Massachusetts Opioid Screening and Awareness Day |  September 22, 2020
Fighting Opioid Misuse in collaboration with the Brigham B-CORE program

COVID-19

The Covid-19 pandemic poses challenges for individuals with opioid use disorders and their families, as well as for their treatment providers. This section discusses some of these issues and ways to reduce their impact. Resources and references specific to the Covid-19 pandemic are included.

INCREASE IN OPIOID OVERDOSE DEATHS
Opioid overdose deaths have increased since the Covid-19 pandemic began. The Overdose Detection Mapping Application (ODMAP), which collects county-wide data on overdoses from emergency agencies, found a 42% increase in the number of overdoses between May 2019 and May 2020 in participating counties. Nationally, about 70% of drug overdose deaths are associated with opioids. The American Medical Association recently issued a warning that opioid deaths have increased in at least 35 states, particularly from fentanyl and fentanyl analogs.

POTENTIAL EXPLANATIONS FOR THE SURGE IN OPIOID OVERDOSE DEATHS
People battling opioid addiction have lost some of their supports during the pandemic. Many treatment centers and recovery programs have been forced to close or significantly reduce their hours and services. Economic and other stressors related to the Covid-19 pandemic may precipitate despair and suicidal crises.

Individuals who are dependent on opioids may misinterpret Covid-19 symptoms as opioid withdrawal and try to manage this by using more opioids. While social distancing measures are in place to reduce spreading infection, social distancing measures also make it less likely that someone else will be present to call 911 or administer naloxone in the event of an opioid overdose. In addition, Covid-19 is increasing emergency medical services response times in some areas.

People with opioid use disorder may also be relying on new suppliers and substances they are less familiar with during this time, increasing the risk of overdose. Some dealers are mixing and/or replacing heroin and cocaine with more powerful synthetic drugs, such as fentanyl and carfentanyl.

ADDITIONAL CHALLENGES FOR PEOPLE WITH OPIOID USE DISORDER

  • Disruptions to normal routines and increased social isolation may increase risk of relapse among people in recovery. Social support is important for people in recovery. While social distancing measures are important for reducing infection, they may be especially difficult for persons in recovery because they limit access to sources of social connection, such as peer-support group meetings or the technology to maintain their support network.
  • People with OUD have a high rate of mental health problems, the effects of which can be compounded by social isolation. People who are isolated and stressed can turn to substances to alleviate their distress. In fact, the CDC has recently reported that 13.3% of survey respondents said that they had started or increased their substance use to cope with stress or emotions related to the Covid-19 pandemic.
  • Medical offices, treatment clinics, and syringe service programs have had to close or reduce their hours. People with OUD may be facing challenges obtaining therapeutic services, medications, and supplies.
  • Emergency departments may be focusing resources on patients with Covid-19 and less likely to initiate buprenorphine for patients with OUD.
  • Many people with severe OUD live in group living situations (e.g., recovery housing, shelters, and correctional facilities) where they are unable to maintain physical distance from others, increasing risk of contracting Covid-19.
  • There is an increased risk of Covid-19 complications in this population because of a higher prevalence of preexisting medical conditions and tobacco use. Those with OUD may also be at higher risk of compromised lung function if they fall ill with Covid-19.

TREATMENT
While the healthcare system is struggling with treatment of Covid-19, we already have very effective treatment for opioid use disorder and opioid overdose, specifically medications for opioid use disorder treatment with psychosocial support and naloxone. It is known that methadone and buprenorphine significantly reduce the risk of death, relapse, and HIV, and that naloxone can be very effective against opioid overdose if it is administered in a timely manner. Moreover, providing sterile syringes to individuals who inject drugs dramatically reduces the risk of bloodborne disease transmission and connects those with OUD to treatment programs. The pandemic should not be allowed to become a barrier to effective treatment for opioid use disorders.

FOR PROVIDERS

Challenges for Providers
One challenge for providers is ensuring that patients who use drugs have access to drug treatment as well as access to screening and testing for Covid-19 infection. It may be a challenge to keep behavioral health centers open due to the financial pressures caused by the pandemic related to decrease in income sources and increase in expenses (e.g., cleaning, disinfectants, and PPE). Covid-19 will impact staff availability to work due illness, preexisting high risk conditions, or childcare and other responsibilities.

Health center staff will be at risk of exposure to infection from patients. Patients attending treatment may be living in situations where infection is spread rapidly, may have difficulty complying with social distancing guidelines, and may be less likely to be tested for SARS-CoV2.

Patients may require self-isolation and quarantine periods for extended periods of time, necessitating some form of home delivery of buprenorphine or alternative take-home schedulre for methadone. In certain situations, prescriptions may need to be delivered to people’s homes through mail, treatment providers, or even law enforcement officers. Ensuring ready access to naloxone is an important safety item, particularly during this pandemic.

Opioid Policy Changes during COVID-19
Federal, state, and local governments have temporarily modified existing laws and policies to increase access to OUD treatment.

