The Leonard Davis Institute of Health Economics (LDI) is considered one of the world’s leading university institutes dedicated to data-driven, policy-focused research that improves our nation’s health and health care. At Penn, the LDI serves as a hub for research on population health, the health care system, and health policy. The “Experts at Home" seminar series explores issues pertinent to health, healthcare delivery and the effects of the COVID-19 pandemic.
On May 8th, 2020, a panel of substance use experts gathered virtually for an “Experts at Home" seminar from the Leonard Davis Institute of Health Economics (LDI). The topic of concern: the impact of COVID-19 on a national epidemic—opioid overdose crisis.
Battling the Opioid Crisis During COVID-19: Panel
On May 8th, a panel of substance use experts gathered virtually for Battling the Opioid Crisis During COVID-19, the fifth “Experts at Home" seminar from the Leonard Davis Institute of Health Economics (LDI) at the Perelman School of Medicine. The topic of concern: the impact of COVID-19 on another recent national epidemic—the opioid overdose crisis. The seminar featured Jeanmarie Perrone, MD, and Zachary Meisel, MD, MPH, of Penn Medicine, and Drs. Yngvild Olsen, Colleen Barry, and Joshua Sharfstein representing programs at Johns Hopkins University and the Baltimore region.
A Professor of Emergency Medicine at the Perelman School of Medicine, and Director of the Penn Center for Addiction Medicine and Policy, Dr. Perrone serves on the staff of the Penn Center for Opioid Recovery and Engagement (CORE), where she maintains a hands-on relationship with the patient population directly affected by the opioid epidemic.
Panelists included Penn Center for Emergency Care Research and Policy, and Penn LDI Senior Fellow Zachary F. Meisel, MD, MPH, MSHP; as well as Yngvild Olsen, MD; Colleen Barry PhD, MPP; and Joshua Sharfstein, MD, representing programs at Johns Hopkins University and in the Baltimore region.
Dr. Meisel is an LDI PolicyLab faculty scholar and the Director of the Center for Emergency Care Policy Research at the University of Pennsylvania. An associate Professor of Emergency Medicine, his research includes pain treatment, opioid use disorder (OUD) and patient safety.
The Vulnerability of Substance Use Disorder Patients
In the two years prior to March 2020, addiction treatment programs in the United States had achieved significant reductions in the opioid overdose death rate. These gains have been recently staggered, however, by the isolation, social distancing and economic measures instituted to prevent the spread of the COVID-19 outbreak.
A key concern for the seminar panelists was how these measures are affecting a population already burdened by the social, mental and physical sequelae of addiction.
“We don't have specific data, but we know that substance use disorder patients are at higher risk for COVID-19 morbidity and mortality as a result of lack of housing, mental issues, isolation and other struggles,” said seminar moderator Jeanmarie Perrone, MD.
Panelist Yngvild Olsen, MD, MPH, reflected on the contrary effects of social distancing and hands-on care for patients with addiction issues. Dr. Olsen is Medical Director of the Institutes for Behavioral Resources Inc., and its Recovery Enhanced by Access to Comprehensive Healthcare (REACH) program in Baltimore, which sees between 250 and 300 patients a day.
“Trying to promote social distancing within that setting was a big concern for us and other providers,” she said, noting that the risk of COVID-19 infection was a source of anxiety for patients, providers and staff alike, particularly in the wake of potential personal protective equipment shortages. In addition, Dr. Olden discussed the risk of relapse for previously stable patients facing isolation, employment and the sudden loss of connectedness crucial to treatment.
For Dr. Olsen’s programs in Baltimore, the prophylaxis for COVID-19 has meant the suspension of in-person services for counseling as well as group counseling and the intensive outpatient program. “We've been incorporating a tremendous amount of phone calls but patients are asking for more contact,” she said.
The loss of contact between caregivers and the addiction community is not unique to the Baltimore region. In Philadelphia, substance abuse consults among ER certified recovery specialists are down about 22%, explained Penn Medicine emergency medicine physician, Zachary Meisel, MD, MPH. He added that this is occurring despite evidence that total number of nalaxone reversals across the city has not abated during the pandemic.
Opportunities to Reconnect with the Substance Use Community
The disparity between the need for care among substance abusers and an understandable reluctance to access care in light of the fear of infection presents a paradox for Emergency Room physicians, Dr. Perrone observed.
However, efforts to reconnect with these patients are evolving. Dr. Olsen's organization is currently exploring relationships with bonded courier services to deliver anti-addiction medications (including methadone and buprenorphine) to patients at home. These drugs are also available now via telehealth, said Colleen Barry, PhD, MPP, due to a temporary relaxation of U.S. Drug Enforcement Administration regulations.
Telemedicine for Opioid Use Disorder Treatment
“There are real opportunities for telemedicine,” Dr. Barry said. “This moment has the opportunity to push a lot of innovation in the ways we connect with individuals who are using drugs and seeking treatment.” Dr. Barry is the Chair of the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health.
The important question in the post-COVID environment is whether these restriction relaxations will continue after COVID, according to panelist Joshua Sharfstein, MD, Vice Dean for Public Health Practice and Community Engagement at the Johns Hopkins Bloomberg School of Public Health. Dr. Sharfstein observed that the question of restriction abatement is particularly acute given the century-old legacy of denying opioid medications to the addicted.
“We have to think of this as an opportunity to develop a real evidence-base for what we can do,” Dr. Sharfstein said. “It would be a mistake to go back to the way things were without further thinking."
Dr. Perrone has observed elsewhere that it will be difficult to put this genie back in the bottle.
All panelists agreed that telemedicine was not an immediate silver bullet for the current crisis in the substance abuse community, noting issues with the initial evaluation of patients, computer and smart phone access, and infrastructure issues such as reimbursement mechanisms.
This is not to say that the picture is entirely bleak, however. “There’s been some progress, more people prescribing effective medicines, because of leaders that want to reduce the number of deaths,” said Dr. Sharfstein, concluding that he would like to see the question become how the nation both reduces the number of overdose deaths and the number of COVID deaths.
Penn Center for Opioid Recovery and Engagement (CORE)
As a CORE team member, Dr. Perrone has a unique insight into one of the ironies of opioid addiction treatment—that successful, short-term recovery can put opioid users at increased risk for overdose and death.
“Being off of these drugs really puts people in a position of higher risk because they leave treatment having lost their tolerance,” Dr. Perrone said in a recent interview. “It’s quite common for people to overdose immediately after leaving a treatment facility.”
The CORE model uses IT support to identify patients rapidly and get peers—certified recovery specialists—to the bedside before a physician consult occurs to reduce the opioid user’s experience of the implied stigma of addiction. The peers, many recovered opioid users themselves—then remain in contact with the patient as he or she begins a structured, medication-based regimen for oioid use disorder.
CORE and COVID-19
During COVID-19, CORE continues to offer free access to medication-assisted treatment and potentially, medications for opioid use like buprenorphine, methadone and naltrexone. CORE is a Pennsylvania Department of Human Services designated Center of Excellence.
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