The nation is focused on the COVID-19 pandemic, but the opioid epidemic remains in full force.
Just as the nation’s other top underlying concerns—hypertension, obesity and diabetes—have gone unabated, opioid-use disorder (OUD), overdoses and deaths continue to be a growing concern.
An AMA issue brief, “Reports of Increases in Opioid-Related Overdose During COVID Pandemic,” lists the steps states must take to save lives, reduce harm and get people the treatment they need. It also notes the concerns stemming from a growing number of national, state and local media reports suggesting swells in opioid-related mortality—particularly from illicitly manufactured fentanyl and fentanyl analogs.
One example cited is in DuPage County, Illinois, a suburban area west of Chicago, where officials were obliged to issue a public safety announcement earlier this month warning residents of a surge in overdose deaths.
“In the past three weeks, we have had 20 overdose deaths, mainly due to opioids,” Richard Jorgensen, MD, the DuPage County coroner, said in the announcement. “We do not know if this is due to a change in the makeup of the drugs, drug usage on the streets or due to current COVID-19-related changes in society.”
To be sure, COVID-19 is a major concern in the area, with the Illinois Department of Health recording 315 deaths in the county from the disease. But the agency also reports that there have been 303 overdoses reported in DuPage hospital emergency departments in 2020.
Dr. Jorgensen said in an interview that state and county numbers are not always a match as coroner reports list the county where people died while the state tracks deaths by where the deceased previously lived.
The issuing of the public safety announcement was prompted by two days on which his office recorded three fatal overdoses. “That’s unheard of in this area,” Dr. Jorgensen said, adding that—after the announcement was released on May 13—there were two more fatal overdoses that night, bringing the county’s three-week total to 22, compared to 96 for all of 2019.
“That’s a marked increase,” Dr. Jorgensen said. He added that he reviewed all the fatal overdose reports and noted in the announcement that many of those who died were living alone, having personal or marital difficulty, had a history of mental health issues such as depression, or recently received treatment for substance-abuse disorder.
After the local media reported on his announcement, Jorgensen said local treatment facilities reached out to him.
“They said we were echoing what they had seen, and they were seeing increasing problems with people they had treated relapsing or reaching out to their sponsors,” Jorgensen said, adding that he was seeing this as a call to action.
“We need to reach out to the vulnerable in our society,” he said. “As physicians, we know which of our patients are having trouble and we need to reach out to them.”
In Shelby County, Tennessee, 391 suspected overdoses were reported to have occurred between April 7 and May 7, resulting in 58 deaths. Other surges have been reported in Milwaukee County, Wisconsin, and Franklin County, Ohio.
The AMA brief cites reports from Franklin County, which includes the city of Columbus, Ohio, where the coroner has also been issuing warnings.
“As you may have seen, Friday night to Saturday night our county saw 28 nonfatal overdoses—this is a high number for our county,” Anahi Ortiz, MD, posted May 3 on Facebook. “COVID-19 has showed us the vulnerabilities and deficiencies in our addiction services—in addition, it has increased the mental health needs of this population.”
She reported that Franklin County had 62 fatal overdoses in April and noted that much of the cocaine being ingested by county residents is cut with fentanyl without their knowledge.
“We need to push naloxone,” Dr. Ortiz wrote. “We need to check in with those who use. And we need to continue to advocate for wiser and better ways of treating those with addictions.”
Emphasizing the importance of naloxone to help save lives is part of the AMA’s recommended state strategies for harm reduction and helping patients with OUD and living with pain.
The AMA encourages physicians to co-prescribe naloxone to patients at risk of overdose when it is clinically appropriate. (The AMA Opioid Task Force has identified several factors physicians should consider regarding when to do so.) Patients are encouraged to take advantage of state standing orders that allow them to obtain naloxone directly from a pharmacy without a patient-specific prescription.
New policies have been enacted on the federal level by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Administration (DEA) that give physicians and other providers more flexibility in providing buprenorphine and methadone to patients with OUD.
One SAMHSA policy, for example, allows patients to obtain up to 28 days of take-home medication if they are stable, and up to 14 days if they are less stable but still patients the treatment program believe can safely handle that level of take-home medication.
“During this pandemic, it is critical for patients to be able to access medication without delay,” said AMA President Patrice A. Harris, MD, MA, also chair of the AMA Opioid Task Force. “With public transportation limited and social distancing being recommended, physicians know that their patients might not be able to come to the opioid treatment program on a daily basis.”
The AMA is advocating that states implement those and other policies. Specifically, the AMA calls for states to:
- Adopt the new SAMHSA and DEA rules and guidance in full for the duration of the national COVID-19 emergency—including flexibility for evaluation and prescribing requirements using telemedicine.
- Remove prior authorization, step therapy and other administrative barriers for medications used to treat OUD.
- Remove existing barriers for patients with pain to obtain necessary medications. This includes removing arbitrary dose, quantity and refill restrictions on controlled substances.
- Enact, implement and support harm-reduction strategies, including removing barriers to sterile needle and syringe services programs.
There have been some positive developments. Indiana Gov. Eric J. Holcomb announced May 18 that his state would use a nearly $1 million SAMHSA grant to distribute naloxone to at-risk populations throughout the state.
“In the face of COVID-19, it’s even more imperative that we provide resources and support for people with substance-use disorders,” Gov. Holcomb said. “Making potentially lifesaving treatments more readily available is one of the top ways we can address this crisis.”
Read the full range of AMA recommendations for states to help patients with opioid use disorder and pain as well as how to further harm reduction efforts.