The Coronavirus (COVID-19) pandemic has brought unprecedented challenges in healthcare delivery to people who use drugs. However, it may also have provided impetus to precipitate innovative changes in providing opioid overdose prevention, syringe services, and medication for opioid use disorder (MOUD) to this vulnerable population. In a new Viewpoint in Psychiatric Services, CHERISH Research Affiliate Yuhua Bao from Weill Cornell Medicine, Arthur Robin Williams from Columbia University, and CHERISH Director Bruce Schackman outline changes in policies addressing the opioid crisis during COVID-19 and highlight the opportunity to continue them after the pandemic subsides.
Social distancing measures and resulting social isolation may exacerbate the risk of fatal overdose due to reduced access to in-person naloxone distribution through harm reduction services and more injection drug use in isolation. In order to adapt to social distancing measures, some syringe service programs have begun or increased delivering naloxone kits and sterile syringes to clients’ homes and have relaxed policies that limit the number of syringes that can be exchanged. Community pharmacies that can distribute naloxone under state-specific standing order policies are also potential resources for naloxone and syringe distribution in areas where syringe service programs are no longer operating in-person services.
COVID-19 also presents unique opportunities to expand MOUD through telehealth and to reduce the burden of frequent visits to opioid treatment programs for medication dispensing. There are three pharmacotherapies approved by the Food and Drug Administration for OUD treatment: buprenorphine, methadone, and naltrexone. Due to COVID-19 and social distancing measures, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued guidance that permits patients to be initiated on buprenorphine through a telemedicine visit (by telephone if necessary) without an in-person exam. SAMHSA has also provided blanket exceptions for extended take home for methadone and buprenorphine dispensed by opioid treatment programs, although adoption and implementation of these measures likely varies at the state and treatment program level.
The Viewpoint authors suggest that payment reforms must accompany the expansion of telemedicine and take-home dosing in order to ensure sustainability. For example, New York State Medicaid moved from fee-for-service payment for opioid treatment program services prior to COVID-19, to adopting the Medicare weekly bundled payment codes and rates for MOUD during the emergency. Adoption of payment changes are also likely to vary by state and treatment program.
While the COVID-19 has pushed the limits of the healthcare system, it has also presented opportunities to implement innovative models of care delivery for people who use drugs. The natural experiments created by COVID-19 will enable researchers to evaluate adoption and health outcomes in order to determine which of these policy changes should be sustained long-term.