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.
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.
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.