In January 2019, New Jersey Governor Phil Murphy announced statewide strategies to address the opioid epidemic, which included a Medicaid initiative establishing two Centers of Excellence (COEs) to support community-based opioid treatment. About a year later, another epidemic — COVID-19 — took center stage. As states enforced shelter-in-place orders, many people receiving treatment for opioid use disorder (OUD) or other substance use disorders (SUDs) experienced a disruption in care, adding to the general stress and anxiety linked to COVID-19.
The Center for Health Care Strategies (CHCS) recently spoke with two physicians overseeing New Jersey’s COEs — which are based at Rowan University’s Cooper Medical School and Rutgers New Jersey Medical School — about their experiences treating people with OUD during the COVID-19 pandemic. Kaitlan Baston, MD, MSc, is the division head of addiction medicine and the medical director of government relations at Cooper University Health Care, and Erin Zerbo, MD, runs an outpatient buprenorphine practice at Rutgers New Jersey Medical School. They shared insights on caring for people with OUD amid the pandemic, as well as opportunities to support this population through state and federal level programs and policies. With support from the Robert Wood Johnson Foundation, CHCS works closely with partners in New Jersey to inform activities to improve health outcomes for Medicaid beneficiaries, including the state’s efforts to combat the opioid epidemic.
Q: How is the COVID-19 pandemic impacting people with OUD?
Small interactions like not being able to see people’s faces and being afraid to go out is a blanket anxiety and trauma that this population is also facing.
A: E. Zerbo: The pandemic is impacting people with OUD disproportionately. The biggest issues they’re facing are disruptions to their illicit drug supply chain and a lack of social connection due to shelter-in-place orders. Small interactions like not being able to see people’s faces and being afraid to go out is a blanket anxiety and trauma that this population is facing.
The financial crisis and the country’s high unemployment rate also increase the risk of overdose. Another additional layer of stress were the protests calling for racial justice sparked by the deaths of George Floyd and countless other Black people. Many of my patients support the protests and wanted to join, but worried about contracting COVID-19. It’s a noble call to action that essentially stressed them out.
K. Baston: All of this helps us understand why overdose death rates are up by eight percent this year in New Jersey. All of the underlying ills of society were exacerbated during this pandemic, and that further isolates and stigmatizes people who are already affected by those factors. We’re taking a disenfranchised population and making it even harder for them to get housing and jobs and meet Maslow’s hierarchy of basic needs. History tells us that when unemployment rates increase, substance use rates also increase.
Q: How have you leveraged telemedicine in your practices, and what has that experience been like both for you and your patients?
A: K. Baston: We now have the ability to reach the highest risk populations by utilizing telehealth. At the southern COE, we utilized telehealth in two major ways. First, we offered it to stable patients to allow them to shelter in place and avoid community exposure to COVID-19. This also opened up in-person visit space for our high-risk walk-in patients. Then, we partnered with a hotel in Camden County that was offering emergency shelter for COVID-19 high-risk and positive patients who were unable to self-isolate. New regulations allowed us to do video or even telephone-only intakes for people currently infected with COVID-19 who needed medication for addiction treatment (MAT).
E. Zerbo: It’s crucial for us to keep the audio-only component of telehealth, in particular for buprenorphine treatment, because we found that requiring video is discriminatory against people who don’t have access to smartphones or those who don’t have the technological ability to do video calls. I’ve been surprised by how much of a lifeline telephone check-ins have become for our patients who are disenfranchised and moving from place to place.
Q: A number of regulations have been relaxed that changed the way people with OUD access MAT during the pandemic. How have these changes impacted your practice?
A: E. Zerbo: It’s all about access. We can now engage someone at home and prescribe them buprenorphine that same day. We all know there is that window when someone decides they want to make a change and it may only last an hour. If you can only get an appointment four days later, who is going to bridge you during that time? That is why it has been so amazing to jump on the phone and prescribe buprenorphine right away.
The number of take-home doses for methadone also increased in opioid treatment programs, which was really helpful. We’re also advocating for making telephones a durable medical device, so they can get covered under insurance.
K. Baston: A policy change that would be helpful is the decentralization of opioid treatment programs and the regulations around them. Methadone is an essential medication — it does require more caution when initiating it than buprenorphine, but we need to decrease regulations and allow access to both drugs everywhere — just like other routine medical treatment.
