Before the pandemic, the United States was already in the midst of an epidemic related to opioid use disorder (OUD) with approximately 130 people a day dying of overdoses. In response to these overlapping epidemics, some regulatory policies have been eased and treatment programs have rapidly adapted their services. Are there some lessons learned for the long term? Could evidence-based models guide policy going forward?
Vulnerable populations with lots of co-morbidities are at the highest risk of dying from COVID-19. “We don’t have any specific data for substance use disorder patients, but we know that their lack of housing, co-occurring mental illness and isolation struggles increase their risk both for COVID and also for morbidity and mortality related to COVID,” said Jeanmarie Perrone, M.D., director of the Division of Medical Toxicology and Addiction Medicine Initiatives in the Department of Emergency Medicine at the University of Pennsylvania and founding director of the Penn Medicine Center for Addiction Medicine and Policy. She was leading off a May 8 online discussion hosted by the Leonard Davis Institute at the University of Pennsylvania about the impact of COVID-19 on opioid treatment programs.
Perrone asked Yngvild Olsen, M.D., M.P.H., medical director of the Institutes for Behavior Resources Inc./REACH Health Services in Baltimore, what she was seeing as the most pressing challenges COVID-19 has created for patients in her program and for the providers caring for those patients.
Olsen, who leads an outpatient substance use disorder treatment program that provides a broad range of services and includes a health home, said that when this started two months ago, there were significant challenges for patients in terms of their increased stress levels related to their concerns about becoming infected and what it might mean for them in terms of the severity of COVID-related illness.
Patients wanted to know how to get their medications safely without having to come in multiple times per week, she added. “We had to pivot very quickly to take advantage of the federal guidance that came out in mid-March to reduce the number of patients we were seeing on a daily basis. We treat between 600 to 700 patients per year on a static basis. That means we see between 250 and 300 patients per day. Trying to promote physical distancing in that setting was a big concern for us as providers. Our counselors, medical providers and front desk staff were extremely anxious about their own risk of developing COVID as well,” she said.
Some patients who have been fairly stable for long periods of time have now relapsed, Olsen explained, because of the stress of isolation, financial burdens, and lost jobs, and losing connectedness that has kept their recovery intact.
“As a result of COVID, we had to put on hold our intensive outpatient program and our group counseling sessions,” Olsen said. “We are really now doing only crisis individual counseling sessions, which has put a big stressor not only on the patients who are asking for more contact but also our providers who are not used to telehealth-type visits, even though we have been incorporating a tremendous amount of phone calls, trying to do as much audio-visual as we can given the limitations that our providers and patients have with respect to those types of platforms.” As more businesses and schools open up, there is talk of balancing risks, she notes. “We are balancing risks of inadequately treated opioid use disorder, risk of overdose and relapse and risk of COVID exposure. That balance is just going to get tougher and tougher.”
Perrone then asked Colleen Barry, Ph.D., chair of the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health , how we might leverage our current pandemic situation into an opportunity to break down barriers related to stigma.
“One of the things that has been most crushing to me about watching the epidemic in the context of the pandemic is that there have been so many important issues that we have been behind on and needed to push forward in terms of getting people the high-quality healthcare that they need — using drugs and also harm reduction services,” Barry said. “We were just beginning to see signs of progress before the pandemic hit. Now these challenges become even more daunting.”
But Barry said she does see some fascinating opportunities that have come out of the pandemic for fighting stigma. “One of the major challenges we face is regulatory challenges,” Barry said. She participated on an Academy of Medicine panel last year looking at medications for opioid use disorder, and one of the core findings of their consensus report was that many of the regulatory regimes that govern the ability to prescribe medications for OUD don’t have grounding in science. “What we have seen has been a critical and thoughtful movement on the part of the provider community to shift away from some of those regulatory barriers. The opportunity to rethink the way we regulate these life-saving medications going forward is going to be important.”
Joshua Sharfstein, M.D., vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health, agreed with Barry about the possibility for regulatory reform.
The Drug Enforcement Administration and SAMHSA are allowing buprenorphine prescribing over the phone or via telehealth and allowing treatment programs to provide longer-duration doses of methadone without needing daily pickups.
Sharfstein, who also has served as in many public health leadership roles, including as secretary of Maryland’s Department of Health and Mental Hygiene, and principal deputy commissioner of the Food & Drug Administration, noted that a lot of programs have been able to shift their approach and keep a lot of people in treatment. Based on that, these regulatory adjustments have been successful so far.
“We have not been reading lots of headlines about massive outbreaks at opioid treatment programs, which I also consider good, although we don’t know everything that is happening,” he said. “In the initial phase, some of these moves have had the important, desired effect, but I think there are important questions about whether these will be continued. Are we going to be able to base decisions on good information? Like Colleen said, we don’t have these regulations because there was some evidence-based process that came up with them, and said they were necessary for public health. We have them because of a legacy of stigma and terrible laws that go back a century. It is not like we have an evidence base for why we were doing things the way we were doing them. We have to think this is an opportunity to rethink them and develop a real evidence base for what we can do.”
Sharfstein referenced a recent op-ed in the Washington Post by Jason Cherkis about mental health treatment. Cherkis wrote that in the pre-COVID era, if you were potentially suicidal, you had to go to the emergency department and wait for hours. “It was really an unpleasant experience, and now in two seconds you can get someone on your phone to talk to. In his view, maybe that is a much better way to take care of people when they are in crisis rather than forcing them to go to the hospital,” Sharfstein said. “We have a chance to rethink some of these things. I am worried it will snap back to the way things were without thinking. That would be a mistake.”
