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"It's a matter of life and loss of life": The Covid-19 Problem of Habit Remedy

When the Covid-19 pandemic forced much of the US to a halt in spring 2020, officials and experts feared the necessary social distancing measures would exacerbate yet another public health crisis – the opioid epidemic. Addiction treatment is traditionally given in person, and restrictions on gatherings and closed business would make it much less accessible.

The federal government responded by relaxing the rules for virtual entry into treatment, which makes it easier for treatment providers to retain patients and attract new ones. Even before the pandemic, experts had been calling for treatment to be simplified in the United States, and the new rules were a big step forward.

With vaccines against the coronavirus going through clinical trials and with the end of the pandemic in sight, proponents fear the old rules will come back into effect, again making it harder to get people into addiction treatment.

Officials relaxed federal regulations in a number of ways. They enabled doctors to prescribe buprenorphine, an evidence-based drug for opioid addiction, via video or audio calls without the need for a personal assessment. They also made it easier to prescribe the drugs across state lines, which previously required prescribers to be approved in both states. And they relaxed the rules for take-away methadone, another proven opioid addiction drug that is traditionally given daily to patients in a personal clinic.

State and federal officials also made it possible for public health insurance programs like Medicare and Medicaid to pay for telemedicine addiction treatment services. And some places were given permission to go further – for example, giving methadone to patients instead of requiring them to collect it in person.

Vendors say the changes really helped. Many of them had to go virtual almost overnight as the coronavirus threat became apparent across much of the country. But they had feared that given the strict rules for such drugs, they would not be able to prescribe the necessary drugs at all, potentially exposing their patients to relapse, overdose, and death.

Things didn't go perfectly, but the relaxed rules, say vendors and experts, helped avoid the worst.

"It was incredibly challenging (for us) as it was for all providers," said Alexis Geier, vice president of government relations at addiction treatment provider CleanSlate. "Fortunately, we really haven't lost many patients. … That was only possible because the federal government responded to public health emergencies."

Addiction treatment has long been difficult to access in the United States. According to the federal government, only 1 in 10 people with a drug use disorder receive special treatment. Several issues play a role in this treatment gap, including a lack of local providers, high costs, and poor insurance coverage. Much of the treatment offered is undetectable or even rejects evidence-based modalities and can even be downright fraudulent, so that potential patients cannot be treated in a broken system.

That is why activists and providers were calling for the prescription of addictive drugs to be simplified even before the Covid-19 pandemic. Pandemic or not, some patients always had problems with transportation or lived in underserved areas that would require a long journey to receive treatment. It would be helpful for these patients to receive prescriptions via telemedicine or telephone, or simply to go to a clinic less often for medication.

On the flip side, patients who now rely on these services for treatment regardless of the pandemic, could lose if the relaxed regulations expire. This is what professionals are concerned about now: if these patients lose their means of treatment, they could give it up altogether.

That would come at a particularly disastrous time for the opioid epidemic. Even before the pandemic, deaths from overdose were trending. But with the pandemic and the continued spread of the potent opioid fentanyl, overdose deaths have skyrocketed this year: In April 2020 (the last month of data) there were nearly 78,000 deaths from overdose according to preliminary federal data – a 13 percent increase versus At the same time last year, 2020 was the worst year for overdose deaths.

According to proponents and experts, this is not a sign that measures to facilitate access to addiction treatment have failed, but that measures did not go far enough and could not go far enough to address a rapidly worsening overdose crisis. While the measures likely helped alleviate some of the pain caused by Covid-19, they did not overcome all of the hurdles for treatment in America. This is a case to build on the laid back rules and not take them away when the pandemic wears off.

"It's a matter of life and death," said Kelly Clark, president of Addiction Crisis Solutions advocacy group. "We absolutely know that people who take their maintenance drugs like buprenorphine for opioid addiction are less likely to die prematurely because of their addiction than those who don't take medication." It is very clear. "

The providers now fear that the lax rules could soon disappear

Two of the three federally approved drugs for opioid addiction, methadone and buprenorphine, are among the most heavily regulated drugs in the country. Methadone is only given in specialized clinics. Patients must go to a clinic as many times a day to receive it, only given the option to take home a few doses over time. Buprenorphine can be prescribed by a doctor and, like other medicines, picked up from a pharmacy. However, the prescribing physician must go through special certification and a personal medical examination is required to start a patient.

Then came the Covid-19 pandemic, which made these requirements almost immediately impossible for patients and providers who now had to be treated virtually.

Therefore, the federal authorities used the federal public health emergency declared to fight Covid-19 to simplify the rules. This has made telemedicine, including video and audio calling, more workable for buprenorphine and relaxed the rules for take-away doses of methadone. Local and state authorities followed suit.

However, the changes only apply until the public health emergency expires. Proponents and vendors are therefore concerned and increasingly sounding the alarm – as early as possible – to get Congress or other officials to act. You have asked federal legislators to pass the TREATS bill, which would make many of the rule changes permanent as soon as possible.

“ASAM speaks for (the American Society of Addiction Medicine) and would like the TREATS Act to be passed with any kind of legislation that goes through during this lame duck (period) so we don't have to deal with this other stranger I'm coming into the year, "said Clark, former president of ASAM and vice chairman of the group's Covid-19 task force.

The typical argument for adhering to the old rules is the fear of distraction: the drugs are diverted to a black market for recreational purposes. Buprenorphine and methadone are opioids, and while they are very effective in treating addiction, they can be abused. Loosening access to both could lead to drugs falling into the wrong hands.

