By Brandon George and Nicolas P. Terry
Earlier this month, Dr. Nora Volkow, director of the National Institute on Drug Abuse identified those with substance use disorder (SUD) as a particularly vulnerable population during the COVID-19 pandemic. She highlighted the negative effects of opioid or methamphetamine use on respiratory and pulmonary health in addition to the disproportionate number of those with SUD who are homeless or incarcerated.
We detail the additional challenges faced by the SUD population and, specifically, the opioid use disorder (OUD) sub-group at this time, identify positive ameliorative steps taken by federal, state, and local governments, and recommend additional steps.
Those with OUD share the same problems faced by those with other chronic diseases. These include difficulties accessing medications and disruptions in outpatient treatment.
However, the OUD populations also face particular difficulties: shelter in place orders and other restrictions on assembly likely will stop recovery meetings; curtailments on visitations will further separate children in protective care and their in-treatment mothers; and, unlike those with other chronic diseases, opioid-exceptional drug regulations mean OUD populations face extraordinary, personal contact-based and other barriers to accessing medications.
Further, while many of their fellow citizens will be able to use rapidly iterating telehealth models of care, that may not be as true with a population characterized by its itinerant nature and reduced access to mobile or other Internet services.
A large subset of those with SUD are in the criminal justice system and so are threatened by the potential for high transmission rates in jails and prisons. For example, It has been estimated that 65% percent of the United States prison population has an active SUD. Of those who are repeat arrests jailed each year, 52 percent suffer from SUD.
Those with SUD outside the criminal justice system continually face the problem of housing insecurity. They are particularly vulnerable to eviction orders. Approximately two-thirds of the homeless have a primary substance use disorder or other chronic health condition. Typically the homeless lack access to bathrooms to maintain basic recommended hygiene such as frequent hand-washing. Tent encampments or crowded shelters exhibit the antithesis of social distancing. There are already reports of COVID-19 spreading through homeless shelters while the virus also threatens the services on which shelters rely. A California model predicts that 60,000 homeless people could be infected in the next eight weeks, with 20 percent (or 12,000 beds) needing hospitalization.
Positive Steps Already Adopted
People will continue to ask questions about the slow response rate of our fragmented federal-state-local public health system and the fragility of our disjointed health care system.
Notwithstanding, federal, state, and local governments do seem aware of some of the enhanced risks faced by those with OUD. At the federal level, the Substance Abuse and Mental Health Administration (SAMHSA) is allowing states to request blanket exceptions for all stable patients in an opioid treatment program to receive 28 days of take-home doses of medication (less stable patients may receive up to 14 days worth).
SAMHSA also issued guidance to providers that prohibitions on the use and disclosure of patient identifying information under 42 C.F.R. Part 2 would not apply in the case of a medical emergency. This follows the typical HIPAA Privacy Rule relaxations during emergencies such as permitting more sharing of patient information. It is supplemented by an Office for Civil Rights (OCR) notification announcing enforcement discretion would be applied if providers used less secure communications platforms such as Facetime, Facebook Messenger, or Skype for telehealth (but not public facing services such as TikTok).
Tragically, opioid treatment for many requires traveling to inconvenient clinics and waiting in long lines. Now, at the request of SAMHSA, the Drug Enforcement Administration (DEA) has issued an exception to 21 CFR 1301.74(i) so that medications can be delivered by persons other than licensed clinicians and through indirect means such as doorstep lockboxes.
Getting out ahead of that DEA exception, the Indiana Division of Mental Health and Addiction and the non-profit Overdose Lifeline have announced that they will be supplying opioid treatment programs with lockboxes to secure take-home doses of methadone and, as a precautionary method, will include naloxone with the lockboxes.
Buprenorphine prescribers still require a DEA waiver, and as such only 7 percent of clinicians are permitted to prescribe the drug. However, because of the public health emergency declaration, clinicians using telehealth will no longer need to have an initial “in-person” meeting with the patient.
More generally, and to the benefit of all patients, the Centers for Medicare & Medicaid Services (CMS) has waived its antiquarian restrictions on Medicare reimbursement for telehealth, dramatically extending telehealth to patients outside of rural areas and to patients in their homes.
Many states have taken appropriate actions that will assist the SUD population (several examples are collected here).
Several states, including California, Indiana, and Rhode Island, have expanded Medicaid reimbursement to most telehealth-provided services, including mental health services as if they took place in person. New Jersey has set up a dedicated telephone support line for those suffering from behavioral health issues.
