Treating Substance Use Disorders in the Era of COVID-19

Our guest columnist is Dr. Lipi Roy, MD, MPH, a physician and former Chief of Addiction Medicine at Rikers Island. Dr. Roy is a recognized expert on a number of health topics, including addiction medicine, mindfulness, and stress reduction.

The novel coronavirus, COVID-19, has been wreaking havoc on a global scale. Since the first case appeared in the U.S. in January, over 750,000 people have been infected with this contagious pathogen and over 41,000 have died, with over 10,000 in New York City alone. Every aspect of society has been impacted by what is projected to be the largest mass casualty event in American history.

Prior to the novel coronavirus outbreak, we were dealing with another epidemic: drug overdose, fueled mostly by opioids. As an internal medicine and addiction medicine physician, I am acutely aware of the unique challenges faced by men and women who experience substance use disorders (SUD). Sadly, of the 23 million Americans diagnosed with an SUD, only 10% access treatment. Barriers clearly existed before the pandemic, and they will sadly worsen if we don’t take action. On March 16th, 2020, I wrote a story about the need for addiction treatment centers to prepare for the COVID-19 outbreak. Since that time, some promising measures have appeared on the horizon.

Unique Challenges

Many individuals with SUD – depending on the severity of their disease and their access to financial and social supports – cycle in and out of homeless shelters, emergency departments, rehab centers and correctional facilities such as jails and prisons. In addition, SUD is often associated with other acute and chronic comorbidities such as heart disease, lung disease, cancer, and mental illness.

“Individuals with SUD are more likely to experience homelessness or incarceration than those in the general population,” wrote Nora Volkow, MD, director of the National Institute of Drug Abuse (NIDA), in Nora’s Blog, “and these circumstances pose unique challenges regarding COVID-19 transmission.”

Addiction treatment also happens in various settings and this adds another layer of difficulty in reducing transmission of COVID-19. While most SUD treatment occurs in outpatient settings, many other treatment sites range from hospitals and inpatient detox/rehab facilities to opioid treatment programs (OTPs, previously known as methadone maintenance programs) and residential facilities. Physical distancing – the most effective means of reducing transmission of this novel coronavirus – is virtually impossible in many of these settings that require group counseling and mutual support groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).

“Many treatment centers unfortunately operate without medical staff or the level of physician involvement that ASAM criteria would require,” according to Kelly Clark, MD, MBA, former president of the American Society of Addiction Medicine (ASAM). “For the health of patients, it is imperative that infection control precautions be followed.”

Actions in Response to the Novel Coronavirus Pandemic

In a recent opinion piece published in the Annals of Internal Medicine, addiction medicine experts William Becker, MD, and David Fiellin, MD, outlined the urgent need for streamlined access to treatment, with special focus on the two most effective medications to treat opioid use disorder (OUD), methadone and buprenorphine.

1. The federal government is easing access to medications for OUD treatment. For methadone, physical exam requirements have been relaxed and medication supply has been extended for stable patients.
2. Methadone delivery needs to be expanded rapidly. This is critical for quarantined patients; mobile teams such as repurposed syringe service programs are a possibility.
3. Telemedicine needs to be maximally utilized. Buprenorphine prescribers need to use this remote technology at all phases of care (evaluation, treatment initiation, monitoring, etc.). The DEA recently eased restrictions by allowing phone-prescribing of buprenorphine without an in-person examination. In addition, the National Consortium of Telehealth Resource Centers has created a COVID-19 Telehealth Toolkit.

As the pandemic continues and new cities and counties emerge as hotspots for COVID-19 outbreaks, we need to be mindful of the many existing and evolving cases of SUD. Of particular concern are the most marginalized and vulnerable among society.

“The economic consequences of COVID-19 will be particularly acute for those who are unstably housed, economically insecure, and who are dependent on social services,” according to Sandro Galea, MD, MPH, Dean of Boston University School of Public Health. He added: “Individuals with SUD often face all three of these challenges, placing them at particularly high risk of experiencing poorer health due to COVID-19-induced society shifts.”

While my heart breaks at the tragic number of lives claimed by this virulent strain of coronavirus, I remain optimistic at the diversity of newly-formed philanthropic programs (e.g. chef Jose Andres’ World Central Kitchen has served over 2 million fresh meals to people in need); large-scale fundraisers (e.g. One World: Together at Home raised over $127 million); and impactful political-nonprofit partnerships (e.g. Massachusetts Republican governor invited Partners in Health to lead a statewide community tracing program).

Let’s continue to practice tried-and-true public health measures – physical distancing, hand hygiene and face coverings – as well as compassion and socially-distanced connection to care for one another. Be safe, everyone.