As we learn about the effects of the COVID-19 pandemic on our society it is clear that they are often felt most deeply in disadvantaged and marginalized communities. This public health crisis has exposed the systemic weaknesses that serve these populations, illuminating clear directions for addressing them now, and highlighting the need to rethink our future strategies, policies, and services.
Especially vulnerable during this crisis are those affected by substance use disorder (SUD). In the face of the demands on our health care system and policies that protect against virus spread, it is nonetheless essential that treatment and intervention, recovery services, and prevention mechanisms remain accessible, operational, and optimized. There are multiple opportunities to leverage the expertise within Penn State to help to address acute and long-term needs. Below I point to several areas of concern that Penn State has the capacity to address in collaboration with local and state partners that serve our communities as well as key opportunities to explore, in a scientific, evidence-based manner, policy and practice shifts that were previously seen as impossible due to political and social climates.
1. Connection to Treatment and Sustained Recovery Services: Of perhaps greatest concern is the risk of relapse for those who are in recovery. For many individuals, access to support networks can be limited due to social distancing, particularly for informal networks like friends and family. Further, many offices for sustained support (i.e. counselors and 12-step fellowship meetings) may be closed due to restrictions. The isolation, financial uncertainty, and stress collectively felt across our society may be strong triggers for relapse for some individuals as they work through their recovery process.
A range of technologies are currently being deployed to help sustain recovery for those with an SUD. For example, recovery organizations are moving their meetings online and conveners of twelve-step fellowships are hosting meetings virtually . There are also virtual counseling options such as cell phone apps like BetterHelp. Although it is promising to watch the collaborative efforts within the recovery community, it is unclear whether these modes of delivery are as effective as in-person. Further, those who are experiencing poverty or lack digital connectivity (i.e. rural areas) may be highly under-served by these services, forced to work through this time alone.
Those who face housing insecurity along with a substance use disorder are likely largely forgotten in this crisis, and organizations that serve these populations may be strained for financial and human resources. Those in transitional or group-level housing for their treatment and recovery process may be at a higher risk of contracting COVID-19 than the general population. These individuals have special need of housing, nutritional, and financial assistance due to the confluence of their poverty and substance use disorder.
2. Access to Healthcare: Some individuals with active substance use disorder or who are in recovery also have underlying health conditions that may place them at higher risk of serious symptoms of COVID-19. Therefore, it is important that these individuals have availability of high-quality health care that can appropriately treat individuals with a SUD. For example, it is important that a person with a substance use disorder not be treated with medications that could lead to relapse of their medical condition in the treatment of their COVID-19 infection.
3. Accessibility of Substances & Harm Reduction Services: While sustained recovery for substance use disorder is the highest goal in treating this medical condition, there is also a need to ensure that those who are actively using remain healthy. Through a harm reduction strategy, it remains important to support individuals through their use into their appropriate pathway for recovery. This may mean that those who are actively using may still need access to substances to avoid withdrawal, which can have dangerous consequences when not managed medically. Additionally, any reduced access to services like syringe exchanges may cause intravenous drug users to share or reuse unsafe needles. Importantly, in Pennsylvania policy changes have deemed these life-saving services.
In Pennsylvania, liquor stores have closed due to COVID-19 infections. There is great concern for those with an Alcohol Use Disorder, because stopping use of alcohol suddenly places these individuals at risk for death. Additionally, supplies of illicit substances are reduced, due to the lack of ability of cartels to move their product through shipments, airline traffic, and other means. While the reduction of this activity is positive for our communities, individuals with an active SUD could face serious negative effects including withdrawal symptoms or using unsafe substances. The effects of these sudden supply shortages could push individuals into already strained healthcare and coroners’ departments.
4. Medication Assisted Treatment Availability: Medication Assisted Treatment (MAT) remains the most effective method for the treatment of substance use disorder, particularly opioid use disorder. However, it remains widely underutilized, and there are significant hurdles for physicians to overcome in order to adopt this treatment pathway, including additional training. While models have been developed to expand access to treatment in Pennsylvania and other states, significant barriers remain to individuals seeking treatment, independent of the COVID-19 pandemic.
In most cases, individuals must connect with a treatment provider to gain access to the medications utilized in their therapy on a regular basis. For some (such as in methadone treatment) this could be daily. While some treatment restrictions are being relaxed and new guidance has been released by SAMHSA and the DEA, there is concern from some providers that not all patients meet the requirements for extended or at-home based prescriptions. These patients must then continue to receive in-person treatment, placing those in treatment and treatment staff at higher risk. As noted above, there is significant concern for those with a substance use disorder and COVID-19 infection due to the potential for underlying health issues. MAT may simply be unavailable in some locations due to staff shortages required to address COVID-19 outbreaks.
