The opioid epidemic’s shocking mortality rate was a constant topic on our front pages and news screens for years before it abruptly disappeared from those media venues in January as the COVID-19 pandemic emerged. But despite its slide off the news cycle, the opioid crisis has neither gone away nor gotten better. In fact, its interaction with the infectious threat, lockdowns, social distancing, and economic paralysis spawned by the COVID-19 crisis has raised major new challenges across the opioid addiction treatment field and the patients it serves.

Convened at the Leonard Davis Institute of Health Economics’ fifth virtual “Experts at Home” seminar on May 8th, five top substance use treatment experts discussed the COVID-driven changes disrupting programs that had, in the previous two years, achieved significant reductions in the national opioid overdose death rate.

We see between 250 and 300 patients a day; trying to promote social distancing within that setting was a big concern for us.

Yngvild Olsen, MD, MPH

Higher risk

“Even from early COVID data we know there’s a three-times higher mortality for vulnerable patients with underlying pulmonary issues,” explained Jeanmarie Perrone, MD, moderator of the Battling the Opioid Crisis During COVID-19 seminar. “We don’t have specific data for substance use disorder patients, but we know that due to their lack of housing, mental issues, isolation and other struggles, they are at higher risk for COVID morbidity and mortality.” Perrone is a Penn Professor of Emergency Medicine, LDI Senior Fellow and Director of the Penn Center for Addiction Medicine and Policy.

Panelist Yngvild Olsen, MD, MPH, Medical Director of the Institutes for Behavioral Resources Inc., and its Recovery Enhanced by Access to Comprehensive Healthcare (REACH) program in Baltimore, pointed out some fundamental barriers to care posed by the COVID pandemic. “We see between 250 and 300 patients a day; trying to promote social distancing within that setting was a big concern for us and other providers,” she said. “There’s a lot of stress. Our patients, providers and staff at our front desk were extremely anxious about their own COVID risks.” She cited inadequate supplies of personal protective equipment (PPE) as a significant issue.

Bonded couriers

Olsen’s organization is currently exploring potential relationships with bonded courier services capable of delivering anti-addiction medications to patients at home.

We are in a moment of opportunity to push a lot of innovation in the context of how we connect with individuals who are using drugs and seeking treatment.

Colleen Barry, PhD, MPP

Olsen also emphasized how the negative impact of the stressors of isolation, sudden unemployment, and a loss of connectedness crucial to treatment, was causing some previously stable patients to relapse back into drug use. “We haven’t been able to continue counseling services, we’ve had to put a hold on our intensive outpatient program and our group counseling,” she said. “We’ve been incorporating a tremendous amount of phone calls but patients are asking for more contact.”

Penn Medicine emergency physician, LDI Senior Fellow and Director of the Center for Emergency Care Policy Research Zachary Meisel, MD, MPH, said that among the non-COVID patients avoiding visits to the ER out of fear of infection, are substance users. He estimated that ER consults by substance use recovery specialists are down 22%. He noted that an innovative special “EMS ambulance” unit known as AR-2, created by the City of Philadelphia to patrol the high overdose neighborhood of Kensington, has been suspended because of COVID.

Meisel said another thing that needs to be closely watched is how treatment organizations’ various responses to COVID challenges may be widening or ameliorating disparities in care and outcomes for substance use patients.

Opportunities

Panelist Colleen Barry, PhD, MPP, Chair and Professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, detailed a unintended benefit of the COVID situation. The two agencies overseeing restrictions governing the use of medications like methadone and buprenorphine — the U.S. Drug Enforcement Administration (DEA) and the Department of Health & Human Services Substance Abuse and Mental Health Service Administration (SAMHSA) — have temporarily relaxed some regulations to allow providers’ use of telemedicine and telephonic services and longer-term drug formulations and practices.

We don’t have the current regulations because there was some kind of evidence-based process that came up with them. They are the legacy of a lot of stigma and terrible law making that goes back a century.

Joshua Sharfstein, MD

“There are real opportunities for telemedicine,” said Barry. “We are in a moment of opportunity to push a lot of innovation in both the  context of how we connect with individuals who are using drugs and seeking treatment and/or harm reduction services, with effective treatment in non-traditional ways. Not just drug treatment itself, but all of the other social support and mental health services that are so important.”

“The important question,” said panelist Joshua Sharfstein, MD, Vice Dean for Public Health Practice and Community Engagement at the Johns Hopkins Bloomberg School of Public Health,” is will these restriction relaxations be continued after COVID? We don’t have the current regulations because there was some kind of evidence-based process that came up with them. They are the legacy of a lot of stigma and terrible lawmaking that goes back a century. We have to think of this as an opportunity to rethink that and actually develop a real evidence-base for what we can do. It would be a mistake to go back to the way things were without further thinking.”

But while all panelists agreed that the permission to use telemedicine and telephonic visits was a positive thing, none of them saw it as an immediate silver bullet.

In-person to start methadone

“Despite the move to telemedicine, there are parts of the process where it still can’t be used,” said Olsen. “One of them is in opioid treatment programs for the initial evaluation of new patients coming in to start methadone. Many programs across the country don’t have the adequate personal protective equipment to really do that safely any more. That is one lagging piece, despite the other amazing things SAMHSA and DEA have done.”

Moderator Perrone pointed out that while telemedicine could be an effective asset, it involved more barriers than may immediately be obvious. “New patients coming to an office may not have a phone or computer,” she said. “They may also not have a health system account to even get started. You really need many other pieces of the puzzle in place in order to make it all come together. Just because it’s allowed, doesn’t mean it can be happening.”

Although enthusiastic about integrating telemedicine more broadly into substance use treatment, Barry was also thinking of the larger picture and infrastructure issues such as reimbursement mechanisms.

Payment system

“Historically, we’ve treated substance use disorder financing as a wholly separate system,” Barry said. “It’s lacked true integration to the detriment in the quality of treatment overall. The root of much of this separation was grounded in stigma. Being in a crisis like this COVID pandemic demonstrates the urgency of advancing a much more integrated financial system across the country for substance use treatment.”

Meisel cautioned against too many short-term expectations of sweeping changes in the immediate wake of the COVID crisis’s denouement.

“One worry is that so many providers and health care systems right now are falling into deep  financial holes as they’ve scaled back on non-COVID revenue-generating procedures. They are going to be less willing to overcome some of the stigma and integrate behavioral health or substance use if they are focused on just trying to recover. Maybe the solutions we’re discussing may have to wait a bit longer because, in the short term, providers are likely to be distracted by the need to reestablish a solid financial footing.”