Keeping up care

Health care providers are struggling to help drug abusers in the era of COVID-19
“The man takes a drink, then the drink takes a drink, then the drink takes the man,” said addictions psychiatrist Dr. Mark Broadhead to a group of 20-odd health professionals and medical students gathered for a Zoom meeting earlier in April.

It was hosted through Project ECHO Nevada, a telehealth program designed to link university-based faculty specialists to primary care providers and others in the medical field to increase learning for professionals and access to specialty care for patients with chronic and complex illnesses. That day’s participants had joined the meeting to discuss medication assisted treatment (MAT). It’s a form of treatment that’s used in situations where, as Dr. Broadhead put it, alcohol—or drugs like heroin or other opioids—have “taken” a person’s life.

The meeting started with the basics, including a discussion of the arrived upon consensus among medical professionals that addiction is a chronic disease that affects both the body and mind and requires treatment, and progressed to cover the types of medications and other interventions involved in MAT.

At Northern Nevada HOPES, where Broadhead is a consultant, the MAT program uses a combination of medication and behavioral therapy to help people recover from addiction to alcohol, heroin or other opioids. The therapy side of the program isn’t optional for those who enroll, and it’s not the only aspect of the program aside from medication. HOPES also works with patients to address co-occurring mental and physical health issues.

The various medications that can be used to treat addiction through MAT programs are prescribed depending on patients’ abuse disorders and needs, and the meeting gave an overview of how some of them work—including medications like buprenorphine, naltrexone and suboxone.

In brief, buprenorphine is an opioid, though one that cannot stimulate the brain as strongly as other opioids, like heroin. When taken appropriately, it can help prevent withdrawal symptoms and cravings. Naltrexone, on the other hand, blocks opioid receptors in the brain and can prevent all of the effects of opioid drugs, including the “high” feeling as well as overdose. Suboxone is a combination of both types of drugs. It contains buprenorphine and a medication called naloxone, an opioid blocker similar to naltrexone. Suboxone comes as a tablet or film, which—when taken orally—allows the buprenorphine to stimulate opioid receptors and prevent withdrawal symptoms. The naloxone in it is intended to prevent abuse. In the event a user attempts to melt and inject suboxone for a bigger high, the naloxone becomes active and blocks the body’s opioid receptors. Some may be familiar with naloxone as the name-brand drug Narcan, which can be given as an injection or nasal spray in emergencies to prevent opioid overdose.

The medications and the therapies and other interventions they’re used in conjunction with depend not only on a patient’s needs and specific substance abuse disorder but also on how long said person has been in addiction recovery. The same is true for how frequently a patient must be seen to receive their supply of medication, with the interval between clinic appointments and the length of supply of medication provided per visit both generally increasing as a patient progresses in recovery.

However, as is so often the case these days, the COVID-19 pandemic has resulted in interruptions to some crucial elements of the usual MAT regimen for patients at clinics like HOPES—a point that was arrived at near the end of the Project ECHO Nevada’s Zoom conference, and one that will be the main focus of the group’s next MAT discussion.

What’s happening with MAT programs during the pandemic?
After the Project ECHO Nevada Zoom conference, Danica Pierce—a licensed clinical social worker and coordinator for the MAT program at Northern Nevada HOPES—took the time outline a few of the ways the pandemic has affected the clinic’s MAT program participants and what’s being done to ensure their continued care.

“If you think about it, here’s the risk,” Pierce said. “The risk is you are taking people who are struggling with addiction, and we’ve created this environment where they’ve lost a significant amount of structure. A lot of people have lost their jobs, and so people aren’t working. They don’t have the same routines. They don’t have the same structure. They don’t have the same access to treatment. All of the mutual aid groups like AA and NA and Smart Recovery … all of the recovery programs are not having any meetings in real life. They’re doing online meetings.”

And that’s if they’re doing meetings at all. At Northern Nevada HOPES, Pierce explained, one-on-one therapy was quickly moved over to telephone and video conference. As of press time, the clinic was working out the kinks, including ensuring adequate privacy, for online group therapy sessions.