SAMHSA issued guidance in late March that allow states to permit patients who are on a stable methadone dose to receive up to 28 days of take-home medication, and for patients who are less stable to receive up to 14 days of take-home medication.

Changes in DEA rules now allow the management of patients via telemedicine. This includes the ability to initiate buprenorphine remotely. Unfortunately, even with the relaxation of rules, some patients with OUD will have difficulty accessing telehealth because of lack of access to a phone or the internet. This may be especially problematic for the urban poor without access to smartphones or computers, or for those living in rural areas with limited cell phone and Internet coverage.

Resources for Providers
Providers are finding innovative ways to provide patient-centered care during the Covid-19 pandemic.

Leppla and Gross (2020) provide extensive practical guidance for clinicians caring for patients with opioid use disorder during the pandemic.  These suggestions include novel ways of administering buprenorphine and conducting laboratory monitoring, as well as strategies for managing telehealth visits. For more information, click here to link to their article. 

Dunlop and colleagues (2020) also have some very useful strategies for clinicians treating OUD patients during the pandemic, such as service changes and harm reduction techniques. They point out the importance of coronavirus mitigation strategies specific to this population, such as hygiene related to drug preparation and handling money.

Professional societies have distributed guidelines for practitioners who are moving away from in-person visits to telehealth services (e.g., National Association of Social Workers, 2020). Such guidelines address important issues regarding maintaining patient confidentiality, building therapeutic rapport, fostering working alliance, and billing for services (e.g., American Psychological Association, 2020).

The Massachusetts Substance Use Helpline also has resources on their website to support treatment and recovery providers.  These resources include:

Additional Resources for Providers
Two groups of experts—one an international panel, the other from the United States—recently established guidelines for pain management during the Covid-19 pandemic. To access these guidelines, see: Cohen et al. (2020) and Shanthanna et al. (2020). Cohen et al. (2020) also provide the following list of Covid-19 resources for the medical community:

  • American Medical Association provides guidance on Covid-19 for physicians.
  • American Society of Anesthesiologists provides anesthesiologists information on managing COVID-19 patients.
  • American Society of Regional Anesthesia and Pain Medicine provides updates on COVID-19 for regional anesthesia and pain medicine specialists.
  • Centers for Disease Control and Prevention provides general information for the public about COVID-19.
  • Centers for Disease Control and Prevention provides health care professionals information about caring for COVID-19 patients including resources for infection control and optimizing the use of personal protective equipment.
  • Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report provides scientific public health information and recommendations.
  • Centers for Disease Control and Prevention, Get Your Clinic Ready for Coronavirus Disease 2019 (COVID-19) provides information for health care providers on how to prepare clinics during the COVID-19 pandemic and how to communicate with patients.
  • The Lancet COVID-19 Resource Centre provides health care workers and researchers information on COVID-19.
  • The New England Journal of Medicine provides a collection of resources on COVID-19, including reports, management guidelines, and commentary.
  • Lahey Clinic Instructional Videos provides visual instruction on donning and doffing personal protective gear.
RESOURCES FOR THE PUBLIC

The Massachusetts Substance Use Helpline has a wonderful list of resources on their website to support those who may be using substances or in recovery. Some of these resources include:

COVID-19 REFERENCES

Alexander, G. C., Stoller, K. B., Haffajee, R. L., & Saloner, B. (2020). An epidemic in the midst of a pandemic: Opioid use disorder and Covid-19. Annals of Internal Medicine, 173(1), 57–58. https://doi.org/10.7326/M20-1141

Alter, A., & Yeager, C. (2020). The consequences of Covid-19 on the overdose epidemic: Overdoses are increasing. Overdose Detection Mapping Application Program. http://www.odmap.org/Content/docs/news/2020/ODMAP-Report-May-2020.pdf

Becker, D. (2020, May 21). The pandemic has changed addiction treatment, some hope for good. WBUR. https://www.wbur.org/commonhealth/2020/05/21/coronavirus-addiction-treatment-changes

Becker, W. C., & Fiellin, D. A. (2020). When epidemics collide: Coronavirus disease 2019 (COVID-19) and the opioid crisis. Annals of Internal Medicine, 173(1), 59–60. https://doi.org/10.7326/M20-1210

Brown, C. (2020, May 29). SouthCoast doctors say telemedicine has proven its worth, hope it will continue. SouthCoast Today. https://www.southcoasttoday.com/news/20200528/southcoast-doctors-say-telemedicine-has-proven-its-worth-hope-it-will-continue

Cohen, S. P., Baber, Z. B., Buvanendran, A., McLean, B. C., Chen, Y., Hooten, W. M., Laker, S. R., Wasan, A. D., Kennedy, D. J., Sandbrink, F., King, S. A., Fowler, I. M., Stojanovic, M. P., Hayek, S. M., & Phillips, C. R. (2020). Pain management best practices from multispecialty organizations during the Covid-19 pandemic and public health crises. Pain Medicine, 21(7), 1331–1346. https://doi.org/10.1093/pm/pnaa127

