As global attention is focused on the COVID-19 pandemic and its effects, the opioid epidemic in the United States continues. What is happening to people with substance-use disorders during COVID-19? And, what do we need to know moving forward to make progress across multiple public health concerns?
The Rockefeller Institute of Government has been examining the opioid epidemic since 2017, most recently in the Epidemic in a Pandemic series. In December 2020, the Institute brought together four experts in a public webinar to discuss what is happening to the opioid epidemic during COVID-19 and what measures we ought to be taking moving forward. The panelists included:
- Shelly Weizman, associate director of the Addiction and Public Policy Initiative, O’Neill Institute
- Craig Apple, Albany County sheriff
- Debbian Fletcher-Blake, chief executive officer of Vocational Instruction Project Community Services, Bronx
- John Bennett, executive director of the Genesee/Orleans Council on Alcoholism and Substance Abuse
This post highlights a few of the key observations by these panelists, including a birds-eye view of policy changes, on-the-ground experiences for different communities, and policy goals for the future.
COVID-19 has put unprecedented stress on Americans, especially on vulnerable populations such as those with substance-use disorders. At the same time, there has been a loosening of federal and state regulations allowing unprecedented flexibility for substance-use service providers. While certain restrictions on medication-assisted treatment have been lifted, giving substance-use disorder service providers greater flexibility, different communities (criminal justice involved, urban, rural) have been differentially affected. Service providers have responded by meeting their particular needs. To achieve better health outcomes, in general, and for opioids in particular, the panelists discussed the need for public policy solutions that prioritize equity.
COVID-19 put unprecedented stress on Americans but also presented unprecedented flexibility surrounding substance-use disorder services.
Although the official overdose statistics are lagged (and therefore unavailable), Shelly Weizman, associate director of the Addiction and Public Policy Initiative at Georgetown’s O’Neill Institute, explained that more current data we do have access to suggest that pandemic stressors have increased substance use. According to the CDC, one in eight survey respondents reported increased substance use since the pandemic began. And, according to the American Medical Association, more than 40 states have reported increases in opioid overdose mortality, indicating that drug use during the pandemic has been more deadly.
Why have overdoses increased? In part, drug use has increased due to pandemic-related stressors and, in part, drug use has become more dangerous. Fentanyl, a potent synthetic opioid, is being mixed with other drugs. And a single bad batch can lead to a large number of overdoses. At the same time, people are having difficulty accessing services such as syringe exchanges or reentry services.
…according to the American Medical Association, more than 40 states have reported increases in opioid overdose mortality, indicating that drug use during the pandemic has been more deadly.
While COVID-19 presents enormous challenges to adequately dealing with substance-use disorders, federal and state agencies have also loosened restrictions, including declarations for public health emergencies, allowing and reimbursing for telehealth services, and making it easier to prescribe medication-assisted treatment such as buprenorphine and methadone. Buprenorphine providers may skip the initial in-person medical evaluations and prescribe via telehealth. Medical personnel may use telehealth to continue to treat existing patients with buprenorphine or methadone. Further, relaxed guidelines made methadone maintenance more accessible. Rather than requiring individuals to come to methadone facilities daily for their medication, medical personnel may prescribe more methadone take-home dosages and opioid treatment program staff members, law enforcement, or National Guard personnel may deliver it to patients.
To benefit from these relaxed federal guidelines, states have needed to take action too: allowing the use of telehealth, permitting initiation of buprenorphine via telehealth, allowing audio-only calls in place of teleconferencing, requesting methadone take-home exceptions, broadening access to Naloxone, and expanding access to Medicaid and the insurance exchanges.
Communities across New York State have been affected by an epidemic in a pandemic, but they are not affected in the same ways; providers have used innovative solutions to target the dual health crises.
People with substance-use disorders who come into contact with the criminal justice system may have a very difficult time. If a facility does not offer treatment, the consequences can be inhumane. Albany County Sheriff Craig Apple created a number of innovative programs, including a treatment center inside the Albany County Jail. Partnering with the New York State Office of Addiction Services and Supports (OASAS), he also created the Sheriff’s Heroin Addiction Recovery Program (SHARP). SHARP has treated upwards of 600 to 700 people, and it is successful. Once released from prison, 70 percent of individuals are still linked to medication-assisted treatment and the rate of recidivism is only 5 percent. Although the criminal justice system is not the ideal method of treatment, it allows some people to get help who may not otherwise have access to it. According to Sheriff Apple, “they’re getting the treatment they need and they’re staying in it.”
When he learned that two-thirds of people on probation and parole had nowhere to go, Sheriff Apple started a shelter in the Albany County Jail. He created a new entrance to access 100 cells (out of 1,140 total) for people who needed a place to stay. Because of COVID-19 and social distancing, the program currently houses about 15 individuals, but it has the capacity to take 50.
Why would a law enforcement official choose to treat (rather than punish) incarcerated individuals and why would he choose to house (rather than ignore) people with nowhere to go? Sheriff Apple said simply, “everybody needs support at some time.”
The results are worth it. Providing mental health treatment, medication-assisted treatment, NARCAN training, housing supports, job training, banking, and enrolling in Medicaid means that justice-involved individuals are able to leave the criminal justice system, rent an apartment, get a job, stay healthy, and choose to interact with Sheriff Apple, filling him in on how they are doing.
But COVID-19 has put stress on substance-use disorder services, and the Albany County Jail is no exception. Social distancing means that peer-to-peer in-person sessions are on hold. Isolation, which is a problem with the epidemic in a pandemic more generally, takes hold for inmates in the county jails, who cannot see their family and their support structure. It threatens the progress that people with substance-use disorders have made.
