Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.


AMA Chief Experience Officer Todd Unger speaks with substance use disorder and pain management experts on how the COVID-19 pandemic has impacted the opioid epidemic.

Learn more at the AMA COVID-19 resource center.

Transcript

Unger: Hello, this is the American Medical Association's COVID-19 update. Today we will be discussing the impact of COVID-19 on the opioid epidemic. I'm joined today by Dr. Patrice Harris, AMA's president and a psychiatrist and former public health director in Atlanta. Dr. Harris is also the chair of the AMA Opioid Task Force. Dr. Elizabeth Salisbury-Afshar, director, Center for Addiction Research and Effective Solutions at the American Institutes for Research in Chicago and Dr. Steven Stanos, the medical director of Swedish Health System, Pain Medicine and Services. I'm Todd Unger, AMA's Chief Experience Officer in Chicago.

As the COVID-19 pandemic continues, so does the nation's opioid epidemic. Dr. Harris, how have people with opioid use disorder been impacted by COVID-19?

Dr. Harris: Well, Todd, as you very importantly note, we were in the midst of an opioid epidemic pre-COVID-19, and certainly, we are seeing, unfortunately, reports in the local media, the state and the national media about the increasing number of overdoses. Now those overdoses are primarily related to illicitly manufactured opioids and fentanyl, but this again has been a problem that is exacerbated by this current pandemic. We've heard those reports from 25 states. And so right at this very moment, it is so important that we continue to work together to increase access to treatment for opioid use disorder, that we increase access to naloxone and also harm reduction programs such as syringe exchange programs. Certainly we know that many are experiencing increased stresses related to unemployment, being able to provide for the family, having enough food. Certainly stress and increase amounts of isolation, and all of those could be triggers for relapse in those who are in recovery or triggers for more use or certainly for an overdose.

Unger: Dr. Salisbury-Afshar.

Dr. Salisbury-Afshar: So I would just like to start by saying, I completely agree with everything that Dr. Harris said. I think it corresponds with what we're seeing clinically in my practice in Chicago. I work in a federally qualified health center where we serve people who are experiencing homelessness, care and addiction treatment needs. And I think one of the greatest shifts that we've seen, in addition to the financial stressors and all of the things that Dr. Harris mentioned, is just the transition.

People usually utilize support services, whether it be 12-step meetings or engaging in church services or volunteer activities. And they really aren't able to engage in those services in the same way or supports. Similarly treatment, if treatment programs are open and unfortunately some that have had closed temporarily or reduce services, we've largely moved to telehealth platforms, which is great because that allows people to remain safe during COVID pandemic, but it's also challenging. And it's really engaging with folks in a different way.

Additionally, I would just say that a lot of the patients we work with actually don't have access to computers or smartphones or data plans. And so we're really relying a lot more on telephonic services, which is just not the same, and so these can put people at risk.

The other thing I just wanted to pick up on that, Dr. Harris said is that for people who are actively using drugs right now, we're seeing a lot of shifts that may be increasing risk and are probably contributing to the increasing rates of overdose death. It could be disruptions in drug markets, limited income that are putting people at risk for withdrawal and also that people are seeing reduced availability of those really, really critical harm reduction services like syringe access programs and naloxone services for a variety of reasons. But I think it's really critical that, as we think about essential services, we recognize that harm reduction services are essential services and that not having access will lead to increase morbidity and mortality for people who are using drugs.

Dr. Stanos: Yes. And I'll comment. I appreciate what's been said. I think the other issue in our pain clinic at Swedish, we also have a pain boarded and addiction boarded physician who has a very large addiction practice. And what we're seeing is really an increase in alcohol use and cannabis use. A lot of patients are at home because of the stay at home order. They're bored. They're if they were working there out of that typical work environment where they have to abstain from alcohol and other drugs. So we are seeing an increase in that. And I think patients are bored in some cases so that's kind of been a tricky time period for them.

I do think that we're in this delayed period. Initially there's the novelty of the epidemic and everyone's, I think, onboard and our patients have been better with regards to their medications, but I think we're going to see, once the reality hits with the economic issues and the job issues, like's been discussed, those patients are really at high risk for becoming unstable. So I think this is going to be a kind of a moving target we have to be careful about.

Unger: Those are some significant challenges, Dr. Harris, what is the AMA doing to address those?

Dr. Harris: Well, the AMA and of course, along with our AMA Opioid Task Force, made up of 25 national and specialty associations and representatives from those associations, been working really hard again on the opioid epidemic pre-COVID-19. But in this particular moment, we've been working with DEA. We've been working with HHS because the key issue here is eliminating treatment barriers. And one thing that has been allowed is the increase of take-home medicine of methadone. That's a medication that's used to treat an opioid use disorder. Certainly telemedicine has been mentioned, and while not a panacea, it certainly is an opportunity to increase access to treatment. But of course, it does not substitute for some of the in-person supports that we will need to make sure we ramp up as we get through this acute phase.

