Individuals with opioid use disorder (OUD) struggle to get effective care: Of 2 million Americans with the illness, only 26% receive treatment. Now, as the coronavirus pandemic presents an added strain on the U.S. health care system, it is creating greater hardships for those seeking OUD treatment. As people across the country continue to practice physical distancing, individuals with OUD may have more difficulty coping with stress and opioid cravings, which could place them at an increased risk for relapse. In addition, people with OUD are more likely to experience circumstances that put them at higher risk of contracting the coronavirus, including homelessness, housing insecurity, and incarceration—which potentially put them in close contact with others at risk—and decreased access to health care.
Consequently, effective strategies to address OUD are needed now more than ever. State policymakers should implement approaches that are proven to help this population achieve recovery, as outlined in this new series of issue briefs.
When the COVID-19 pandemic struck in early 2020, the federal government began allowing people to receive opioid use disorder (OUD) treatment services remotely, or via telehealth, by interacting with doctors and other providers over the internet and by phone. Emerging research shows that allowing telehealth-based OUD treatment has helped patients initiate and remain on medication treatment, and also that these patients stayed in treatment and abstained from illicit opioids at rates comparable to individuals who received care in person. Clinicians who used telehealth during the pandemic reported that it increased access and convenience for their patients, particularly among historically underserved populations. State Medicaid agencies and lawmakers can take several measures to increase access to care via telehealth.
Opioid treatment programs (OTPs) are a critical component of the U.S. substance use treatment program. These facilities are regulated by the federal Drug Enforcement Administration and Substance Abuse and Mental Health Services Administration, as well as stage agencies, and are the only treatment facilities legally able to offer all three medications for opioid use disorder (OUD). Despite the key role OTPs play and the large number of people in need of treatment, federal, state, and local jurisdictions restrict the availability and accessibility of medications for OUD at these facilities. State and federal policymakers can do more to ensure that comprehensive OUD care at OTPs reaches populations in need and is integrated into systems delivering other health care services.
Buprenorphine is one of three FDA-approved medications for the treatment of OUD and reduces the risk of overdose, illicit opioid use, and infectious disease transmission that can accompany injection drug use. Because it is highly regulated and therefore can be difficult to access, some states have amended or enacted policies to facilitate “low-threshold” buprenorphine treatment—an approach that prioritizes prescribing medication as soon as a person is interested in treatment, at low or no cost, without placing additional conditions on the patient (e.g., counseling or abstinence). Yet barriers remain for providers seeking to implement low-threshold buprenorphine treatment programs, and there are steps that state and federal policymakers should take to facilitate prescribing.
Syringe services programs (SSPs) provide access to and disposal of drug equipment as well as referrals to substance use and mental health treatment. Evidence shows that SSPs reduce the transmission of HIV and hepatitis C virus infections, increase proper disposal of used needles, and improve participants’ levels of engagement in treatment. Although the federal government supports, and in some cases funds, the implementation of these programs, state approval is required to successfully enact them. Stigma and misconceptions about SSPs, whether from policymakers and/or community members, can result in barriers to establishing programs and providing services. Actions from state policymakers, such as passing SSP-authorizing legislation, decriminalizing drug use materials, and increasing public funding for SSPs, can help ensure that people who inject drugs receive the resources and access to treatment they need.
In the months since the COVID-19 pandemic began, the opioid overdose crisis has only gotten worse, with more than 40 states recording increases in opioid-related deaths. Evidence shows that increasing the availability of naloxone—a prescription medication that reverses the respiratory depression caused by an opioid overdose—reduces the rate of opioid overdose deaths. Naloxone can be safely administered to prevent overdose-related injuries and death not only by medical professionals but also by laypeople who witness an overdose. And it’s been shown that increasing access to naloxone does not increase nonmedical opioid use.
All U.S. states have enacted at least one law that expands access to naloxone. However, the scope of these laws differs, and not all of them ensure that naloxone can get into the hands of people most likely to experience or witness an opioid overdose. State policymakers, such as legislators and health agency directors, can take steps to make naloxone widely available to people at risk of experiencing or witnessing an overdose.
During this period of turmoil in the health care system, approaches to patient treatment are being adapted to accommodate the current landscape, such as use of telehealth. These changes make coordinating patient care across providers more important than ever. Because medical provider capacity is being diverted to address the pandemic, OUD care coordination approaches such as the nurse care manager model or hub-and-spoke systems can help ensure quality of care while maximizing the availability of limited providers to treat the most patients possible.
Treatment approaches in criminal justice settings and re-entry
In recent years, many correctional systems have increased the number of incarcerated people who are able to start or continue medications for opioid use disorder (MOUD). MOUD reduces overdose deaths and is the gold standard of care for individuals with OUD. Although physical distancing presents challenges for all institutions, correctional facilities should ensure continuity of these medications as they would for any other chronic diseases.
As part of the response to coronavirus, many jurisdictions are expediting the release of some individuals to reduce prison and jail populations. For individuals with OUD who are incarcerated, the time immediately following release puts them at risk of overdose because of lower tolerance to opioids after an extended time of not using the drugs. Re-entry counselors now have the difficult challenge of preparing already medically vulnerable individuals for quick release during a global pandemic. For patients in prison- or jail-based MOUD programs, making connections with community providers and insurers before release is especially critical because of potentially reduced OUD treatment capacity. State agencies need to ensure prompt reactivation of medical insurance and increased social supports, particularly for individuals who have been released and may have unstable housing, or are in circumstances that do not adequately enable physical distancing.
During the pandemic, prescribers and pharmacists should continue to check their state’s prescription drug monitoring program (PDMP), a database that helps providers to identify patients who misuse opioids or have OUD and allows them to connect patients to lifesaving treatment. As drug use patterns shift during the pandemic, policymakers should consider incorporating nonfatal overdose data in their PDMPs by requiring first responders, such as emergency medical personnel, to report this information. Knowledge of a past overdose may prompt a health care provider to discuss opioid risks and safety with a patient, prescribe naloxone, and/or refer them to treatment. Nonfatal overdose data can allow researchers to study overdose trends and recommend strategies to mitigate risk. In addition, the Substance Abuse and Mental Health Services Administration reports that an increase in demand for treatment is expected in disaster situations because of a disruption in the supply and distribution of illicit drugs. To address this, state and local health officials can utilize population-level PDMP data to monitor risk factors for OUD and overdose. Monitoring trends can serve as an early warning system for communities and help inform the response.