COVID-19 adds to challenges of treating deadly addictions

In states like Ohio, the arrival of the coronavirus pandemic has meant many healthcare providers are now combating two epidemics at once.

“We were still in the opioid epidemic and now we got hit with the coronavirus epidemic,” said Dr. Tanvir Singh, medical director of recovery services at the University of Toledo Medical Center. “And now we’re trying to balance the two.”

Despite a 4% decline in mortality from 2017 to 2018, the number of drug overdose deaths reached nearly 70,000 in 2018, according to the Centers for Disease Control and Prevention, more than two-thirds of which involved opioids.

Ohio had the fifth-highest drug overdose mortality rate in the country in 2018 with 40 deaths for every 100,000 residents and was the state with the fourth-highest total number of overdose deaths, at more than 3,900.

For Singh and other addiction specialists, efforts to address one epidemic can put patients at increased risk for the other. As cities and states throughout the country ban many public gatherings, concerns over the pandemic have compelled addiction medicine providers to limit access to their facilities and temporarily halt in-person group therapy sessions and replace them with counseling over the phone or through videoconferencing.

Efforts to practice social distancing are raising concerns that it could help worsen the opioid epidemic. Isolation creates the type of environment that can put those with substance use disorder issues at higher risk to use more and those in recovery at higher risk for relapse.

“They’re already in isolation because of drugs and alcohol,” said Dr. Chris Johnston, chief medical officer at Pinnacle Treatment Centers. “One of the goals of treatment is to break down the isolation, and now we have an illness that’s going around where a big part of the treatment is to isolate.”

And the outbreak has exacerbated long-standing problems with access to treatment services that under normal circumstances provide support to a relatively small share of those in need.

Of the more than 21 million Americans estimated to have been in need for substance use treatment in 2018, approximately 3.7 million received access to such services over the previous 12 months, according to a 2018 U.S. Substance Abuse and Mental Health Services Administration report.

But the access challenges caused by the pandemic are forcing many treatment professionals to re-examine their normal processes for providing care. Some view the current outbreak as an opportunity to identify new ways of delivering services that they hope will lead to addressing some of the long-standing barriers that have prevented more people from receiving treatment.

“I think we’re learning a lot on how we can make our services have even lower barriers still,” said Dr. Jessica Taylor, assistant professor of medicine at Boston University School of Medicine and an attending physician at Boston Medical Center.

Some patient advocates for years have called for federal regulators to relax the rules around the prescribing of medication-assisted treatment, or MAT, considered a key part of what experts call the “gold standard” of addiction therapy.

Methadone, the oldest and one of the most widely used maintenance medications for treating substance use disorder can only be dispensed at one of nearly 1,500 federally approved opioid treatment programs. Patients are required to visit in person daily to receive their dose for at least a year until they may be considered stable enough to be eligible to take home dosages.

Prescribing restrictions are a little less tight around buprenorphine, which allows any healthcare practitioner to prescribe it after they go through eight hours of training to become certified. Patients are expected to visit a qualified prescriber to start treatment.

But in March, SAMHSA temporarily changed its rules regarding patient eligibility, allowing stable patients to get up to 28 days of take-home doses of MAT and less stable patients to receive up to 14 days in recognition of the need for individuals to stay at home to reduce their risk of exposure to coronavirus.

In addition, federal regulators have temporarily suspended rules requiring patients to visit a provider in person in order to initiate buprenorphine treatment, allowing them instead to use telehealth services.

“That is an advantage where we can actually start patients and continue patients, check in with patients and prescribe the medication without having to have that face-to-face visit,” said Dr. Yngvild Olsen, vicepresident of the board of directors for the American Society of Addiction Medicine.

Dr. Jasleen Chhatwal, chief medical officer for Arizona-based recovery treatment center Sierra Tucson, said other federal rule changes have made it easier to prescribe medication-assisted treatments like suboxone, a combination of buprenorphine and the overdose reversal drug naloxone, to patients in other states if they can’t find a provider in their area.

“It’s been a bit of challenge connecting individuals with suboxone clinics as they’re leaving from here,” Chhatwal said. “I’m hoping with the relaxed regulations over the last couple of weeks that will make it easier for suboxone and methadone clinics to stay open and continue providing MAT services.”

Some say federal regulators have not gone far enough to amend prescribing rules for MAT in light of the pandemic. Patients are still required to have an in-person visit with a clinician before getting their first methadone treatment. Olsen said clinicians have expressed concerns that maintaining those requirements would likely be unsustainable during the pandemic and puts patients and healthcare workers at increased risk, especially those lacking access to personal protective equipment.

“I don’t know that there’s anyone who has a great answer as to how to manage those situations because we don’t have the appropriate PPE,” Olsen said. To lower the risk to older physicians, Johnston said many of Pinnacle’s younger physicians have been visiting facilities when needed while doctors at high risk provide the majority of their services through telehealth.

Dr. Wendy Welch, chief medical officer at North Carolina-based Medicaid managed-care plan Cardinal Innovations Healthcare, said she sees the current emergency as a chance to learn how some of these temporary rule changes on prescribing MAT might be used after the pandemic if they are shown to be effective in providing greater access to care.

“What I hope is that we have some researchers studying this so that once the pandemic is over, we don’t have to go backwards and require things like everybody with addiction has to be seen in person,” Welch said.

Laura Sovine, executive director for Austin (Texas) Recovery, a not-for-profit addiction treatment provider that operates both outpatient and residential programs, said the facility was still accepting inpatients as of late March. Around 52 of the facility’s 62 beds were occupied.

Sovine said much of the program has changed due to COVID-19 fears. In-person visits from volunteers, speakers and outside contractors to hold yoga and art therapy classes have all been converted to virtual meetings. All outpatient programs were also switched to online in early March. Sovine said inpatient group counseling sessions have been reduced in size from 10 to 12 to six in a room at a time in order for individuals to be able to stay six feet apart.

Despite the changes, Sovine said it was likely social-distancing measures would result in an increase in substance use. She was concerned that Texas Gov. Greg Abbott’s recent decision to allow restaurants to deliver alcoholic beverages with food purchases would make it more difficult for those with substance use disorder issues to stay sober.

“We’ve got a lot of isolated people who are very anxious with really easy access to alcohol,” Sovine said.

Correction: Dr. Yngvild Olsen is vice president on the board of directors for the American Society of Addiction Medicine. Her title was originally misstated in this story.