We also have to talk about the relaxation of testing requirements, which is good. And I'm glad Dr. Stanos has mentioned pain because, of course, pain and opioid use are sometimes intertwined. And we have to make sure that we are supporting our patients with an opioid use disorder, actually, any substance use disorder, but also our patients with pain. We need to make sure that they continue to receive the care that they deserve throughout this pandemic.

Unger: Well, let's follow up on that. Dr. Stanos, as a pain medicine physician, whose patients often have multiple comorbidities. How was your practice adjusted to address the needs of these patients during the pandemic?

Dr. Stanos: Well, I, you know, I think we've looked at it like most pain practices and focusing on risk mitigation for patients and not losing a sense of that. So really doing close monitoring of patients, doing an increasing access to virtual care, but thinking of virtual care, not just to refill medications, but to really check in on patients. And we've been able to add virtual visits for psychology and relaxation for our patients. And so I think using the virtual visits in the right way and kind of adjusting how you use virtual visits.

We've also actually been focusing not just on our patients, but our health care providers. In most systems, our physicians and staff members are under a lot of stress. So we've actually started webinars where we have 15 and 20 minutes classes for chair yoga, meditation and breathing and we've gotten a lot of support from our hospitals. So I think you have to think of the risk mitigation for patients, how do you increase access to virtual visits, but also taking care of your staff members and the hospital members, so we've been kind of looking at it as a three prong approach.

Unger: And Dr. Salisbury-Afshar, you recently published an article in the Journal of Preventative Medicine about vulnerable populations with opioid use disorder during COVID. Can you tell us how the pandemic is affecting these populations?

Dr. Salisbury-Afshar: Sure. So my coauthors and I actually wrote that article, but as often happens in medical literature, by the time it gets published, already feels like old news, but we wrote that article anticipating that we would see that certain populations, particularly people experiencing homelessness, people who are incarcerated and people with opioid use disorder would be disproportionately impacted for a variety of reasons, psychosocial reasons, in addition to factors around just sort of congregate living, physical space, et cetera.

Unfortunately, those fears have come true. And now we have seen documented cases of outbreaks and correctional facilities as well as in shelter-based settings. And we are seeing, unfortunately, as Dr. Harris mentioned, increases in overdoses at least in 25 states. So what we had hoped to do at that time was really alert public health and other health system officials that these are things we need to get out in front of.

We need to have really comprehensive plans and be thinking actively, not only for the sake of those individuals from a human rights standpoint, but also recognizing that this is an infectious condition and any sort of vector, any place that the virus is living and being spread impacts all of us. So really hoping that we would see a lot of attention paid to these populations because of their inherent risk in their environment.

You know, I will say I live and work in Chicago, and we have been part of a much broader citywide response of a variety of shelter and health care providers really thinking proactively about how to ensure that people who are unsheltered have access to a safe place to isolate and quarantine. And one of those things that we've been really focused on is for people with substance use disorders and opioid use disorder in particular, if someone's diagnosed with COVID and get sent to a shelter for isolation and their OUD symptoms aren't being treated, there's a really, really tough position for that person to be in.

And thanks to some of the regulatory changes that now allow us to initiate buprenorphine, which is another medication treatment, my clinic and several others have been able to offer telehealth services into those shelter-based setting to ensure that people who need access to medication treatment can be started without having an in person visit, which has just been so crucial during this pandemic.

Unger: Dr. Harris, any final thoughts for physicians treating patients with opioid use disorder during COVID-19?

Dr. Harris: I think there's one key word here and that word is connection, and we certainly want to and have, as you can see from the conversation here, do all that we can to increase access, to be able to connect with our patients, patients who have substance use disorder and our patients who have pain. And then, of course, the AMA and all physicians will continue to work with the federal government, with our state governments, with the legislative branches to do what we can to mitigate, eliminate any barriers to that support, any barriers to that connection.

And I will end by asking anyone, if they need more information specifically about the AMA's opioid work, and I'm going to read it because I want to make sure that everyone gets the right URL. It's www.end-opioid-epidemic.org. And they can go there to find any additional information about the great work of the Opioid Task Force and really all of the physicians who are working on the opioid epidemic across this country, physicians and organizations.

Unger: Well, Dr. Harris, thank you, and the taskforce for your continued work. And thank you, Dr. Salisbury-Afshar and Dr. Stanos for being here today and sharing your perspectives. We'll be back on Monday with another COVID-19 update. For updated resources on COVID-19 go to the AMA COVID resource center at ama-assn.org/COVID-19. Thanks for being with us here today and take care.

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