A public health crisis that has been brewing since the 1990’s in the United States is the opioid epidemic. Deaths attributed to opioid misuse have increased by a factor of six since 1999 with almost 47,000 deaths in 2018[i] alone. Overall, in the last 19 years, nearly 450,000 Americans have[ii] lost their lives to an opioid overdose. Minor reductions in the number of opioid related deaths[iii] were reported from 2017-2018, however newly published data shows an increase in deaths.
These new spikes, in part, are believed to be directly correlated with safety precautions put into place to help prevent the spread of the novel coronavirus (COVID-19). Such containment recommendations as social distancing and stay-at-home orders create significant barriers for those with addiction seeking support and treatment services. In addition the global pandemic has led to economic instability[iv] and increased unemployment rates[v]. Lack of access to service coupled with hard economic times have resulted in increases of substance misuse and overdoses.[vi]
Medication assisted therapy (MAT[vii]), considered the gold standard for OUD treatment, combines medical intervention with behavioral therapy. In light of widespread shutdowns, federal agencies amended their guidelines to make MAT more accessible through telehealth, thereby reducing the need for in-person contact. Telehealth services include[viii] live videoconferencing, transmitting personal health information, and sending health information via mobile devices.
Federal Agency Efforts
Amid these converging public health crises, the Office for Civil Rights within the Department of Health and Human Services lifted Health Insurance Portability and Accountability Act (HIPAA) restrictions prohibiting health care providers from communicating with patients via common virtual platforms[ix] with a goal of making it easier for doctors and patients to communicate with each other. The Drug Enforcement Agency also lifted certain restrictions[x] for some medications used as MAT. Prior to March 2020,[xi] the medications most commonly used in MAT were only available to patients after at least one in-person meeting with a doctor. Now, those seeking to begin MAT can receive a prescription virtually, without having to visit their doctor’s office. To ensure access to telehealth coverage, the Centers for Medicare & Medicaid Services temporarily changed their insurance policies[xii] to cover telephone and video calls instead of only traditional in-person appointments.
Federal Legislation and Funding
Prior to COVID-19, lawmakers introduced a series of bills focused on expanding access to treatment for those with OUD. The Mainstreaming Addiction Treatment (MAT) Act[xiv] would allow health care providers to prescribe buprenorphine for OUD without the required DEA waiver which is often seen as a barrier to helping patients. The Medicaid Reentry Act[xv] would make incarcerated individuals eligible for Medicaid coverage 30 days before their scheduled release date. This bill could be life-saving as individuals recently released[xvi] from jails and prisons are over 40 times more likely to die of an opioid overdose within the first two weeks of release compared to the general population. The Comprehensive Opioid Program Extension Act of 2019[xvii] reauthorizes funding for the opioid abuse grant program through 2024, which provides funding for local governments[xviii] to develop and implement efforts to support those impacted by the addiction epidemic.
Even with the COVID-19 outbreak, some lawmakers have remained focused on making OUD treatment more accessible, eliminating provider barriers, and expanding the duration of care through Medicaid. Members of the U.S. Senate have introduced the Telehealth Response for E-prescribing Addiction Therapy Services (TREATS) Act[xiii] to make certain federal changes permanent and ensure addiction treatment remains accessible via telehealth after the pandemic. In addition to the TREATS Act, the Coronavirus Aid, Relief, and Economic Security Act (CARES) Act also addresses OUD treatment. The CARES Act[xix] awarded $153.5 billion to public health[xx], with funding going to the CDC, FDA and expanding telehealth programs, now critical to providing support to those living with OUD. Furthermore, lawmakers on the Bipartisan Opioid Task Force[xxi] organized a virtual conference to discuss the hardships caused by COVID-19 for those living with an opioid disorder.
Analysis
Both addiction medicine experts and lawmakers realize the importance of keeping our sights on the opioid epidemic during the novel coronavirus pandemic. Given that some data show that the coronavirus pandemic has increased rates of opioid use[vi], policy changes are essential to supporting people living with OUD. Adjustments to certain federal rules and regulations have been implemented, expanding access to opioid treatment, expanding coverage of telehealth services, and easing restrictions on healthcare providers so more people can receive the treatment and support they need. Making these adjustments permanent could lead to even more Americans[xxii] accessing virtual treatment. While newer legislation including the TREATS Act and the CARES Act address challenges many with OUD have faced during the time of COVID-19, other bills that also support overcoming the opioid crisis have been introduced but do not address the new challenges people are facing as a result of the pandemic. As the U.S. continues to see opioid related overdoses rise, continued support must be given to the opioid epidemic and to those most affected by the crisis.
