Two weeks ago, as Covid-19 began to gain ground, one of the Chris Atwood Foundation’s clients – recently laid off from a job and in self-isolation in a house in Sterling, Virginia – died from an overdose.
“It’s scary to think about because I know this is going to become a lot more common,” said Ginny Lovitt, the executive director of the foundation, which provides harm reduction services, peer support, and housing grants to people with substance use disorders.
For people who rely on addiction-related services – whether it’s syringe exchange programs, medication-assisted treatment, or counseling – the growing reach of Covid-19 brings particular challenges and risks.
They’re confronting interrupted access to care and resources, as some health care organizations suspend services, support groups move online, and syringe exchanges become fraught or impossible. They’re experiencing increased stress as they worry about the pandemic, lost jobs, or fragile circumstances. And by necessity, they’re isolating themselves.
That last, Lovitt said, is particularly dangerous, because substance use disorders can be exacerbated by isolation, triggering a relapse or even an overdose.
But the pandemic has brought a few silver linings. Governmental restrictions around some medications have been relaxed. And at least one health care organization, trying out a new way to connect with patients safely, has stumbled upon a happy accident.
“Messages are conflicting right now.”
Choice Health Network in eastern Tennessee provides a range of services, including a harm reduction program that includes a syringe exchange, a support group, and distribution of naloxone – a medication that can immediately reverse an opioid overdose.
Covid-19 has changed that.
“We’re not currently offering syringe exchange services, which is pretty crushing,” said Genoa Clark, Choice Health Network’s harm reduction director. “But we don’t know at all the scope of Covid-19, especially in east Tennessee.”
The organization is used to distributing syringes in inside spaces provided by other organizations. While they’d like to start distributing outdoors, that would take time. Each space has to be approved in advance by the state’s Department of Health, Clark said, a process that can take up to two months.
“Usually 200 people come to see us at a time. Logistically, it’s really, really hard to do it without having a crowd,” Clark said. Pausing the syringe exchange program also makes it harder to pass out naloxone, which the organization receives from Direct Relief and distributes widely among clients.
Clark and Lesly-Marie Buer, Choice Health Network’s research director, said they’ve been trying to anticipate their clients’ needs. “For the last few weeks we have been giving people a lot more syringes, a lot more supplies, telling people to take what they need,” Buer said.
But both of them have concerns about the increased risk of infection to their clients, about what will happen if they can’t distribute naloxone – and, more broadly, what will happen to clients who are already at risk.
“I think it will be likely that some people will be sent into forced withdrawal from some drugs because they won’t have access, which makes me nervous that people will take things they’re just not familiar with,” Buer said.
Lovitt, at the Chris Atwood Foundation, is concerned that social distancing and financial insecurity will be a dangerous time for her organization’s clients.
“They’re sitting around with way too much time on their hands to think about things and be driven to use again,” she said. “They’re also extremely stressed because they don’t know where their next paycheck is going to come from.”
“A message of harm reduction is to never use alone, so those two messages are conflicting right now,” Buer explained.
Lovitt said there are some resources to make solitude safer, such as a hotline that people can call before using drugs. In general, however, substance use disorder is often a disease of isolation.
“Anytime somebody relapses, they’re deeply, deeply ashamed. They’re going to do it in secrecy. They’re not going to tell a roommate, ‘Hey, come watch me,’” she said.
“They know they’ve got tracks on their hands.”
Covid-19 also poses a particular risk to patients who use drugs, said Marla Pfohl, a health care program manager at Santa Rosa Community Health, also in California. This population is “fantastically famous for having a compromised immune system,” she said.
Drug use can take a heavy toll on the immune system, Pfohl explained. Her patients also have higher rates of hepatitis than the general population.
In addition, Pfohl said, many lead “dangerous, stressful lifestyles that cause these patients to have high levels of cortisol floating through their systems at all times.”
Santa Rosa Community Health provides suboxone for patients with opioid use disorder as part of its integrated approach to primary care. Pfohl is passionate about reducing the stigma associated with substance use disorder, and treating it as one would any other illness.
But she knows that’s not always the case.
“My main concern would be…people who do not have access to primary medical care,” she said. “The vast majority of people who are suffering with substance use disorder are often ashamed and treated poorly when they come in for regular medical care. They know they’ve got tracks on their hands.”
“Equal or better outcomes.”
But as health care providers and organizations work quickly to adapt to the changing demands of the Covid-19, there have been some positives, according to Caleb Banta-Green, a research scientist at the Alcohol and Drug Abuse Institute and affiliate professor at the University of Washington.
For people recovering from opioid use disorder, which can be effectively treated using methadone and buprenorphine, there’s good news.
“Access to these medications is extremely restrictive in what I think is a punitive and harmful way. However, [the Drug Enforcement Agency] and some states have reduced some restrictions temporarily,” he wrote in an email.
Eased restrictions from the Drug Enforcement Agency and the Substance Abuse and Mental Health Administration allow first-time meetings to be done virtually rather than in person, and make it possible to write longer prescriptions for some patients, Mother Jones reported.
“This is exciting and I have every reason to believe that fewer visits for medications and longer prescriptions will result in equal or better outcomes for most people,” Banta-Green wrote.
In reaction to the coronavirus, consultations with mental health providers – along with support groups and other resources – have moved online.
According to Santa Barbara Neighborhood Clinics, that may be a good thing. The California health center recently launched a telehealth program for patients receiving treatment for substance use disorder during the Covid-19 outbreak.
It’s been a remarkable success, said Alexandra Taylor, a psychiatric nurse practitioner who manages the substance use disorder clinic.
“We had fewer no-shows yesterday than we frequently have in person in clinics,” she said.
The clinic’s patients, like everyone else, are concerned about Covid-19 – and uncertain about how best to continue receiving care while the outbreak is active. “The telehealth is really really helping with that,” Taylor said.