Czeisler, M. E., Lane, R. I., Petrosky, E., Wiley, J. F., Christensen, A., Njai, R., Weaver, M. D., Robbins, R., Facer-Childs, E. R., Barger, L. K., Czeisler, C. A., Howard, M. E., & Rajaratnam, S. M. W. (2020). Mental health, substance use, and suicidal ideation during the COVID-19 pandemic—United States, June 24–30, 2020. Morbidity and Mortality Weekly Report, 69(32), 1049–1057. https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6932-H.pdf?deliveryName=USCDC_921-DM35222

Davis, C. S., & Samuels, E. A. (2020). Opioid policy changes during the Covid-19 pandemic—And beyond. Journal of Addiction Medicine, Publish Ahead of Print. https://doi.org/10.1097/ADM.0000000000000679

Dubey, M. J., Ghosh, R., Chatterjee, S., Biswas, P., Chatterjee, S., & Dubey, S. (2020). COVID-19 and addiction. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14(5), 817–823. https://doi.org/10.1016/j.dsx.2020.06.008

Dunlop, A., Lokuge, B., Masters, D., Sequeira, M., Saul, P., Dunlop, G., Ryan, J., Hall, M., Ezard, N., Haber, P., Lintzeris, N., & Maher, L. (2020). Challenges in maintaining treatment services for people who use drugs during the COVID-19 pandemic. Harm Reduction Journal, 17(1), 26. https://doi.org/10.1186/s12954-020-00370-7

Farber, S. (2020, July 2). The pain management revolution amid coronavirus and the opioid crisis. ABC News. https://abcnews.go.com/Health/pain-management-revolution/story?id=71554778

Haynes, J. (2020, July 7). COVID-19 pandemic brings changes for addiction treatment. Havelock News. https://www.havenews.com/news/20200707/covid-19-pandemic-brings-changes-for-addiction-treatment

Henry, B. F., Mandavia, A. D., Paschen-Wolff, M. M., Hunt, T., Humensky, J. L., Wu, E., Pincus, H. A., Nunes, E. V., Levin, F. R., & El-Bassel, N. (2020). COVID-19, mental health, and opioid use disorder: Old and new public health crises intertwine. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S111–S112. https://doi.org/10.1037/tra0000660

Issue brief: Reports of increases in opioid-related overdose and other concerns during COVID pandemic. (2020). American Medical Association, Advocacy Resource Center. https://www.ama-assn.org/system/files/2020-07/issue-brief-increases-in-opioid-related-overdose.pdf

Khatri, U. G., & Perrone, J. (2020). Opioid use disorder and Covid-19: Crashing of the crises. Journal of Addiction Medicine, Publish Ahead of Print. https://doi.org/10.1097/ADM.0000000000000684

Leppla, I. E., & Gross, M. S. (2020). Optimizing medication treatment of opioid use disorder during Covid-19 (SARS-CoV-2). Journal of Addiction Medicine, Publish Ahead of Print. https://doi.org/10.1097/ADM.0000000000000678

Opioid overdose. (n.d.). Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. https://www.cdc.gov/drugoverdose/index.html

Robeznieks, A. (2020). COVID-19 may be worsening opioid crisis, but states can take action. American Medical Association. https://www.ama-assn.org/delivering-care/opioids/covid-19-may-be-worsening-opioid-crisis-states-can-take-action

Samuels, E. A., Clark, S. A., Wunsch, C., Keeler, L. A. J., Reddy, N., Vanjani, R., & Wightman, R. S. (2020). Innovation during Covid-19: Improving addiction treatment access. Journal of Addiction Medicine, Publish Ahead of Print. https://doi.org/10.1097/ADM.0000000000000685

Shanthanna, H., Strand, N. H., Provenzano, D. A., Lobo, C. A., Eldabe, S., Bhatia, A., Wegener, J., Curtis, K., Cohen, S. P., & Narouze, S. (2020). Caring for patients with pain during the Covid‐19 pandemic: Consensus recommendations from an international expert panel. Anaesthesia, 75(7), 935–944. https://doi.org/10.1111/anae.15076

Vigo, D., Patten, S., Pajer, K., Krausz, M., Taylor, S., Rush, B., Raviola, G., Saxena, S., Thornicroft, G., & Yatham, L. N. (2020). Mental health of communities during the COVID-19 pandemic. The Canadian Journal of Psychiatry, 070674372092667. https://doi.org/10.1177/0706743720926676

Volkow, N. D. (2020). Collision of the Covid-19 and addiction epidemics. Annals of Internal Medicine, 173(1), 61–62. https://doi.org/10.7326/M20-1212

Wan, W., & Long, H. (2020, July 9). Wave of patients strains health field: A tandem toll as U.S. overdoses soar. The Washington Post.

Wang, Q. Q., Kaelber, D. C., Xu, R., & Volkow, N. D. (2020). COVID-19 risk and outcomes in patients with substance use disorders: Analyses from electronic health records in the United States. Molecular Psychiatry. https://doi.org/10.1038/s41380-020-00880-7