Sources
(i)Centers for Disease Control and Prevention, “Data Overview,” Centers for Disease Control and Prevention (March 19, 2020). https://www.cdc.gov/drugoverdose/data/index.html
(ii)Centers for Disease Control and Prevention, “Understanding the Epidemic,” Centers for Disease Control and Prevention (March 19, 2020). https://www.cdc.gov/drugoverdose/epidemic/index.html
(iii)National Institute on Drug Abuse, “Overdose Death Rates,” National Institutes of Health (March 10, 2020) https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates
(iv)Business Insider, “Coronavirus Business & Economy Impact News,” Business Insider https://www.businessinsider.com/coronavirus-business-impact
(v)U.S. Bureau of Labor Statistics, “Civilian unemployment rate,” U.S. Bureau of Labor Statistics (August 2020). https://www.bls.gov/charts/employment-situation/civilian-unemployment-rate.htm
(vi)American Medical Association, “Issue brief: Reports of increases in opioid related overdose and other concerns during COVID pandemic,” American Medical Association (September 8, 2020). https://www.ama-assn.org/system/files/2020-09/issue-brief-increases-in-opioid-related-overdose.pdf
(vii)Centers for Disease Control and Prevention, “Treat Opioid Use Disorder” Centers for Disease Control and Prevention (August 23, 2017). https://www.cdc.gov/drugoverdose/prevention/treatment.html
(viii)The Office of the National Coordinator for Health Information Technology, “Telemedicine and Telehealth,” The Office of the National Coordinator for Health Information Technology (September 28, 2017) https://www.healthit.gov/topic/health-it-initiatives/telemedicine-and-telehealth
(iv)U.S Department of Health and Human Services, “OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency,” U.S Department of Health and Human Services (March 17, 2020) https://www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html
(v)U.S. Department of Justice, “COVID-19 Information Page,” U.S. Department of Justice (n.d) https://www.deadiversion.usdoj.gov/coronavirus.html
(vi)Levine, Sunny and Wein, Emily, “COVID-19: DEA and SAMHSA Guidance for Treating Opioid Use Disorders via Telehealth,” The National Law Review. (April 10, 2020) https://www.natlawreview.com/article/covid-19-dea-and-samhsa-guidance-treating-opioid-use-disorders-telehealth
(vii)American Medical Association, “CMS payment policies & regulatory flexibilities during COVID-19 emergency,” American Medical Association (August 17, 2020). https://www.ama-assn.org/practice-management/medicare/cms-payment-policies-regulatory-flexibilities-during-covid-19
(viii)Eric Wicklund, “Senators Seek Telehealth Expansion for Substance Abuse Treatment,” mHealth Intelligence, (July 6, 2020) https://mhealthintelligence.com/news/senators-seek-telehealth-expansion-for-substance-abuse-treatment
(ix)Rep. Tonko, “The Mainstreaming Addiction Treatment (MAT) Act,” Rep. Tonko https://tonko.house.gov/uploadedfiles/mat_act_fact_sheet.pdf
(x)Rep. Tonko, “The Medicaid Reentry Act,” Rep. Tonko, https://tonko.house.gov/uploadedfiles/medicaid_reentry_fact_sheet.pdf
(xi)University of North Carolina, “Former inmates at high risk for opioid overdose following prison release,” Gillings School of Global Public Health, (July 19, 2018) https://sph.unc.edu/sph-news/former-inmates-at-high-risk-for-opioid-overdose-following-prison-release/
(xii)U.S. Congress, House, Comprehensive Opioid Program Extension Act of 2019 or the COPE Act of 2019, H.R. 1528, 116th Cong., 2D Sess. Introduced on March 5, 2020 https://www.congress.gov/bill/116th-congress/house-bill/1528?s=1&r=7
(xiii)Department of Justice, “Comprehensive Opioid, Stimulant, and Substance Abuse Program (COSSAP),” Office of Justice Programs https://bja.ojp.gov/program/cossap/overview
(xiv)U.S. Congress, Senate, CARES Act, S. 3548, 2D Sess., Introduced March 19, 2020 https://www.congress.gov/bill/116th-congress/senate-bill/3548/text?q=product+actualizaci%C3%B3n
(xv)Kelsey Snell, “What's Inside The Senate's $2 Trillion Coronavirus Aid Package,” NPR (March 26, 2020) https://www.npr.org/2020/03/26/821457551/whats-inside-the-senate-s-2-trillion-coronavirus-aid-package
(xvi)Brian Fitzpatrick, “Bipartisan Opioid Task Force Holds Virtual Discussion on Addressing COVID-19 and the Opioid Epidemic,” Brian Fitzpatrick (June 24, 2020) https://fitzpatrick.house.gov/media-center/press-releases/bipartisan-opioid-task-force-holds-virtual-discussion-addressing-covid
(xvii)Lab Blog, “Barriers to Addiction Care Fell Because of COVID-19. Now the Challenge is Keeping Them Down,” Michigan Health Lab (July 1, 2020) https://labblog.uofmhealth.org/rounds/barriers-to-addiction-care-fell-because-of-covid-19-now-challenge-keeping-them-down