When Covid-19 emerged earlier this year, the health care industry shifted operations and resources to treat patients to the best of their ability. One side effect of the epidemic, however, has largely flown under the radar: the potential to exacerbate the nation's opioid crisis. In 2018, 47,600 people died from opioid-related drug overdoses in the United States. That number isn't as high as the over 100,000 Covid-19-related deaths we've seen in the United States, but it's certainly not trivial and warrants continued attention.
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The federal government has made several changes to mitigate Covid-19's impact on health systems' opioid-related strategies, but health systems need to develop a comprehensive strategy that meets the evolving needs of this patient population amid Covid-19.
Below I outline three main opioid-related implications that health system leaders should keep in mind.
Implication #1: Stay-at-home orders create barriers to OUD treatment access
Only about 26% of the 2 million Americans with an OUD received specialty addiction treatment in 2018. The Covid-19 epidemic has created even more barriers to OUD treatment. Once social distancing orders went into place this year, patients stayed home and many medication-assisted treatment (MAT) clinics reduced service or closed. The Drug Enforcement Administration (DEA) and Substance Abuse and Mental Health Services Administration (SAMHSA) have changed several regulations to increase MAT access amid the Covid-19 crisis.
Doctors are now able to prescribe MAT via virtual visits and evaluate patients over the phone. For methadone, that only applies to existing patients rather than new ones who would still need an in-person physical assessment. For buprenorphine, doctors can prescribe via telehealth for existing patients, patients across state lines, and without first evaluating patients in person.
In addition, SAMHSA is allowing patients to take larger quantities of methadone home to reduce the amount of in-person time in the clinic. Previously, patients were only able to take home small doses of treatment (e.g., a single dose per week) depending on how long they were enrolled in the opioid treatment program. Now, stable patients in an opioid treatment program can take home 28 days' worth of their OUD treatment. Less stable patients who are deemed able to safely handle their treatment can take home 14 days' worth of medication.
Despite this new flexibility, hospitals and health systems still need to consider the barriers to implementation and provider concerns. Telehealth increases access for some OUD patients, but others may lack the necessary technology or stable housing to get their treatment outside of the clinic. In the case of buprenorphine, providers still need a waiver to prescribe the drug—a process that has been a historical barrier to MAT access, since only 5.7% of medical professionals are waivered. Lastly, some providers are concerned about the potential for misuse, overdose, and diversion with larger quantities of OUD medications leaving the clinic.
Implication #2: Social isolation may produce new behavioral health diagnoses—including OUD
Public health experts anticipate an increase in behavioral health diagnoses, such as depression, anxiety, and substance use disorders, as a result of social distancing and stay-at-home orders. We don't yet have the data to understand Covid-19's full impact on new OUD diagnoses, but as patients stay home and avoid regular health care interactions, we may be left with not only more patients with OUD diagnoses, but more severe cases of OUD.
Implication #3: Supply chain disruptions cause opioid-related shortages
Clinicians use opioids to sedate patients before placing them on ventilators. As a result, certain opioids have been in shortage during the epidemic as more severe patients require mechanical ventilation. In response, the DEA has increased the 2020 aggregate production quotas (APQ) by 15% for some schedule II substances including fentanyl, morphine, hydromorphone, codeine, ephedrine, and pseudoephedrine. The DEA will also increase the APQ for methadone to ensure that OUD clinics have enough supplies to treat their patients.
These quota increases are necessary to accommodate the demand from Covid-19 surges and ventilated patients. However, again, some providers are concerned the volume increases will lead to misuse, drug diversion, and the possibility that these drugs may end up on the black market.
How should providers prepare?
Given these changes and concerns, health systems need to put a plan in place to monitor and respond as the Covid-19 epidemic evolves. Strategies include:
- Supporting providers in their efforts to treat OUD patients via telehealth;
- Allocating resources to manage a potential increase in OUD cases and more severe OUD cases;
- Understanding your supply chain and pharmacy leaders' plan to address opioid-related shortages to ensure proper treatment of severe Covid-19 patients;
- Monitoring potential drug diversion as a result of increased opioid quotas (from both staff and patients); and
- Thinking about ways to support community organizations that are providing OUD treatment and support resources
Right now, there are more open questions than answers about this epidemic's impact on the opioid epidemic. Will social isolation increase the prevalence of opioid use disorder? Will the interim telehealth regulations become permanent and increase access to OUD treatment? It is likely still too early to quantify the exact impact, but the health care industry needs to take steps now to continue to treat and support patients with OUD.