specified populations without first applying for individual permissions like providers must do normally.

“As of the 9th we have essentially put out seven different types of blanket takehome exception requests that programs can request per federal law to allow a large majority of individuals who are considered stable—and that’s determined at the discretion of each program medical director—to allow them to move beyond just daily or close to daily dosing,” said Jessica Blouse, of the Washington State Opioid Treatment Authority. “For buprenorphine there are no federal rules, so [those patients] can be moved to whatever level can be determined as safe.”

But that doesn’t mean all Washington patients will receive these benefits. Tanna, a patient who lives between the cities of Seattle and Tacoma, said she has not been offered any takehome doses. The reason, she was told, is because she has been with that provider just over three months, so she is still considered a new and therefore unstable patient—even though she transferred from another clinic where she had earned a month of takehomes.

She is also required to attend four hours of group therapy each month. Last week, her group had eight attendees and she did not notice any special precautions in place due to the virus.

“The only accommodation they’ve made [in the clinic] is at the dosing window there’s now hand sanitizer, the trash is moved a little bit, nurses wear gloves, and the [dosing] window screen is lowered,” she said.

On March 16, SAMHSA updated its guidelines specifying that all states with declared states of emergency could request blanket exceptions in order to provide stable patients with 28 days of takehome medication, and 14 days of takehome medication for patients considered less stable but still able to safely handle the extra medication. In states without a declared emergency status, each clinic is eligible to apply for similar exceptions for their patients.

The updated guidelines from SAMHSA allow states and providers greater flexibility to dispense takehome medication—but that does not mean that every clinic will utilize that flexibility to its fullest extent, nor that they will apply it to each patient.

“It may come down to the fact that patients will need to be given 14 day supplies,” said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence. “However it should be case by case …We want to let people quarantine to clearly stop the spread of the disease, [but] remember we are dealing with opioids. Opioids in the hands of unstable patients can be dangerous. We don’t want to flood the community with a lot of methadone in the hands of unstable patients who may not be able to deal with the fact that suddenly they have a two-week supply.”

“People who are least likely to get takehomes are people who are new to treatment and people who have unstable housing, unstable psychosocial situations, people who might be continuing to use other substances, people with underlying health concerns; things that mean they have instability in their life. I would argue they are the people who should get takehomes immediately,” said Keith Brown, a harm reduction advocate currently working at the county level in Schenectady, New York on the COVID-19 response. “This is going to get into the argument about which is more dangerous, giving people takehomes they might sell or whatever—but in a public health crisis, people are going to have to make determinations about what makes sense. Having a few hundred people come into a clinic every day is a transmission nightmare.”

It’s impossible to know what every single state and clinic will do with their expanded discretion. Reports coming in from patients and providers indicate the response is as varied as opinions on addiction.

Justine Waldman, the medical director of REACH, a harm reduction-based buprenorphine clinic in Ithaca, New York, has begun offering one and two month scripts to her buprenorphine patients, giving longer scripts to those who have a harder time getting in to the office or who have a history of missing appointments. Her emphasis is on access and patient health over surveillance. The caveat, she stressed, is that this is an entirely new situation that is evolving each day.

“We might decide tomorrow that the way we’re doing it now isn’t working. We are really having to come together and take it day by day,” she said.

Jana Burson, who is the medical director of an OTP in North Carolina, said that while her clinic is not giving most patients extended takehomes, they are utilizing measures to help keep the facility sanitized, and to enforce social distancing while patients are in the building. For example, the lobby chairs have been spaced to be at least six feet apart, and some counselors with smaller offices are moving individual counseling sessions to larger rooms. They are aggressively disinfecting chairs, door handles, countertops, and other shared surfaces.

In a public health crisis, people are going to have to make determinations about what makes sense.

Vanessa, a patient in North Carolina, reported that her clinic was not dispensing any extra takehomes. She normally receives takehomes for Saturday, Sunday, and Monday, but was called in this Monday for a drug test and bottle check, a practice observed by some clinics in which they count patients’ takehome bottles. She described her clinic as “really business as usual” besides seeing staff taking patient temperatures. She noted that her temperature was not taken when she stopped by for the drug test. On Thursday morning she texted me an update that she was going to be given seven takehomes, but would have to pay for them out of pocket.

Stephanie, a patient in Pennsylvania, says she has continued to receive her regular six takehomes, but that group meetings and individual counseling sessions have been canceled until further notice. When she pressed for more information, her counselor replied that for the clinic to shut down “it would have to be the end of the world and there would be zombies,” but conceded that they were giving some extra takehomes to medically fragile patients.

Emily, who has hepatitis C, has not been offered any takehome doses by her Lexington, Ky., clinic, but reported that all patients are being stopped upon entering the building and questioned about potential symptoms. People who report feeling unwell are dosed from their cars, and only five patients are being allowed to enter the building at a time. Groups have been canceled, and individual counseling sessions are being done over the phone.

Samantha, a pregnant patient in Central Florida, reported that she was given 13 takehomes and had a doctor’s appointment canceled so she would not have to go in on an extra day.

In South Florida, my husband Ricardo still goes in for dosing every day, but told me his clinic was advising patients to be prepared to pay two weeks in advance should the need for two weeks of takehomes arise. For my husband, that means shelling out $224. For patients at other clinics, the price can vary in either direction, but not typically by much.

My husband’s experience highlights another concern facing patients on these medications. For some, extended scripts mean more money up front. Some methadone patients who pay out of pocket are only able to do so daily, relying on cash tips or weekly paychecks to pay for their medicine. Buprenorphine patients who are used to paying for one or two weeks at a time might not have additional funds for a month-long script. Patients whose medications are covered by grants or insurance sometimes have caps on the amount of doses that can be covered at one time, leaving them to pay out of pocket for extra doses. If they can’t pay, clinics are not required to dose them.

Because buprenorphine prescribing is not burdened with as many stringent regulations as methadone, it is easier for providers to adhere to social distancing recommendations while still keeping patients appropriately medicated. Many providers have reverted to telehealth. On March 17, the Secretary of Health and Human Services lifted restrictions on telemedicine practices that prevented Medicare patients from engaging by using cell phones in homes or shelters. On the same day, the Drug Enforcement Administration also waived requirements that patients starting on buprenorphine have an initial in-person visit, temporarily allowing new buprenorphine patients to engage via telemedicine from the start.

But even with these changes, economically disenfranchised patients may struggle to utilize telehealth options. “Not all of my patients have the right smartphones to do telehealth, or the minutes. When I asked them about doing telehealth, they said no way,” said Waldman.

Like Talbott stressed, the response to this crisis is going to vary between states and clinics, with wide discretion placed in the hands of prescribers and medical directors. It is a situation that is changing by the day, as states and counties continue to evaluate the impact of COVID-19 in their communities and how they wish to respond.

“I think my biggest duty right now is to reassure patients that they will not be abandoned,” said Burson.

Correction: An earlier version of this articles stated that all registered nurses were able to prescribe buprenorphine. Only advance practice registered nurses can prescribe that medication.