As the Drug Enforcement Administration put it, “Under normal circumstances, the DEA would not consider initiating controlled substance treatment based on a mere phone call to be in line with the Controlled Substance Act because it does high risk of distraction. "

Vendors take these concerns very seriously and have implemented a number of methods such as: B. Regular urine tests to make sure people are actually taking their medication and are not relapsing. Many providers fear that loosening the rules too much and providing simple virtual treatment could make it difficult to prevent a distraction.

At the same time, some experts argue that distraction concerns are exaggerated. For one thing, some research suggests the distraction is due to people being unable to legally receive buprenorphine or any other treatment, forcing them to resort to illegal means to obtain the medication. So the stricter regulations could create more distraction, not prevent it.

This indicates that a balancing act is required. If the pandemic shows that expanding telemedicine for buprenorphine will increase access without much, if any, distraction, then the right balance may be more of a looser regimen than long-standing laws and rules suggest.

"These agencies are trying to balance the public safety side with the public health side to make these changes," said Geier, who previously worked on addiction treatment under the Obama administration. "From the CleanSlate perspective, the benefits of these things far outweigh the (distraction) concerns."

Some researchers are working to find out if this is the case and investigate how the virtual treatment worked during the pandemic. An article by JAMA Psychiatry noted that there was a lack of research on the role of telemedicine in addiction management, including whether it could be improved access and done without significant distraction.

"This could be very helpful in getting people on board," said Allison Lin, lead author of JAMA Psychiatry and addiction psychiatrist and researcher at the University of Michigan and the VA Center for Clinical Management Research. “We need more research to provide this data. We don't have such answers yet. "

Additionally, providers share their own experiences, arguing that despite the obvious disruption Covid-19 caused, they were able to maintain some level of care and even attract some patients during the pandemic. However, they also fear that after the pandemic ends, losing the new tools they have now could lead to the opposite outcome and spark an overdose crisis that is already worsening.

Effective addiction treatment is inaccessible to many Americans

Although the Covid-19 pandemic has overshadowed them in some ways, the American opioid epidemic is still in full swing. This year it has gotten even worse based on the data we have. The widespread sense of isolation and despair many people have experienced this year, as well as the greater difficulty in finding help for such issues with many places closed, have contributed to more deaths from drug overdose. Linked to this, the potent synthetic opioid fentanyl has continued to displace heroin in the illicit market – and in part because it is so potent that it is more likely to cause overdoses and death.

"While our attention is rightly focused on Covid, our overdose deaths have skyrocketed," said Clark. "We need to keep overdose deaths on the map."

One of the main contributors to this crisis was the lack of access to evidence-based treatment. Good treatment in the US is still very difficult – it can cost tens of thousands of dollars out of pocket and, despite that high cost, is still often of poor to mediocre quality. One family I spoke to last year told me they spent $ 200,000 on treatment before they found something that works. This is an extreme example, but it's not uncommon that, given the thousands of responses to Vox's survey on the subject, people spend an exorbitant amount on treatment and end up with little to nothing.

It's not because there is no evidence-based treatment. The drugs have been shown to work well for opioid addiction. Studies show that buprenorphine and methadone cut all-cause mortality in opioid addicts by half or more and are far better at helping people treat themselves than non-drug approaches. There are all sorts of other good treatments for other types of addiction, including medication and payment for people to stay on treatment (known as emergency management).

However, these evidence-based approaches are dramatically underused. According to the federal government, only 42 percent of the nearly 15,000 facilities covered by the Agency for Substance Abuse and Mental Health (SAMHSA) offer drugs for opioid addiction. This is largely due to stigma – the misconception that drugs replace one drug with another when the drugs have been shown to improve outcomes compared to continued use of illicit drugs.

So there is a shortage of providers of evidence-based treatment. If these providers are available, they may not be insured and cost thousands out of pocket. If someone has previously gone to a treatment facility and has had a bad experience due to inadequate, evidence-free care, they may also be skeptical that good help is even available. All of this makes treatment less accessible and people less receptive to it.

Because of this, much of the work in tackling the opioid epidemic, from legislation passed by Congress to government efforts to more local approaches to lawsuits, has gone into expanding access to treatment: If there is truly effective treatment, it must just ensuring that it is open to the public.

With this in mind, activists had been pushing for better access to telemedicine for years. Of particular concern were underserved areas with few providers – like rural West Virginia, which is experiencing a massive overdose crisis and not enough addiction treatment providers to meet patient demand. Telemedicine can make it easier for existing providers to fully serve other areas of the state or even people in other states.

It is also about expanding the range of care. Everyone dealing with addiction is different. Some people are good at taking medication; Some people aren't. Some will like zoom or phone treatment; Some won't. Some have a car; Some do not have reliable transportation. By providing a variety of options for the way and how care is provided, the hope is that fewer people will go untreated as there is no option for them.

"It's not saying that everyone should get telemedicine or everyone in person (treatment)," Lin said. "It was just that everyone was personal beforehand because that was the only option available."

Covid-19 has made many things worse, including the opioid crisis. A silver lining to all of this is that we also conducted a large, ongoing experiment to see if a telemedicine model is appropriate for addiction management.

Some vendors are now hoping that the possible end of the pandemic isn't the end of this experiment – as that may help stave off what is already the worst drug overdose crisis in American history.

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