Why has COVID sparked a rise in drug overdoses? I pose that question to Dr. Brandy Henry, a professor in the School of Social Work at Columbia University. The literature that I’ve read points to the fact that social distancing and psychological trauma from disasters lead to a rise in substance abuse disorders.[2] Dr. Henry points out that access to some drugs has gotten harder during the COVID pandemic, which has led people to use whatever they can find. “Pure heroin has gotten less and less available over the years and with COVID has become even harder to get,” she reveals. “We are finding that poly-use (meaning that there is a mixture of drugs being used) is on the rise, and this is decidedly more dangerous.” Social distancing also means that people are more likely to use drugs in isolation without someone there to administer the lifesaving naloxone that can reverse the overdose. If users want to be safer, they need to call a friend or post on social media letting people know what they are doing. It is a good idea, but it’s much easier said than done.

But Dr. Yuhua Bao, a health economist at Weill Cornell Medicine Graduate School of Medical Sciences sees a glimmer of hope. The COVID pandemic has pushed legislators to authorize reforms in addiction management that mental healthcare providers have been requesting for years.[3] Traditionally, people with substance use disorders looking for treatment using methadone, buprenorphine, and naltrexone have had to go to officially certified opioid treatment programs to get the needed therapies. Public health professionals have argued for years that it is a mistake to put up such access barriers. The Journal of American Medicine argued last year that fatal overdoses decrease significantly when neighborhood pharmacies are allowed to distribute methadone as well as naloxone, the drug that can reverse an overdose.[4] Now, because the opioid treatment programs have had to close, the Substance Abuse and Mental Health Services Administration (SAMHSA) has authorized pharmacies to distribute methadone, naloxone, and sterile syringes. A person who is trying to stop using can now get methadone for twenty-eight days instead of the previous two—all from their local pharmacy. The SAMHSA has also removed the requirement for in-person evaluation to get started on buprenorphine. The level of change and adaption to COVID has differed from state to state, with places like New York acting quickly and places like Arizona only responding after hundreds have died. Nonetheless, one of the strangest consequences of the COVID-19 pandemic is that it has brought the United States in-line with how methadone treatment is delivered elsewhere in the world.[5]

Unfortunately, even these steps have created unforeseen problems that have made access to treatment harder.[6] The local opioid treatment programs play a vital role in helping people on the path to recovery and are still necessary for getting started with the right counseling and prescriptions. They are mostly closed to in-person appointments now, which means that it is harder for new patients to get started. Many of the programs are facing bankruptcy. In places where Medicaid and Insurance do not cover the costs of these services, the programs make most of their money by collecting cash payments from patients. Now all of that is gone. How do you bill a patient for their take-home medication and telecounseling if they do not have a bank account?[7] And how likely are they to be able to do telecounseling in the first place?

Social and legal hurdles block the way. The one-for-one syringe exchange rules are still largely in place, which requires frequent visits to pharmacies to get clean needles. The stigma associated with going to the public pharmacy for methadone remains. No mail-order system supplies high-risk areas. It would take an armada of mobile units to take up the slack.

Notes

[1] Nana Wilson, “Drug and Opioid-Involved Overdose Deaths — United States, 2017–2018,” MMWR. Morbidity and Mortality Weekly Report 69 (2020), https://doi.org/10.15585/mmwr.mm6911a4.

[2] Molly McCann Pineo, “Commentary on the Coronavirus Pandemic: Anticipating a Fourth Wave in the Opioid Epidemic.,” Psychological Trauma: Theory, Research, Practice, and Policy (US: Educational Publishing Foundation, 20200604), https://doi.org/10.1037/tra0000622.

[3] Yuhua Bao, Arthur Robin Williams, and Bruce R. Schackman, “COVID-19 Could Change the Way We Respond to the Opioid Crisis—for the Better,” Psychiatric Services, August 12, 2020, appi.ps.202000226, https://doi.org/10.1176/appi.ps.202000226.

[4] Rahi Abouk, Rosalie Liccardo Pacula, and David Powell, “Association Between State Laws Facilitating Pharmacy Distribution of Naloxone and Risk of Fatal Overdose,” JAMA Internal Medicine 179, no. 6 (01 2019): 805–11, https://doi.org/10.1001/jamainternmed.2019.0272.

[5] Julie Bruneau et al., “Management of Opioid Use Disorders: A National Clinical Practice Guideline,” CMAJ : Canadian Medical Association Journal 190, no. 9 (March 5, 2018): E247–57, https://doi.org/10.1503/cmaj.170958.

[6] Yuki Noguchi, “A New Addiction Crisis: Treatment Centers Face Financial Collapse,” NPR.org, June 15, 2020, https://www.npr.org/sections/health-shots/2020/06/15/865006675/a-new-addiction-crisis-treatment-centers-face-financial-collapse.

[7] Centers for Medicare & Medicaid Services, “Medicare Telemedicine Health Care Provider Fact Sheet,” March 17, 2020, https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.