It is an understatement to say that the COVID-19 pandemic has caked the entire world with a layer of stress. For those who experience addiction and mental health concerns, the additional stress can pose a serious risk to health — especially in the midst of an opioid crisis in North America.
Prior to COVID-19, people with opioid addiction already struggled to obtain comprehensive care due to widespread stigma and misinformation, in addition to systemic and socioeconomic barriers.
Now, a health dilemma is afoot: The rightful and necessary need to respect physical distancing has unfortunately also resulted in social isolation and increased levels of stress for many people, including those who use opioids.
The current situation is quickly producing additional barriers to accessing evidence-based care: such as pharmacotherapy, psychotherapy, harm reduction services, addiction medicine, and social supports. It is vital that our peers who use opioids still have access to essential health and social services during this time — even if it is remote access.
Opioid Agonist Therapies (OATs)
People who use opioids need enhanced access to lifesaving medications — such as buprenorphine/naloxone and methadone — and to have extended prescriptions for these medications throughout the duration of the pandemic. These medications, known as opioid agonist therapies (OATs), maintain tolerance, improve treatment retention, reduce risk of relapse, and importantly, reduce overdose risk compared to abstinence only-based approaches to opioid addiction treatment. OATs also reduce the rewarding effect of stronger opioids, such as heroin or fentanyl, which can discourage use and may prevent overdose in case of relapse.
OATs are the best treatments that we have for opioid addiction. They reduce the risk of death by up to 59% compared to no medication. Unfortunately, OATs are prescribed only to a small percentage of patients in the United States.
Sadly, stigma and misinformation about addiction treatment are rampant in North America. Misguided beliefs — such as OATs are “just substituting one drug for another” or that people who are treated with OATs are “still not entirely clean and sober” — are steadfast in society and difficult to defeat. Many people experience this type of stigma from friends, family, and sometimes even from healthcare providers. Often, people internalize and truly start to believe such detrimental misinformation.
These stigmatizing beliefs are inaccurate, cheapen the complexity of addiction treatment, and discourage people from seeking evidence-based care.
Imagine if people with diabetes were told that taking insulin is a “cop-out” or “not natural.” Ludicrous, right? The same kind of misinformation about opioid addiction and its treatment should not be tolerated anywhere. These medications are often important and necessary tools for recovery for many people.
To truly reduce stigma, we must make it acceptable for people who use drugs to ask for help, without being judged, ostracized, or disciplined. We must also have immediate and available on-demand, person-centered care.
Access to Care
It is estimated that 50%-75% of people who experience addiction — including opioid addiction — meet criteria for one or more mental health disorders, such as post-traumatic stress disorder, anxiety, and depressive disorders. The benefits from treatment in opioid addiction are more likely to happen when people receive integrated treatment for both addiction and mental health at the same time. However, prior to COVID-19, treatment services were already fragmented and only a small fraction of people received this level of complex care.
In many geographical areas, few evidence-based treatment options exist for people who use opioids. Additionally, patient values and preferences are often not involved in the treatment decision-making process, despite evidence that people who experience addiction want to be involved in treatment decisions and want more options. People with opioid addiction who are prescribed OATs are more likely to be abstinent from illicit opioid use in comparison to placebo or programs where no medication is offered.
Without OATs, it only takes a short period of abstinence — for example, less than a week — until people can start to rapidly lose their tolerance to opioids. This is problematic because if a person subsequently relapses to opioids, then they are at serious risk for health complications, particularly if they use the same dose of opioids that they used prior to starting the treatment program. Without the protective opioid tolerance provided by OATs, a relapse episode can lead to overdose or death.
Episodes of relapse followed by periods of remission are notorious and hallmark features of addiction. They are a normal part of the recovery process. Lessening harms associated with use and relapse is vital for improving public health.
What Is Harm Reduction?
In its broadest sense, harm reduction is what it sounds like: it means reducing the harms that are associated with human actions. The principles of harm reduction are evidence-based, person-centered, and long overdue in the world of addiction treatment. The approach emphasizes the importance of the relationship between patients and providers, and its philosophy is rooted in non-judgmental acceptance.
Harm reduction theory accepts the idea that the use of drugs and alcohol is an intrinsic part of being human and that it is impossible to entirely stop drug use in society. It is therefore important to reduce the risk of harms from drug use with knowledge and the right supports.
One example of harm reduction is physical distancing to prevent the transmission of COVID-19. Even though we can’t stop COVID-19 transmission entirely, we can reduce its impact by informing ourselves and changing our behavior, which will slow the rates of infections and ultimately preserve vital health resources and save lives.
Adapting Opioid Addiction Treatment to COVID-19
Several approaches can be taken to improve access to evidence-based treatment for opioid addiction, such as OATs. The use of virtual care is paramount in supporting those who would benefit from OATs while reducing the risk of viral transmission in the current COVID-19 pandemic.
Buprenorphine/naloxone has been traditionally prescribed under the watchful eye of the prescriber and often pharmacist. It has involved a number of parameters, including office initiation, witnessed dosing, and urine drug screens. These are often standards of care, which are based on state-to-state law. There is no evidence that any of these parameters reduce risk of death, improve retention to treatment, or improve recovery. They are designed to reduce the risk of a person using the medications illegally — known as drug diversion — rather than improve the treatment of the person looking for help.
We suggest exploring a number of adaptations to standard care: removing witnessed doses, which can reduce cost and improve retention to treatment; temporarily stopping the use of urine drug screening; and allowing people to begin the use of buprenorphine/naloxone at home in collaboration with their physician — known as home induction. These changes strike a balance between evidence-based opioid treatment and respect for physical distancing, with a view towards reducing the risk of viral spread to our most vulnerable populations.
Methadone, the gold standard OAT, is more complex than buprenorphine/naloxone because of its elevated risk of overdose and higher risk of misuse. Applying new adaptations at pharmacies could be helpful: having the medication delivered to patients; allowing longer times between dispensing, especially for those who are showing stability; and making use of virtual care. Again, these changes can go a long way in improving physical distancing and reducing risk of viral spread.
Crucially, we will also need to reduce the bureaucracy of waivers for prescribing evidence-based treatments, particularly for buprenorphine/naloxone. The bureaucracy of waivers places limits on who can prescribe and it places an unnecessary administrative burden and time delay on the delivery of effective treatment. The waiver also acts as a barrier to getting the help that people want and need, further perpetuating the stigma of addiction.
The use of OATs reduces people’s need to engage in criminal activity to find illicit opioids to prevent debilitating withdrawal. Importantly, it keeps people home: a most necessary step to flatten the curve and reduce the strain on our healthcare systems.
Harm reduction services will need to remain open and operating during the pandemic. These vital services require access to personal protective equipment to protect people and healthcare workers alike. Data suggest that our most vulnerable peers are succumbing to the coronavirus, including people of minority and lower socioeconomic status, which highlights the necessity to be proactive.
We are witnessing the intersection of two health crises. Protecting our peers is an ethical imperative that will also serve to protect us all by reducing the spread of one of the most deadly viruses seen in modern times.
It cannot be overstated enough: people who experience mental health and addiction concerns require ongoing support during this pandemic. Lives depend on timely policy action. We need to make new and necessary policy changes; reduce face-to-face interactions; and support evidence-based, person-centered care.