The COVID-19 pandemic has led to a major spike in substance use and drug overdoses, according to a flood of alarming reports from across the nation, and emergency physicians are calling for a unified strategy to help address the crisis.
“At least 30 states have reported increases in opioid overdoses over the past several months, essentially wiping out all the progress that has been made against this epidemic over the last couple of years,” said Scott Weiner, MD, the chief of health policy and public health in the department of emergency medicine at Boston's Brigham and Women's Hospital and the director of the Brigham Comprehensive Opioid Response and Education (B-CORE) program.
A report in the Washington Post pulled data from the Overdose Detection Mapping Application Program (ODMAP), a federal initiative that collects real-time data from ambulance teams, hospitals, and police, and found that overdoses (not all were fatal) increased by 18 percent in March 2020 compared with the same month last year. (July 1, 2020; https://wapo.st/39dGCZD.) They jumped by 29 percent in April and 42 percent in May. Fourteen suspected overdoses were reported to ODMAP in May 2020 compared with 10 in May 2019. No one expected the data from June to be anything but worse.
The phenomenon is national. From Duluth, MN, and Jacksonville, FL, to Kentucky, West Virginia, and New York City, local authorities are sounding frantic alarms about dramatic increases in overdoses and deaths. (Star Tribune. May 31, 2020, http://strib.mn/2CVeu17; News4Jax. April 13, 2020, https://bit.ly/3eKbguL; CNN. May 14, 2020, https://cnn.it/3eLlPhk; The Forum. June 5, 2020, https://bit.ly/3jlBAil.)
“The epidemic has led to extensive social isolation, which just feeds into addiction and substance use disorders,” Dr. Weiner said. “More people are using at home and dying at home. And they're afraid to come to the hospital for fear of exposure. I have heard of patients ... who have adamantly refused to come to the hospital after being revived because they're scared they will get COVID.”
At the same time, many people in treatment for substance use disorders have experienced disruptions in care. “Individuals who may have been benefiting from access to methadone, buprenorphine, and other ongoing treatment were unable to do in-person visits and get counseling,” said Kathryn Hawk, MD, an assistant professor of emergency medicine at Yale New Haven Hospital and a specialist in opioid overdose prevention. “This is all in the background of a huge stressor that is impacting every single person in this country. We know that increased stress and significant disruption in your routines, schedule, and normal social life certainly create a window for people to either have a return to use or develop substance use disorders that were not there before the pandemic.”
Adding to the concern for many emergency physicians is the change in the illicit drug supply caused by the pandemic. “With the southern border closed, the supply chain of illicit drugs is changing,” Dr. Weiner said. “We are now hearing reports of pills that look like oxycodone but contain a lot of fentanyl coming through the mail, with a very different potency than people are used to. Up in the Northeast, we saw a lot of potent fentanyl analogues early on, so that hasn't changed the presentation much for us, but Southern and Midwestern states will be hit harder because of that change. I also predict that if opioids become more difficult to obtain, we are likely to see more cocaine and methamphetamine abuse.”
Avoiding the ED
The emergency department is on the front line of the opioid use epidemic, serving as the primary health system contact for many individuals with opioid use disorder (OUD). Research shows that ED-initiated buprenorphine therapy is effective in engaging patients with untreated OUD in treatment, but no one wants to be in a hospital emergency department right now if they can avoid it.
“We have seen a significant dropoff in the number of people entering into treatment over the past few months,” said Aimee Moulin, MD, an associate professor of emergency medicine at the University of California-Davis and the behavioral health director for the UC-Davis Medical Center emergency department. Dr. Moulin is also one of the principal investigators for the California Bridge program, which involves 52 of the state's hospitals. These provide evidence-based substance use disorder treatment (medication for addiction treatment or MAT) in the emergency department and in all other hospital departments, do not stigmatize substance use, and actively work to connect people who use drugs to increase access to care, equity, and harm reduction.
“We saw people not just afraid to go into the hospital ED, but afraid to use public transportation or go to places they rely on like food banks and food kitchens for fear of exposure,” Dr. Moulin said. “This has limited a lot of the outreach that we usually do through those types of community organizations. It was a cascade of effects on our vulnerable patient populations: decreasing their ability to access care while increasing the conditions by which use disorders are fostered and/or exacerbated.”
