By now, most people are aware of a novel coronavirus, COVID-19, that is wreaking public health havoc on a global scale. As of today, March 16th, 2020, over 3700 cases of novel coronavirus and 69 deaths have been reported. Once testing becomes widespread, these numbers are expected to increase significantly.
Specific populations face unique challenges. Over 23 million Americans experience a substance use disorder (SUD), among whom only 10% access treatment. Depending on the severity of their disease and access to economic and social supports, many people with SUD cycle in and out of emergency departments, addiction treatment centers, homeless shelters and correctional facilities like jails and prisons.
“Individuals with SUD are more likely to experience homelessness or incarceration than those in the general population,” wrote Nora Volkow, MD, director of the National Institute of Drug Abuse (NIDA), in Nora’s Blog, “and these circumstances pose unique challenges regarding COVID-19 transmission.”Today In: Healthcare
The American Society of Addiction Medicine (ASAM) has issued clinical guidance on their webpage, based on federal recommendations. ASAM is also sharing state-specific actions including New York State’s Office of Addiction Services and Supports, Ohio Mental Health and Addiction Services and Washington State Health Care Authority.
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“Many treatment centers unfortunately operate without medical staff or the level of physician involvement that ASAM criteria would require,” according to Kelly Clark, MD, MBA, former ASAM President and founder of Addiction Crisis Solutions. “For the health of patients, it is imperative that infection control precautions be followed.”
In this story, I will highlight the potential impact of COVID-19 on individuals with SUD (i.e. drug addiction) as well as the impact on treatment facilities. I have reached out to many experts across the country to get a sense of what’s happening at their sites, what more needs to happen, and how these rapidly-evolving global health events are impacting their vulnerable patients.
Addiction Treatment Happens at Various Settings
Most SUD treatment occurs at outpatient settings. That is, people with SUD go to work, go to school, take medications if needed, attend individual or group therapy, go back home. Many others, however, receive treatment at different clinical settings including hospitals, inpatient detox/rehab facilities, opioid treatment programs (OTPs, previously known as methadone maintenance programs) and residential treatment facilities. Vulnerable patients are being transported to and from various programs and facilities such as detox/rehab, jails, sober living and residential programs. Other facilities frequently host large-group gatherings such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA) and naloxone (“Narcan”) teachings. All of these activities are associated with a great deal of close interaction with sick or soon-to-be sick people. Not exactly the social-distancing model that public health officials are advising.
Specific Considerations for People with Substance Use Disorders
Many individuals with SUD have chronic illnesses such as heart, kidney and liver disease, which are risk factors for developing COVID-19 infection. And depending on their socioeconomic situations, many people with addiction receive poor access to high-quality health care, which means fewer vaccinations (flu, pneumonia), fewer medications to treat acute and chronic issues, and unresolved and/or worsening health issues. I once had a patient whose tiny (3mm) facial boil festered into a 2-inch, pus-oozing abscess. Why? Amidst food stamp pickup, AA meetings, court dates and case worker appointments, “I didn’t have time to come to clinic.”
COVID-19, as most people know by now, attacks the lungs and causes respiratory symptoms. This virus can seriously impact people who smoke tobacco or marijuana or who vape. In addition, individuals with opioid use disorder (OUD) and methamphetamine use disorder are vulnerable to lung injury including respiratory failure and death.
“Substances such as tobacco, cannabis and crack cocaine reduce lung function and increase susceptibility to respiratory infections,” said Peter Selby, MD, a clinician scientist at the Centre for Addiction and Mental Health (CAMH) in Toronto.
Other risk factors for coronavirus-related infection among people with SUD, as mentioned before, include decreased access to health care, unstable housing and increased risk of arrest and incarceration. If our hospitals and clinics are at capacity, then patients with addiction who are already underserved and stigmatized, will face additional barriers to treatment for COVID-19.
Social distancing, the primary preventive measure advised by the CDC, poses unique problems for people experiencing SUD and attempting to achieve or maintain long-term recovery. A common saying in this community is that the opposite of addiction isn’t sobriety, it’s CONNECTION.
“This is an especially challenging time for people with SUD since an important part of recovery is social support,” said Joshua Lynch, DO, an emergency medicine physician and co-founder of Buffalo Matters, a program designed to aid healthcare providers in treating people with opioid use disorder (OUD).
