October 19, 2020
An OpEd by ACEP member, Dr. Nathan Schlicher
While the COVID pandemic has witnessed a morbid fascination on the death toll from the disease, the epidemic of substance use has raged on in the background.
Drug overdoses spiked during COVID-19 as loss of normalcy, economic uncertainty and the psychological impact of the crisis prompted some individuals to self-medicate.But while the federal government relaxed policies around medication-assisted treatment (MAT), other barriers to care remain—or even worsened—putting lives at risk.
Overdoses from opioids and other drugs rose 18% during the first four months of the pandemic, with more than 40 states seeing an increase in opioid-related fatalities. But these numbers may not reflect the full impact of substance use related to COVID-19. An analysis of hospitals in the Collective Medical network indicates that overdose visits as a percentage of emergency department (ED) visits have climbed 35% since March.
Yet as cases of substance use disorder (SUD) surge, care for drug use is harder to receive during the pandemic. These include disruptions in treatment facility operations, lack of online resources to reach specialists virtually and limited approaches to data sharing among providers. As a result, those who need specialized support face difficulties accessing appropriate treatment when they need it most.
The COVID-19 Substance Use Crisis
As an inner-city ED physician, many of the patients I see are dealing with SUD in some way. Their illness manifests in a variety of ways, from a cocaine-induced heart attack to methamphetamine-induced stroke or psychosis to a heroin-induced abscess. There have been days when 60% to 70% of my patients are living with SUD, although this illness may not be the reason why they have come to the ED.
That is why legislative officials must go beyond tallying the number of overdoses treated in healthcare facilities to gain a comprehensive view of the impact of SUD, including opioid use disorder (OUD).
It’s true that cases of SUD, including OUD, were rising before COVID-19 struck. However, COVID-19 exacerbated the pressures that make some individuals more susceptible to drug use. These pressures include loss of employment, isolation and the feeling of being in a continual state of crisis. Under these conditions, relapses were common, even among those who stayed drug-free in the first weeks of the pandemic.
Throughout the pandemic, we’ve seen efforts by the federal government to mitigate the challenges those suffering from SUD typically encounter in trying to receive one-to-one care. With restrictions around telehealth loosened during the pandemic, appointments to prescribe certain forms of MAT—the gold standard in evidence-based treatment for OUD—can now take place virtually. That’s critical because of the national shortage of physicians who can prescribe MAT. It’s a move that not only ensures access to MAT when clinics are unable to provide in-person care, but also extends the reach of MAT to rural areas and other communities where such services are unlikely to exist. Physicians also can manage MAT patients via phone or virtually, making care easier to obtain.
Patients on MAT also may be given larger quantities of MAT medications home—up to 28 days’ worth—to maintain access to treatment when hours for treatment facilities are restricted and in-person visits are harder to come by.
But telehealth and phone consultations are not the solution for everyone, especially for patients who lack stable housing, reliable access to technology and family support.
Breaking Down Barriers to SUD Care
The reality is that a large stigma surrounding SUD and OUD continues to exist. You may have caught it in the recent presidential debates, as one candidate attacked the other as a failed parent for having a son who battled cocaine addiction. These are diseases that people are afraid to talk about out of fear that they will be judged by family members, friends or employers. While federal support for telehealth care for SUD during the pandemic is a great start, it doesn’t necessarily help individuals who are sheltering at home with their families during the pandemic. Where might an individual find space for a private telehealth consultation in the home? It’s an important question to consider, given that broken family dynamics can exacerbate addictive behaviors.
Within the medical community, there are also concerns around whether SUD patients who are newly diagnosed via telehealth during the pandemic can be successfully engaged via virtual modes of care. Some suggest an in-person visit should take place before telehealth visits are initiated. Given the shortage of physicians authorized to treat OUD, these attitudes can present barriers to treatment in communities where in-person resources do not exist.
