Before the COVID-19 pandemic emerged, the opioid epidemic was arguably the nation’s most significant and widespread public health threat. Opioids took the lives of approximately 130 people in the US each day in 2018, and new preliminary numbers show that overdose deaths climbed again in 2019. Unfortunately in many communities hit hardest by the opioid crisis, the pandemic is not only additive but is synergistic, further amplifying the detrimental effects and threatening any progress that has been made.
The pandemic has led to some dramatic changes in the way patients can receive treatment for substance use disorder, indicating that the landscape of substance use disorder treatment may have been ripe for change all along.
A Second Wave: The Behavioral Health Crisis
COVID-19 has impacted the mental health of nearly half of the US adult population and has also caused a massive increase in the number of unemployed individuals, which can also negatively impact mental health. It comes as no surprise that, according to the Kaiser Family Foundation, the recent job loss is associated with increased anxiety, distress, depression, and increases the risk of substance use disorder and suicide.
In addition to financial struggles that may fuel substance use disorder, the isolation of social distancing makes it more difficult to manage addiction treatment. Social support is a critical tool used in recovery and the isolation felt by many people during the pandemic is particularly detrimental for patients utilizing social connection to sustain treatment progress. Formal support groups such as Narcotics Anonymous and Alcoholics Anonymous aren’t able to meet in person or at all, and peer coaches are needing to find new ways to engage with their clients outside of the group setting.
In a recent HealthLeaders webinar, Enrique Enguidanos, MD, FACEP, MBA, CEO and Founder of Community Based Coordination Solutions reported that many resources for those struggling with substance use disorder, such as medication-assisted treatment (MAT) options became less accessible during quarantine as well. These increases in contributing risk factors, coupled with reduced access to treatment services, are setting us up for what some fear may be a national relapse.
When patients are maintained in MAT programs for opioid use disorder (OUD), their risk of overdose death greatly decreases. This further illuminates the critical need for patients to maintain their access to medication treatment throughout these times of necessary social distancing.
Policy Changes to Facilitate Treatment
Patients receiving treatment for OUD through MAT programs often need to go to treatment centers multiple times per week—leading to long lines, potentially excessive touchpoints and, in the setting of COVID-19, increases opportunities for exposure to the virus. Acknowledging this risk, the Substance Abuse and Mental Health Services Administration (SAMHSA) along with the Drug Enforcement Administration (DEA) have relaxed some prescribing guidelines.
Previously, an in-person evaluation was required to initiate treatment with buprenorphine or methadone and daily visits were often required to pick up methadone doses. While an in-person evaluation is still required to initiate methadone treatment, the DEA and SAMHSA are allowing buprenorphine to be prescribed via telehealth or over the phone.
For both medications, the new SAMHSA guidelines allow treatment centers and programs to dispense up to 28 doses for clinically stable patients and up to 14 doses for less clinically stable patients. This is a notable change and one that providers in the OUD treatment space have been advocating for years. As a result, a variety of initiatives across the country are testing out new treatment modalities which may further expand options for patients with substance use disorder in the future.
However, despite the enthusiasm, these new guidelines have not been widely adopted or taken up with ease universally, and the status quo has been maintained in many states across the US. Advocates note that, although reducing this barrier to treatment has huge potential for improving services, both state policy and practices at treatment facilities seem to be held back by inertia and are slow to change even during this critical time point.
The Importance of Care Collaboration
During uncertain times where policy is being adjusted and patients are struggling, clear communication between care teams is more important than ever. Patients struggling with behavioral health concerns and substance use disorder often can’t have their needs met at a single point of care. The emergency department often serves as a point of treatment initiation, but successful treatment is driven by sustained collaboration with community providers, peer recovery specialists, social workers and care coordinators, among others. Sharing information across these settings and providers is vital to providing appropriate and effective care.
To improve awareness around and understanding of its patients with patterns of high utilization and complex needs, Bartlett Regional Hospital in Juneau, Alaska implemented care collaboration technology.
Coordinating between the hospital and community providers and tying into community resources and the state’s Prescription Drug Monitoring Program (PDMP), Bartlett staff guide care in a way that’s most beneficial for patients. By involving resources outside the four walls of the hospital, Bartlett patients enrolled in a buprenorphine MAT program have a nearly 64 percent retention rate, 15 percent higher than the national average.
Laura Cedro, PharmD, MPH
Senior Clinical Solutions Lead