What Needs To Happen
1. Screen before arrival – before they come to clinic, ask patients about symptoms (fever, cough, shortness of breath), exposures and recent travel; advise sick patients to stay home. “We need to get the high risk patients out of waiting rooms and other crowded areas,” said Ross Sullivan, MD, Medical Director, SUNY Upstate Opioid Emergency Bridge Clinic. “We have to do whatever it takes to take care of our patients but also keep everybody safe.”
2. Waiting room precautions – post signs about hand hygiene and cough etiquette; advise people to sit 6 feet apart; mask and isolate sick patients in private rooms if possible
3. Ensure and expand access to medications. This is particularly relevant to OTPs that require people to come in daily to receive their medications. Allow take-home doses like they do in Portugal. “We are releasing medications to ill patients and decreasing pickup schedules for people who have risk factors for complications,” said Melissa Stein, MD, medical director of the Montefiore Division of Substance Abuse. Outpatient clinics are also adapting. “We’ve put policies in place that encourage providers to prescribe buprenorphine (i.e. “Suboxone”) refills without necessarily requiring visits,” according to Chinazo Cunningham, MD, MS, former member of the New York City Mayor’s Heroin and Prescription Opioid Public Awareness Task Force.
4. Revamp group therapy models – behavioral therapies are a key component to a patient’s treatment plan and long-term recovery. At residential treatment centers (RTCs), people often involve congregate in small spaces. “Therapy will need to switch to more individual sessions,” advised Michael Miller, MD, DFASAM, past president of ASAM. Intensive outpatient programs (IOPs), AA and NA will need to implement social distancing measures. Dr. Miller added: “Everyone needs to adapt to this pandemic.”
5. Telehealth implementation – now is the time to utilize technology. According to James Darnton, MD, University of Washington, “The DEA needs to approve use of Telehealth and phone visits to allow the safe assessment of symptomatic patients by OTP providers so that symptomatic patients can be assessed and safely offered take-home medications as appropriate.”
Last but certainly not least, every facility needs to implement widespread disinfection of surfaces such as doorknobs, desks, kitchen tables, stairwell handles, elevator buttons, etc. Patients and staff need to wash hands with soap and water regularly; and facilities need to make hand sanitizer widely available (it is considered contraband in many locations because of its alcohol content. And sick staff need to stay home, and management should be non-punitive.
“The economic consequences of COVID-19 will be particularly acute for those who are unstably housed, economically insecure, and who are dependent on social services,” Sandro Galea, MD, MPH, Dean, Boston University School of Public Health. “Individuals with SUD often face all three of these challenges, placing them at particularly high risk of experiencing poorer health due to COVID-19-induced societal shifts.” Our patients need strong leadership including reassurance from the health care system, from medical directors to social workers. Each staff member plays a critical role in caring for vulnerable patients.
These are unprecedented times. But I am remain optimistic: with widespread implementation of social distancing, hand hygiene, cough/sneeze etiquette and the other precautions laid out by the CDC and WHO, we’ll be able to flatten the curve and provide a safe environment for ALL members of our local and global communities. Be safe, everyone.
I am an internal medicine physician board certified in addiction medicine. I serve as clinical assistant professor at the NYU Langone Health. Previously, I served as Chief of Addiction Medicine for NYC jails including Rikers Island, overseeing substance use treatment and recovery services at the nation’s second-largest jail. Prior to moving to New York, I was a primary care doctor to Boston’s vulnerable homeless population among whom the leading cause of death was drug overdose. I also served as an attending physician at Massachusetts General Hospital and faculty at Harvard Medical School where I taught Clinical Nutrition and The Healer’s Art. Featured on CNN, Dr. Oz and Charlie Rose, I am a sought-after, charismatic speaker and media personality who has been published in the Huffington Post, STAT News and KevinMD.com, and featured in the Wall Street Journal, The Boston Globe, Cooking Light and Oprah.com. My mission is to educate and empower the public to make healthy decisions through my website, articles, YouTube channel and public speaking. My diverse public and global experiences in addiction, homeless health, incarceration, evacuation from Hurricane Katrina and medical relief to earthquake victims in Haiti have given me a unique perspective which I enthusiastically share with the public!