Don't Miss an Opportunity
When patients present to the ED, Dr. Moulin noted that this may be their only point of access to the health care system when access to outpatient care and community services has decreased. “We have to start these patients on treatment when we have them and not hope that the patient will get picked up by primary care,” she said. “In every episode of care, we need to link them to treatment. And if treatment falls apart and the rest of the system is overwhelmed, as it inevitably will be as budgets start to get squeezed, our role as the safety net provider is going to expand. We need to start bringing in the resources we will need to meet that demand now.”
California's model focuses on using specially trained substance use navigators (SUNs) in the ED to help facilitate links to outpatient care by conducting initial brief assessments, introducing patients to treatment programs, including programs that provide MAT, expediting appointments at MAT-capable clinics, serving as the primary coach for their clients, and maintaining ongoing contact. They also assist with access to other services such as financial counseling, primary care, mental health services, social services, and residential treatment facilities.
“That has been instrumental to our success,” Dr. Moulin said. “Even in this financial crunch, we have been able to secure funding from the state legislature to expand the program. It's in everybody's best interests to provide this essential public health service in the ED using public-private partnerships to expand our role as a safety net provider.”
The California Bridge SUN program has now been in place for more than a year, and has served nearly 10,000 patients. (November 2019; https://bit.ly/3eOSLVS.) Initial data assessing the program's success are still being aggregated, but a 2018 review from the Urban Institute found that a screening, brief intervention, and referral to treatment for substance use disorder in the ED are cost-effective. (June 2018; https://urbn.is/2ZM1p3d.) “Everybody has started to recognize the value of having substance use treatment accessible and available in the ED, but you can't just add services without adding resources. Navigators are a cost-effective way to provide those resources,” Dr. Moulin said.
The COVID-19 guide from the American College of Emergency Physicians offers several recommendations for emergency physicians to assist in treating patients with substance use disorders during the pandemic:
- It may be difficult for patients to go to follow-up appointments or the pharmacy or to get a new prescription, so emergency physicians who have an X-waiver allowing them to prescribe buprenorphine should consider writing longer prescriptions, up to 30 days if they are comfortable doing so.
- Use ACEP's BUPE tool for assistance with prescribing buprenorphine. (https://bit.ly/3jpilEA.) Home induction can minimize time spent in the ED; the California Bridge program offers a useful guide. (https://bit.ly/32FewoR.)
- Provide information from the Harm Reduction Coalition's guide for safer drug use during the COVID-19 outbreak. (https://bit.ly/3jsN3gf.)
- Consider establishing a virtual bridge clinic under the DEA's rule (https://bit.ly/2CA5LBJ) allowing DEA-registered practitioners to prescribe controlled substances (such as buprenorphine) without having to interact in person with their patients during the public health emergency. The initial evaluation of patients with opioid use disorder and the prescription of buprenorphine can be done via telehealth or by phone.
Dr. Weiner, whose 2019 study found that those presenting to the ED after a nonfatal overdose have a one-year mortality rate of more than five percent (Ann Emerg Med. 2020;75:13), urged emergency physicians who do not have an X-waiver to pursue one. (SAMHSA, April 16, 2020; https://bit.ly/3jnlDrY.) “Prescribing buprenorphine in the ED is an important opportunity to intervene in these cases,” he said. “If some of your meetings are cancelled and you're not traveling as much due to the pandemic, it's a good time to do that eight-hour online training.”
The first online-only buprenorphine waiver training for emergency physicians, held in May, attracted more than 1000 participants. Check the Providers' Clinical Support System calendar of events to find more training opportunities. (https://bit.ly/2WHvsHI.)
Many emergency physicians would like to see the X-waiver eliminated altogether. “Requiring an eight-hour additional training in order to write a prescription for this medication—particularly for emergency physicians who are going to write something for a couple of days to link people to treatment—communicates that this is not necessarily part of their job without extra training,” said Dr. Hawk. “Emergency clinicians use much more dangerous medications on a daily basis, and are able to comfortably and safely do that.”
She stressed that nonjudgmental, patient-centered conversations are critical to ED management of substance use disorders, particularly in the current environment. “That has traditionally not always been the dynamic in the ED, which has led to a lot of conflicts. But I will tell you that these are some of the most gratifying patients I see. When you have someone who is miserable, in withdrawal, and has nowhere else to go and you treat their withdrawal and give them an experience where someone listens to them and meets their needs, that is very important,” Dr. Hawk said. “Every emergency department needs to have widespread, easy access to evidence-based treatment for these disorders, and that is more urgent now than ever before.”
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Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.