Gabriel Perna | August 11, 2021
Before COVID-19, the opioid crisis was one of the most frequently talked about public health challenges in America. It was a topic that had the attention of high-level stakeholders across the industry, generated a significant amount of funding opportunities for public and private organizations, and it was the target of numerous federal and state legislative bills.
In fact, in the course of two years, a deeply divided Congress passed two bipartisan laws to address the opioid crisis. The first came in July of 2016 with the Comprehensive Addiction and Recovery Act, authorizing the use of more than $180 million to respond to the opioid epidemic. Two years later, in October of 2018, Congress passed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, another comprehensive bill addressing the crisis.
Naturally, COVID has changed people’s priorities. But while health care leaders have been appropriately focused on vaccines, mask mandates, COVID education and improving public-private collaboration since March 2020, the opioid crisis hasn’t gone away. In fact, according to recent CDC data, it has gotten worse.
“We’ve all been so focused on the global pandemic of COVID that we’ve really lost visibility to the opioid epidemic that is bubbling over in our country,” says Gerry Stanley, MD, CMO of Harvard MedTech. “It’s evident by the number of overdoses we’ve seen, not just from prescription opioid but with street drugs.”
The CDC recently released provisional data on the number of drug overdose deaths in 2020, and while some states have yet to report their information, it’s going to be the worst year on record with more than 93,000 overdose deaths, which represents a whopping 30 percent increase from 2019. Most of these deaths, the CDC says, come from opioid-related incidents. Mayo Clinic released its own data on non-fatal overdoses and found that while emergency visits on average decreased 14 percent in 2020, visits related to opioid overdoses increased by 10.5 percent.
“The number of overdoses we saw increased by a large amount—by about 10-11 percent,” says Molly Jeffery, PhD, a health economist and researcher at Mayo Clinic and one of the authors of the study. “While that doesn’t seem like much, at the same time emergency department visits had fallen off a cliff, especially in the early part of the pandemic. We did a study and found that across the country, regardless of how many COVID cases there were locally, everyone stayed home at the same time. People stopped going to the emergency department. In the early part of the pandemic, ED visits were down 40 percent across the country.”
Thus, when put into context with the reduction in ED visits, the increase is even more substantial, she notes, saying that it essentially equates to a 30-percent increase in overdoses relative to the drop off. “Things have gotten quite bad, and they continue to be bad,” Jeffery says. For the data, Mayo looked at EDs across Alabama, Colorado, Connecticut, North Carolina, Massachusetts, and Rhode Island.
Why it’s gotten worse
A 30-percent increase doesn’t happen in a vacuum. There were several reasons for this dramatic shift. The biggest driver for opioid overdoses in recent years is the proliferation of illicitly manufactured fentanyl, says Deni Carise, PhD, Chief Scientific Officer of Recovery Centers of America.
Pharmaceutical fentanyl has seen a reduction in prescriptions from doctors in the last few years thanks to the physician drug monitoring program, according to CDC data. However, Carise says illicitly manufactured fentanyl remains a huge challenge. Jeffery notes that disruptions in the drug supply chain during COVID may have also likely contributed to an increase in the supply of fentanyl in the formula of several drugs, not just heroin.
“Many of these illicitly manufactured fentanyl products are laced into cocaine, amphetamines, and even marijuana, often without the buyer’s knowledge. That actually started to tick up in 2019, but it got worse last year,” says Carise. “The field in general—people in treatment and recovery—were profoundly impacted by the pandemic.”
Indeed, COVID was a major factor in the increase of opioid-related overdoses. Carise says that people with substance abuse problems across the country lost their support systems during the pandemic. These undoubtedly led to an increase in relapses, she says. Jeffery agrees and adds that the interruptions in normal, day-to-day activities of someone who is recovering from drug abuse puts them at risk.
Furthermore, not only did they lose in-person access to the substance abuse recovery communities to which they belong, but they lost access to methadone clinics and other treatment programs, says Jeffery. “If you are getting methadone treatment, because of federal regulations you essentially have to go to the clinic every single day. You usually don’t get an appointment. You have to stand in line, you get a cup of liquid methadone so you can’t walk out and sell it. They are usually open early and not in great neighborhoods. You have to go, stand in line and hope you get out of there in time to go to your job,” says Jeffery. “When COVID hit, no one wanted to stand in line with a bunch of people they don’t know. Some of the treatment programs actually closed down.”
While there were some temporary changes from the Drug Enforcement Agency and the Substance Abuse and Mental Health Services Administration that allowed methadone clinics to give people take-home treatments, it wasn’t enough to curb the opioid related overdose rates. Recent research from Yale highlights how slow these clinics were in giving people access to treatment compared to facilities from Canada.
