—By Karen Blum

The opioid crisis has become an epidemic within the COVID-19 pandemic, a panel of public health experts said during a recent webinar.

Some people with opioid use disorder have turned to alcohol or benzodiazepines as a temporary substitute for lack of access to opioids, and suicides due to depression and/or unemployment are occurring, they said in a discussion of how the COVID-19 pandemic is impeding efforts to prevent and treat opioid use disorder. On the plus side, a more widespread adoption of telehealth services has increased access to opioid and substance use disorder therapy and treatment, they noted in the discussion, which was organized by the Association of Schools and Programs of Public Health.

“This is a perilous time for people with opioid use disorder,” said Brandon Marshall, PhD, an associate professor of epidemiology at Brown University School of Public Health, in Providence, R.I. “Counterintuitively, disruptions in the drug supply and lack of income to purchase illicit opioids might have led to a drop in drug use during the COVID pandemic. However, this could lead to a surge in overdoses in the next few months. That’s because tolerance decreases after a period of nonuse, which then increases the risk for overdose once people resume taking opioids at their previous doses.”

“People in recovery, even long-term recovery for several years, are relapsing,” added Anne Hazlett, JD, the special advisor for rural affairs in the White House Office of National Drug Control Policy (ONDCP). “We’re also hearing anecdotally of increases of alcohol consumption.”

Law enforcement partners reported increased calls regarding domestic violence, and because schools are closed, calls from nurses and other authorities regarding potential child abuse and neglect are down, Ms. Hazlett said.

The respiratory nature of the SARS-CoV-2 virus and the interactions that people with substance and opioid use disorders have place this population at risk, said Regina LaBelle, JD, the director of the Addiction and Public Policy Initiative at Georgetown University Law Center, in Washington, D.C. The nation needs to focus on both issues simultaneously, she said.

Policy Changes Could Help

On a positive note, agencies such as the Drug Enforcement Administration (DEA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) have made numerous policy changes recently to increase access to care, Ms. Hazlett said. “Much of the focus of the administration during this time has been to ensure, from the start of this public health emergency, that there is flexibility in policy as well as resources—whether information or dollars—to make sure access to treatment and recovery support are available.” She cited the following examples:

• The DEA is allowing registered providers to prescribe medication-assisted treatment to patients across state lines through telemedicine. 
• The DEA and SAMHSA are permitting practitioners to prescribe buprenorphine to new and existing patients with OUD through telehealth or telephone. 
• The Centers for Medicare & Medicaid Services has permitted opioid treatment programs to provide therapy and counseling using telephone calls besides two-way interactive audiovisual technology. 
• SAMHSA also has allowed programs to provide stable patients with 28 days of take-home methadone doses to reduce in-person interactions. The ONDCP has produced a fact sheet about these updates.

A Rush to Treatment/Recovery Facilities

Some treatment and recovery centers are reporting that phone calls and admissions for those able to accept new patients are up, and providers are seeing a surge of appointments being kept because telemedicine has taken away the barriers of travel time and transportation, Ms. Hazlett said.

However, the pandemic brought some challenges, she noted. Many people in recovery lost their jobs and therefore cannot pay rent for transitional housing offered through some programs. Those who have social enterprise work programs may have been suspended due to the pandemic. Additionally, some recovery facilities closed because of a positive COVID-19 test result from staff members or residents, leaving some patients with no place to go—a dangerous scenario for people who need to maintain separation from family or previous associates.

The pandemic provides a natural experiment through which organizations and treatment facilities can determine how best to reach people interested in receiving treatment for their addictions who may not be able to access it in a traditional way, Ms. LaBelle said. Telehealth has been important in both rural and urban locations during this time, she said, and looking at the patient experience and outcomes could help inform changes in policy.

“We also need to view treatment facilities as health care facilities with providers on the front line,” she said, “and states need to do their own part ensuring access to treatment.”

It is challenging to track precise causes of death in this crisis, Dr. Marshall said. Because COVID-19 is a respiratory illness, if someone is using opioids and has the virus, it may be difficult to distinguish the cause of death. In addition, surveillance systems that track opioid overdoses may be hindered by the pandemic, as coroners may not have the resources to follow up on opioid-related deaths, and those in hospitals may be too busy to report overdoses to the same extent. There also is some evidence that people who have overdosed are staying away from hospitals, due to fear of contracting the coronavirus.

Ms. Hazlett remained undaunted. “We simply will need to be innovative and build new partnerships to do our jobs and save lives,” she said. 

A Pain Pharmacist’s Perspective

Addiction is a disease of isolation, and although recovery programs temporarily have turned to online or phone appointments to continue services, it’s easier for participants to disengage through these methods than through live, in-person sessions, commented Ernest Dole, PharmD, a clinical pharmacist at the Pain Consultation and Treatment Center of the University of New Mexico Hospitals, in Albuquerque.

People who are committed to getting help still should do well in this scenario, he noted, but for those less interested, it could be easier to slide. For those individuals, smaller in-person meetings that adhere to social distancing are more helpful.

“This whole new reality is stressful even under the best of circumstances,” Dr. Dole said.