Meanwhile, restrictions around sharing of medical records for SUD and OUD patients except in an emergency medical situation can prevent providers from gaining a 360-degree view of these patients. This means that when patients present with healthcare symptoms that are drug-induced, physicians may be unable to make critical connections between the issue at hand and the addiction that brought the patient to the office. This prevents patients from receiving vital support that could help stop the cycle of addiction.
What is needed is a compassionate approach to SUD and OUD care that builds upon the advancements in access made during the pandemic. Here are three approaches that healthcare providers, legislators and communities should consider.
Tighten connections between EDs and programs that provide MAT services. For example, in my community, there is an outpatient clinic with a 24-hour hotline that providers can call when patients are in immediate need of suboxone treatment, one form of MAT. This changes the conversation with patients who are struggling with the effects of addiction at 3 a.m.: “Let’s get you on buprenorphine at 9 a.m. today.” It changes the care plan to one of action rather than a theoretical approach (e.g., “Let’s schedule an appointment for next month”). It also provides an opportunity for a warm hand-off, which is essential in ensuring patients receive the right care at the right time.
At my hospital, we’ve also established a buprenorphine program in the ED that provides access to this treatment at the moment of crisis. One of the barriers to MAT is that it is often easier for someone suffering from SUD to purchase heroin at all times of the day than it is to start on MAT. As a nation, we need to make it easier for individuals to receive care that can help patients overcome the pattern of addiction when they are ready, regardless of the time of day or location. Striking while the iron of addiction-related complications is hot can increase uptake of treatment and success.
Seek ways to support more informed care in your network while protecting patient privacy. It’s so easy for SUD patients to become lost in the cracks of the healthcare system. The federal law protecting confidentiality of SUD patient records, 42 CFR Part 2, is vital, given that one in 10 people do not receive SUD treatment because they are afraid of the impact on their jobs, their reputation and their relationships with family members. However, healthcare providers and health plans could consider enacting a three-pronged approach to consent—full consent, partial consent and no consent—that would help providers gain access to vital information that could strengthen health outcomes and a patient’s chances for recovery:
- Full consent allows providers to enter care plans, attachments such as pain contracts, and other information for collaborating patient care. This consent also allows other facilities to view this information.
- Partial consent allows providers within a network to see some visit information, such as care team members, but limits visibility into care plans, security events, and additional attachments.
- No consent allows SUD providers to receive “read-only” information from other facilities but does not allow the provider to contribute patient information to the care platform for access by others. However, patient data can still be added and viewed at the consenting facility.
Support access to technologies that could enable patients to access virtual treatment—privately. One research scientist suggests bringing back telephone booths, but enabling them with Wi-Fi—a solution that could expand access to virtual care—in the moment or scheduled—for vulnerable populations, such as those that lack stable housing. Community centers, churches and housing shelters could also provide vital support for confidential care in safe places by offering access to telehealth in private rooms that are conducive to medical visits. Given the stigmas around SUD treatment, these efforts should not be limited to those suffering from SUD. However, they could provide a lifeline to those who need specialized support quickly. During the pandemic, the federal government should consider ways to fund efforts by community groups to support SUD care.
By taking a compassionate, collaborative approach to SUD treatment, healthcare providers, legislators and communities can collectively empower individuals coping with SUD to receive the care they need regardless of their location and in spite of limited resources. It’s a move that could reverse the trend of SUD and OUD overdoses and deaths during the pandemic and beyond.
Hon. Nathaniel Schlicher, MD, JD, MBA, FACEP, is Regional Director of Quality Assurance for the emergency departments of CHI Franciscan Health, Tacoma, Wash., and Associate Director of the TeamHealth Litigation Support Department. He has previously served as Legislative Advisor on the Board of Directors of the Emergency Medicine Residents’ Association and the Past-President of the Washington Chapter of the American College of Emergency Physicians. Dr. Schlicher spent a year in the Washington State Senate, representing the 26th District.
This article is a collaborative effort with Collective Medical.