Molly Jeffery, PhD, Mayo Clinic
New breakthrough treatments
In a year full of morbid and depressing news, 2020 had the most opioid-related deaths on record. It’s hard to find the “silver lining” from that grim reality, but what does seem hopeful to those on the frontlines of the opioid epidemic is that different treatments and strategies have emerged to treat this disease.
Michael Presti, MD, PhD, a Mayo Clinic -trained neurologist, lost a good friend to an opioid-related overdose in the early 2000s. This set him on the path to where he is today as the founder and CEO of SafeRx, a company that produces an alcohol-resistant opioid, which can act as a painkiller for patients experiencing pain but also as an alcohol deterrent. He says that one-quarter of opioid-related overdose deaths are attributable to the fact the patient was drinking at the time the opioid was in their system.
“When those substances are in your body at the same time, they have a synergistic reaction. Basically, one plus one doesn’t equal two anymore. One plus one equals 100. They interact in a multiplicative way, rather than an additive way when they have this reaction,” Presti says. In the future, he says that opioid-related alternatives for pain treatment are in the works, but they aren’t ready for widespread distribution.
“Opioids are going to remain in widespread use for the foreseeable future. If that’s the case, we need to do everything possible to enhance the safety of them because we know they are inherently dangerous medications,” Presti adds. The company’s alcohol-resistant opioid is currently under consideration for FDA approval using an accelerated pathway. Carise notes that many people with opioid addiction often times have an alcohol dependence as well.
Stanley at Harvard MedTech is taking a more high-tech innovative approach to the opioid crisis. His company combines a virtual reality device, artificial intelligence and behavioral health change techniques to treat chronic pain patients. The virtual reality system guides patients through corrective exercises to treat chronic pain, leverages AI to drive insights into patient behavior and uses consultations with behavioral health clinicians to adjust when necessary. In general, he is confident that problem can be addressed with patient engagement and innovation, rather than regulatory enforcement.
“As a medical industry, we’re just paying lip service to the opioid crisis. We’re not looking at the root cause as well as the optimal solution. The answer for many people is to just cut off access. Let’s make it harder to get the drugs. Let’s watch the doctors. Let’s limit what we’re doing. That has value in the future, but in the present, there are a lot of people on these medications and by creating these barriers, we’re just forcing people to go the streets and look for black market solutions,” Stanley says. “While we are treating the opioid epidemic, we have to treat people.”
Increased access and telehealth
While breakthrough therapies and innovations may reverse the opioid overdose trend, a less dramatic change could move the needle, says Jeffery. For instance, she would like to see the temporary COVID-related changes involving methadone access made permanent. She’d also like to see increased access to the two of the three drugs used to treat opioid use disorder—methadone and buprenorphine. Health care needs to do a better job in reducing the stigma for these medications, she says, which often get derided in the Justice system and in 12-step programs as treating one habit with another.
“When you look at the evidence, it’s so obvious that people should have access to methadone and buprenorphine, but it’s just not happening. We have these effective treatments and they are so hard to get,” Jeffery says. “Up until 2018, Medicare didn’t cover methadone. It’s absurd.” Carise notes that there are still hoops to get patients covered for many substance abuse treatments, even though insurers are getting better at covering them.
Jeffery would also like to see another COVID-related temporary change, increased telehealth access for substance abuse treatment, expanded and made permanent. Carise agrees and says that telehealth has proven to be a vital lever for treating opioid use disorder during the pandemic. This is especially the case, she says, when factoring in treating this disease in underserved communities, which the opioid epidemic has ravaged in 2020 and previous years.
“Public and private health care organizations need to work together to offer a comprehensive system of care for people. It’s the democratization of care. Virtual care does that. The day people can get the same level of care, regardless of their socioeconomic status, their race, where they live, what they look like, that’s the goal for me,” says Carise. “If you comb through the different way that telehealth applies to our field, treating patients with substance abuse disorder, you’ll see why we can’t go back to the way things were.”
As an example, she says that many patients in a residential treatment program don’t have access to a psychiatrist and telehealth is a way to provide that necessary service in a more efficient, time sensitive manner. It also addresses challenges with stigma and transportation, she says. In general, health care’s leading stakeholders, those who paid close attention to this problem before COVID, need to take multiple approaches to reversing 2020’s damaging trend.
“To health care leaders, we need to look at all aspects of the problem and all of the different things that can help,” Carise says. “There are too many people that do things with recovery one way and that’s the only way to treat it. That would be like saying we should only treat heart disease one way. You don’t see that in any other field of medicine. We need to embrace different kinds of treatment.”