Of importance to those with SUD in the criminal justice system, some states have already triggered emergency procedures applicable to courts. These toll deadlines allow proceedings to be suspended, and permit certain processes to be transferred to videoconferencing (similar closures and restrictions are being adopted by federal courts).
In some cases, of course, the inevitable slowdown in judicial processes may result in some persons being held in jail for a longer period of time. On a more positive note, New York’s Department of Corrections and Community Supervision has suspended the requirement for in-person parole visits.
States, rather than the federal Department of Housing and Urban Development (HUD), also have taken initiative with regard to the homeless. For example, Indiana has received a $5 million grant to establish a quarantine facility for homeless individuals who test positive.
California is even further ahead, converting buildings such as hotels, motels, and recreation centers into shelters with the Governor providing $150 million in emergency funding. For example, San Diego is looking to provide 2,000 hotel beds for high-risk and symptomatic individuals. The state has also purchased 1,300 trailers from the Federal Emergency Management Agency and private vendors to serve as isolation sites.
Some, but not enough, cities and counties have acted to reduce jail and prison populations at high risk of transmission. For example, in Denver and Boulder, Colorado, and Philadelphia, law enforcement have defaulted to issuing summons rather than arresting those suspected of low-level, non-violent property, prostitution, and drug crimes.
While New York’s jails are being described as “the epicenter of the epicenter,” in San Francisco, the District Attorney and Public Defender are working to release pre-trial detainees who are at heightened risk for illness from coronavirus, particularly those who face misdemeanor charges or drug-related felony charges. New Jersey seems out in front of this trend, ordering the release of large numbers serving time for probation violations and low-level crimes. Approximately 1,700 inmates have been released from the LA. County jail.
However, many states appear opposed to reducing their at-risk prison populations despite positive tests of staff and inmates. For example, Mississippi has announced reduced visiting hours and transfers but has no plans to reduce its population, while the Jackson, Mississippi Police Department has announced it will not be making changes to its arrest protocols.
What Else Is Needed?
Like their fellow citizens, those with SUD will benefit from streamlined health care, more proportionate policing, and protections from eviction and unemployment. Additionally, state and local governments should consider introducing the SUD-specific measures discussed above. Most of these measures likely will be on the radar of local policymakers; the urgency of their broad adoption may not.
Equally, policymakers should be conscious of unintended effects. For example, it might make sense in terms of social distancing to close all liquor stores in Pennsylvania, but the impact of ethanol withdrawal can result in seizures and delirium tremens which will require hospitalization and further burden our healthcare system. As a result, some state lists of “Essential Businesses and Operations,” such as Indiana’s, include liquor stores.
Similarly, the most dangerous time for the incarcerated with OUD is immediately after release. While inmates released from the Allegheny County Jail in Pennsylvania are provided with a bus pass and a dose of naloxone, access to treatment services and secure housing also should be important priorities. Urgent attention should be given to initiatives such as one in Boston where non-profits are distributing a “Survival Kit” to the newly released, including naloxone, fentanyl test strips, and information about local services, particularly virtual resources.
Approximately 70,000 persons in the U.S. die each year because of drug overdoses. For the time being, that number dwarfs the number of COVID-19 cases in the country. Even as our attention rightfully shifts to the virus, we must not lose sight of the fact that the U.S. currently faces two public health emergencies. Indeed, they will intersect increasingly as homeless and incarcerated populations become further infected. Furthermore, supply chain disruption is not limited to legal products; as methamphetamine and fentanyl become harder or more expensive to acquire users will face withdrawal or experimentation with riskier sources or compounds, further creating health care demand.
Steps taken to improve our responses to COVID-19, such as reconsidering “soft” arrests and filling our jails and prisons, or easing restrictions on prescribing and increasing the use of telehealth, also highlight better responses to treating OUD.
As coronavirus increasingly consumes our attention, as SUD clinical staff are reassigned to higher priority emergency services, and as health care facilities in crisis increasingly have to decide which dying patients will be prioritized, we need to be vigilant and protect all vulnerable populations from being further marginalized and ensure equitable treatment.
Brandon George, Director, Indiana Addiction Issues Coalition. He can be reached on Twitter @icmyserenity.
Nicolas Terry, Executive Director, Hall Center for Law and Health, Indiana University Robert H. McKinney School of Law. He can be reached on Twitter @nicolasterry.