There are also worries that extend beyond the therapy aspects of MAT to the medications themselves and the ways they’re being prescribed—with more and more clinics filling prescriptions for longer periods of time, sometimes providing up to 28 days worth, in order to keep down in-person crowd sizes.

“So we’ve taken these folks who need a high level of structure in order to stay clean and be successful, and we’ve taken away a whole bunch of their structure—and so they’re at a high risk of relapse,” Pierce said. “And then we’re giving them a medication that has a street value—and these people are not working. So it’s very unsettling for us to know, to ethically and morally kind of balance what’s the right thing to do. We’re putting people at risk and trying to prevent a different kind of risk. We don’t want you to come into the clinic and get sick or get other people sick with this separate illness. But we also feel that we’re contributing to some pretty significant risk for relapse, possible overdose, possible death. So it’s real scary, man.”

The health care professionals at HOPES are trying to mitigate this risk as best they’re able by being discerning about which patients receive these longer-term supplies of medication.

“We run a tighter ship for buprenorphine than a lot of other places do,” Pierce said. “We’ve loosened that up for the purposes of this COVID situation that we’re in, but we’re also not just handing over 28 days of medication to everybody. … We’re talking about every patient individually and trying to make the best decision based on how stable they are and how engaged they are and what their risk factors for relapse are and things like that. So we are giving people more medication than we would normally give them, but we’re not doing, like, a blanket everybody gets a month’s worth.”

However, there are also concerns for people who may be using their medications correctly, at least initially, but know others who are still using street drugs.

“You know, their partner or their cousin or their sister or their friend who’s still out there using and now can’t get access and is sick, and it’s like, ‘Oh, my god. I’m so sick. Please help me. Give me some medication. … Give me half of your medication,” Pierece said. “You know, it’s hard to say no to somebody who you love who’s suffering like that. And it’s just terrible, terrible withdrawals to watch and to see somebody go through, let alone somebody you care about.”

And there’s concern that this could become a bigger problem going forward, because street supplies of drugs like heroin are rumored to be drying up as interstate travel lessens during the pandemic.
“I have heard that from a few different people, like other providers and other therapists who are treating people who are struggling with addiction and also from clients who are kind of seeing the same thing, that they’re—of course not them, but their friends—are saying it’s becoming more and more difficult to come by,” Pierce said.

And this could lead not only to more diversion of prescriptions by MAT program participants, but also more program participants in general.
“Opioids are particularly challenging because the withdrawal is so terrible,” Pierce said. “If you’re smoking pot or doing meth or some of the other things, you know—if you can’t get your hands on it—you might feel kind of desperate and want to get a hold of it, but it’s not the same as with opioids, or benzos for that matter. But particularly opioids—the withdrawal is so physiologically terrible.”

Thankfully, for now, the HOPES clinic isn’t short on supplies of MAT medications like buprenorphine and naltrexone.

“We have not seen a shortage in supplies of medication yet. We’re not having that issue yet, but it’s definitely something that we’re all talking about and are concerned is going to happen,” Pierce said. “And part of that is because … we’re going to have more people seeking access to the medication, and … it’s being prescribed in larger quantities at a time. So the thought would follow that if they’re not manufacturing at that pace that there could be a shortage.”

In the meantime, the clinic is continuing to troubleshoot the ways in which it can put medications into the hands of patients while also reducing the risk of spreading the virus—a threat that becomes clearer as the number of cases in the county continues to rise.

“We work pretty closely with some other treatment programs in town,” Pierece said. “So, today, we were having an issue where we have some clients who are in another program who are getting MAT services from us who have potentially been exposed to the virus. So they can’t come into our building. So we were troubleshooting today, like, ‘How do we get them this medication?’ because it’s a controlled substance. So it’s not like I can go down there and say, ‘Hey, give me that controlled substance. I’m just going to walk it over to them.’ So we’re trying to figure out how to coordinate to do parking lot—it’s like doing a parking lot drug deal. … It’s like, ‘Come to my parking lot. Roll down your window, and I’ll give you your opioids.’ … It just trying to figure out how to navigate all of the rules. The [Drug Enforcement Administration] is the one that controls all of these substances. And there’s only so much wiggle room that we have to try to fit all of the pieces together. It’s pretty tricky.”