Underserved Urban Communities
In its annual review of county health, the Robert Wood Johnson Foundation consistently ranks the Bronx last: 62nd out of 62 counties in New York State. The same factors that are responsible for health disparities in the Bronx make the epidemic in a pandemic more potent. Debbian Fletcher-Blake, chief executive officer at Vocational Instruction Project (VIP) Community Services, Inc., explained that when it comes to heroin overdoses and hospitalizations the rate in the Bronx is three times as high as in New York City as a whole. Complex problems call for more systematic solutions. VIP provides outpatient treatment, residential programs, and a 1,500 capacity methadone program. It also offers primary care, housing, shelter, and vocational programs. And it has invested in innovative practices, such as a 24-hour open-access center.
In short, making sure that people who need help get it, which may mean prioritizing resources and giving more to those who need it most—especially underserved communities of color.
COVID-19 meant shifting those services to remote options. Although internet is readily available in the Bronx, it does not mean it is accessible to Bronx residents who need it. Many people lack internet or computer access to use virtual platforms. And, while federal waivers meant more take-home doses, overcrowding means that not everyone had a safe, secure place to store methadone. Unemployment also increased food insecurity and VIP serves meals to patients who come into the facility. And finally, like other substance-use disorder service providers during COVID-19, VIP has faced workforce challenges: being able to maintain a workforce (when shortages were a problem across the US even before the pandemic) and managing frontline workers’ fear of COVID-19.
What can we do to address the needs of underserved urban communities? Some of the relaxation in federal and state regulations have worked well, but, ultimately, tackling the epidemic in a pandemic requires the same strategies as dealing with health disparities more broadly: addressing health inequities, ensuring delivery systems that work, and addressing social factors. In short, making sure that people who need help get it, which may mean prioritizing resources and giving more to those who need it most—especially underserved communities of color.
As we have discussed in our ongoing Stories from Sullivan project, rural communities face a different set of challenges and have a different set of resources compared to urban areas. Rural counties have few resources, but they cover a wider geographic area. John Bennett, executive director at Genesee/Orleans Council on Alcoholism and Substance Abuse (GCASA), serves one of the poorest counties in the state.
With high overdose rates and few resources to address the problem, Bennett and colleagues created the tri-county opioid task force to address the social determinants of health in their rural communities. Bennett and colleagues created new residential program beds, new detox beds, a new opioid treatment program, and a recovery center. They created a mobile unit, expanded jail services (like Sheriff Apple) to include medication-assisted treatment in two counties, and expanded peer services.
But COVID-19 brought new challenges to a comparatively small provider. The hospitals closed to nonpatients (including friends and families), peers went home, and the recovery center was closed to the community. What could they do about methadone dispensing? Bennett contacted federal authorities, who authorized GCASA to dispense methadone from the mobile unit in the parking lot.
GCASA shows how rural challenges (large geographic spaces) can present rural opportunities (mobile dispensing in a parking lot on a large campus). Yet, like other substance-use service providers—who note the challenges accessing technology and the lack of human connection—GCASA has found it difficult to engage people in group telehealth.
The epidemic in a pandemic will never be solved by any one individual or organization alone, no matter how innovative and creative they are. The opioid epidemic, COVID-19, and health disparities, more generally, are large-scale problems that require public policy solutions.
According to Weizman, Congress and federal agencies are already considering a number of policies to address the opioid epidemic, including:
- the Mainstreaming Addiction Treatment Act, which removes DEA waiver requirements to prescribe buprenorphine;
- the TREATS Act, which makes regulatory flexibility (e.g., expansion of telehealth, not requiring in-person exam) permanent;
- expanded access to mobile methadone;
- targeted expansion of access to Medicaid and evidence-based treatment for those at highest risk of overdose, including justice-involved individuals; and,
- President-elect Biden’s plan to spend $125 billion related to substance-use services.
Yet, in the long term, piecemeal solutions will not be the answer. Weizman suggests that we have to think about bringing systems of care together in a national, comprehensive strategy to address root causes. Because of regulations, Bennett explained, he is limited to providing single services. Both he and Fletcher-Blake think more integrated services are the answer so “there’s no wrong door” for people seeking help. Policymakers can work to close the gaps and provide comprehensive services to fix problems and provide support, because as Sheriff Apple noted of government and elected officials, “that’s what we are supposed to do.”
Although public attention shifted to the COVID-19 pandemic, the opioid epidemic did not go away. In fact, all evidence suggests it is getting worse.
However, with limited resources and growing need, how do we target policy solutions? All Americans are affected by the pandemic, but they are not affected in the same ways. For people with or at risk for substance-use disorders, stressors coupled with the inability to access supports and services, can be particularly troublesome. People who are involved with the criminal justice system, people who are homeless, people of color, and people in rural or urban communities face different obstacles and opportunities.
The goal in addressing the epidemic in a pandemic is to improve public health. COVID-19 shone a light on health disparities: the least well-off have been disproportionately negatively affected. Improving public health—whether the opioid epidemic, COVID-19, or health disparities more generally—requires equity so people do not fall further behind. As Fletcher-Blake explained, “providing equity means giving more to those who need it the most.”
Although public attention shifted to the COVID-19 pandemic, the opioid epidemic did not go away. In fact, all evidence suggests it is getting worse. With FDA approval for a COVID-19 vaccine and hope that we will successfully address one public health crisis, another one looms large. In the Epidemic In a Pandemic series, we shine a spotlight on people doing innovative work, the challenges that addressing the epidemic in a pandemic brings, and their suggestions for ways to move forward. Our goal is provide policymakers, people on the frontlines, and the public with information they need to find more equitable solutions.
ABOUT THE AUTHORS
Patricia Strach is a fellow at the Rockefeller Institute of Government
Elizabeth Pérez-Chiqués is a fellow at the Rockefeller Institute of Government
Katie Zuber is a fellow at the Rockefeller Institute of Government