5. Drug-Related Criminal Activity: As previously noted, local and trans-national criminal organizations, similar to legitimate businesses, are experiencing supply-chain disruptions both for the illicit substance as well as the other components required to make the substances. This is driving up street prices of substances. This could further exacerbate poverty issues for those with a substance use disorder. Due to competition, this has the potential to escalate drug-related violence as cartels and dealers strive to maintain their income.
Though crime rates are falling, users may increase criminal activity (i.e. property crime, burglary) to obtain the additional funds required to purchase the substances to maintain their current use patterns. Particularly in urban areas, where some individuals who are housing insecure or experiencing poverty may rely on donations from passersby, the lack of foot traffic due to stay at home orders to reduce COVID-19 infections is likely driving down availability of funds from such sources. This could lead to increased criminal activity in these neighborhoods.
6. Overdose Death Resurgence: While the previous issues are likely more acute, it is what happens after the COVID-19 pandemic that is perhaps most concerning. I predict that we will likely see an increase in opioid overdose deaths as the pandemic restrictions are lifted. As supply chains become restored for illicit supplies of substances, there is likely to be a glut of these substances in our communities through criminal organizations who need to move these products quickly and prices will likely be reduced. Further, for those who may have adjusted down their use pattern due to increased cost or lacking availability, they may try to return to previous higher use patterns quickly, triggering fatal and nonfatal overdoses. (Note: Due to likely continued issues of supply chain lag, fentanyl from Chinese markets may not be as prevalent and not found as adulterants in heroin and counterfeit pill supplies. That may reduce overdose fatalities for a short period of time, but it will likely return as the supply chain recovers.)
Being aware of the individual, community, and systemic issues exposed during the pandemic, like those outlined above, presents us with an opportunity to reinforce mechanisms to better meet the needs of those affected by substance use disorder now and in the future. Key opportunities include the following:
1. Distribute information widely about the virtual resources available, including the following:
Mental Health Support: Crisis Text line: Text PA to 741741
2. Evaluate Effectiveness of Alternative Deliveries of Recovery Services: We need evaluations of digital and virtual delivery of services on sustained recovery to evaluate their effectiveness so that, through academic and provider partnerships, we can widen the availability of evidence-based recovery services. Programs to assist with internet services delivery and expansion of coverage to underserved areas and communities also could help us address limitations in recovery supports and services access. Further expansion of cellular phone/smart phone programs to provide access to economically disadvantaged individuals with a substance use disorder, such as in the context of a clinical trial, may provide further evidence of the need for public policy shifts and programmatic expansion.
3. Prepare Providers and Evaluate Different Modes of Health Care Delivery: This current context presents an immediate need for training of healthcare professionals, but also for greater awareness of the healthcare community, regarding treatment pathways for acute and chronic conditions for those with a substance use disorder. Technical assistance and training programs, in conjunction with evaluations, could be a way to ensure appropriate delivery of care. To understand the vulnerabilities that may be distinct to those with a SUD, we must study individual health effects of COVID-19 on this population as compared to the general public.
4. Rethink Harm Reduction Strategies: The sudden change in supply chains provides the opportunity for us to think more critically about harm reduction strategies for future policy. For example, syringe exchanges remain illegal in Pennsylvania, but could we explore the effects of exchanges in PA remaining open as compared to those states that closed services? Perhaps it is time to revisit the viability of Heroin Assisted Therapy as a treatment option? Further examinations of disruption of supply chains could help to understand the need for greater connection and alignment between supply-side and demand-side reduction strategies.
5. Continue to Optimize the Delivery of MAT: Overall, this presents us with the ability to reconsider existing MAT practices and guidelines, to ensure successful, sustained recovery for those utilizing this treatment pathway. The relaxation of prescribing guidelines could be a permanent shift in policy, pending evaluation on its effectiveness for treatment.
6. Monitor and Interrupt Drug Supply Lines: We have clear opportunities to understand illicit markets from a criminological perspective. Research on these mechanisms could help to understand how to further interrupt drug supply lines in the future. Additionally, this has the potential to develop social policy to reduce criminal activity due to poverty mechanisms, based on potential analyses of crime trends.
7. Prepare for Potential Surge in Opioid Overdoses: With this information, our first responders and hospital systems should work to adequately prepare for such a surge in activity. As we have learned in the COVID-19 pandemic, we are not as equipped as we would like for wide-spread public health issues. Perhaps now more than ever, we need to be sure we are prepared to continue to push forward aggressively with prevention, treatment, recovery services, and supply reduction mechanisms to ensure the opioid crisis continues to subside rather than resurge.
Read more about fatal overdosing during social distancing in the "Daily Beast".