Access to Medication Assisted Therapy is Critical
Over the past few years, health systems around the country have made great strides to support patients struggling with opioid use disorder. The COVID-19 pandemic must not be allowed halt these advances, particularly since “shelter-in-place” and physical distancing measures create significant barriers for many patients.
Vituity Chief Medical Officer Gregg Miller, MD, outlines how emergency departments and hospitals can ensure both access to and continuity of care for medication assisted therapy.
I recently treated a couple made homeless due to the COVID-19 pandemic. They lost an already tenuous income and their marginal housing with a friend. Now living out of their car, they had increased their heroin and Xanax use and were trying to stop. They came to the emergency department (ED) asking for help managing withdrawal symptoms.
With the media focus on COVID-19, it’s easy to forget that the coronavirus is riding the coattails of our generation’s first great epidemic: opioid use disorder (OUD). Even before the coronavirus arrived, 130 Americans were dying from an opioid overdose every day. Tragically, this number has likely increased in recent months.
Peter Grinspoon, MD, a primary care provider who treats people with OUD, points out that these overlapping pandemics are “additively deadly” and that they highlight many lingering weaknesses in our healthcare system. In this post, I’ll share some of the challenges facing patients with OUD and other substance use disorders (SUDs), plus steps emergency departments can take to improve care for this vulnerable population.
Nora Volkow, MD, director of the National Institute on Drug Abuse, has called the pandemic “a very scary time” to be a person with heroin addiction. She notes that substance use tends to increase during disasters as people attempt to cope with stress and anxiety. What’s more, evidence suggests that this effect can linger for years. Three years after Hurricane Katrina ravaged New Orleans, substance use-related hospitalizations were elevated 35% above pre-disaster levels. While overall we’ve seen dramatic declines in ED visits for all diagnoses—strokes, depression, injuries, etc.—Vituity’s internal analysis shows substance use visits have been the least impacted. We continue to see almost the same number of visits related to drug use as before the COVID-19 pandemic.
These statistics raise grave concerns about the 2 million patients living with OUD in our country. Among the first issues we must consider is access to care. The OUD population tends to be underserved by the healthcare system, and the pandemic is likely to make things worse. Many clinics and outpatient treatment programs are temporarily closed or have limited hours. Some states have closed syringe exchange programs and other harm reduction organizations, deeming them “nonessential” services.
Those currently in treatment could also face interruptions. Methadone, a conventional medication for addiction treatment (MAT), is typically dispensed each day in person at outpatient treatment centers. Some of these clinics treat thousands of patients a day. This can be especially alarming to some people with OUD who have underlying health problems (hepatitis, HIV) and socioeconomic challenges (incarceration, housing instability) that put them at higher risk for severe COVID-19.
Physical distancing also creates unique challenges for people with OUD because social isolation is a risk factor for relapse and substance misuse. In addition, using opiates while alone increases the risk of death by overdose, because no one is present to administer a rescue dose of naloxone. (Dr. Grinspoon notes that cases have surfaced of law enforcement refusing to administer overdose reversal medication, citing fears of coronavirus transmission.)
And finally, patients with SUD may lack the social supports to navigate the pandemic safely. Housing insecurity, lack of access to technology, interruptions in public transportation, and ever-present systemic discrimination may make it difficult to physically distance while accessing needed healthcare services.
While this is a difficult time for patients with SUD, the pandemic might improve care for this population over the long term. The pre-pandemic model of treatment emphasized frequent (sometimes daily) in-person visits. This approach demands both time and access to transportation. It’s especially burdensome to patients in rural areas, who may need to travel long distances for care.
Strangely, the coronavirus pandemic has been a catalyst for positive change in OUD treatment. The relaxing of telehealth and prescribing guidelines beyond the current public health emergency could improve access to care and allow more people to benefit from evidence-based treatments like MAT.
Gregg Miller, MD
Chief Medical Officer
EDs represent a potential lifeline for people with OUD. With evidence-based treatments now available, a single visit with an informed emergency medicine provider can start a patient on the road to recovery. What’s more, emergency waivers and relaxed regulations are increasing treatment options for this population.
So how can emergency medicine providers and their hospitals help?
See this Health Affairs article for detailed information on the above strategies. For more information on the benefits of incorporating a MAT program in your ED and resources to help implement one, please check out this article written by Vituity’s MAT program director, Dr. Dylan Carney.
I was able to treat the couple successfully with several doses of buprenorphine in the ED. Our social worker connected them to a local MAT clinic that, despite the pandemic, is open for business and is providing more support via telehealth. Coming to the ED for help was a great first step, and I hope that with their substance use under better control, the couple will be able to get back on their feet. Opioid use is likely worsened by COVID-19, and continued innovation is needed to address both epidemics.