Patient Story: A Hopeful Turnaround
“We have this one patient who struggled a lot — he wasn’t taking his buprenorphine consistently, but was forthright and engaged in group sessions. He lived and quarantined with his grandmother who he was always trying to impress. If we called, he never wanted us to leave our name on the voicemail because he wanted to protect her, even though she was aware of his SUD. Since they were quarantining together, she begged him to not go outside. So instead of going outside to use, he called us. This happened at the onset of the pandemic when everyone was scrambling to figure out what to do, so he was so grateful he could call us to seek treatment. Over the phone, we told him to go to this pharmacy, and he was already walking there as he was talking to us. We’ve been trying to get him to use buprenorphine consistently for three, four months before that, and once the pandemic started, he finally started complying with it. Ever since then, he’s been doing great. He is most proud that his family now trusts him and relies on him to help out with small day-to-day tasks. He says, ‘They know they can count on me now.’”
—Erin Zerbo, MD
Q: What resources do you recommend to providers working with people with OUD in this current environment, particularly in New Jersey?
A: K. Baston: As COEs, we want to provide the best resources for providers who are working to initiate MAT. We have several resources, including a hotline number (1-844-HELP-OUD) that providers can call 24/7 with medical questions about how to treat patients with MAT and a website for both the northern and southern COEs with resources for NJ providers in various settings, including clinics, hospitals, and emergency rooms. We’re trying to help people make the initial leap to offering MAT, because it is actually one of the easiest things you can do in health care.
Patient Story: One Call Away From a New Start
“A young man who I’ve been trying to engage in treatment for a long time has been wanting help. He’s been on methadone and buprenorphine, he’s overdosed and been to inpatient treatment several times. He’s also been incarcerated. We recently came to this moment where he said, ‘I’ll try anything to get better.’ He was incarcerated, sober, came out, and immediately called us for a telephone check-in. I asked him, ‘What do you want to start?’ And he said, ‘Buprenorphine.’ We got it to him the same day. Luckily, we found a pharmacy that was open late since he came out of incarceration at night.”
“He took the buprenorphine, but he was still struggling, so we kept working with him to find what worked best for him. He agreed to try injectable extended-release buprenorphine. I communicated this to his mom with his permission, and we brought him in to get his dose. I recently heard from his mom, and he feels better than he’s ever felt before. He’s stable, on cloud nine, and he says that that was the best thing that’s ever happened to him. We don’t always know what the right path is for a person, but we’ll just keep going until we find what works. He is finally happy and has had a month without using.”
—Kaitlan Baston, MD, MSc
Q: What can people do to better support people with OUD through this pandemic and in the future?
On an individual level, we need to destigmatize drug use, meet people with SUD where they are, and meet them with radical kindness.
A: E. Zerbo: We need to radically re-conceptualize the way we see drugs and view them as substances. When people have a problem, direct them to treatment, but give them autonomy to make those choices themselves.
K. Baston: On a community level, we need to advocate for the decriminalization of these substances because the racial disparities in our country have caused previous substance use epidemics to deeply affect communities of color — yet we’ve done nothing but criminalize it in our society. Now that the opioid epidemic is affecting primarily white and affluent people, we’re trying to use this as an opportunity to focus on all communities. We need to get urgent medical help and social stabilization to people affected by SUD and to treat this disease by addressing that hierarchy of needs that I mentioned earlier.
On an individual level, we need to destigmatize drug use, meet people with SUD where they are, and meet them with radical kindness. In our COEs, no matter how many times a patient comes in combative or irritated, we continue to treat them with respect and dignity. We have to work on helping people understand the neurobiology of addiction, so they can understand the behavior of someone with SUD. With knowledge of the medical model of addiction and empathy, you can guide practitioners to employ harm reduction strategies, and reach our communities in need.
CA Bridge is a statewide initiative aimed at starting MAT in all California hospital emergency departments by 2023. In the spring of 2020, we were collecting data from 52 hospitals across the state with MAT programs in their EDs. In this recently published article (https://authors.elsevier.com/c/1cMgH2eOOM0NKJ), we document the disruption in care patients experienced during the COVID shelter-in-place orders in the spring. Patient volume has rebounded since then, and hospitals have taken advantage of the federal policy changes that make MAT more accessible via telehealth. Like the rest of the country, California is seeing significant rises in overdose deaths which, in… Read more »