In recent months, the opioid epidemic in North Carolina and across the United States has intensified in parallel with the ongoing COVID-19 pandemic. Isolation and disruptions in access to essential medications, treatment services, and other support services have increased the risk of fatal and non-fatal overdose, reflecting the suffering experienced by many and highlighting the need to protect and increase access to high-quality, evidence-based care.
According to a new report from the North Carolina Division of Public Health’s Injury and Violence Prevention Branch, emergency department visits related to overdose have increased by 22% compared to 2019. In total, nearly 6,300 overdoses involved opioids. Robeson, Caldwell, and Richmond counties had the highest rates of emergency department visits related to overdose in September. These counties, along with other rural counties, have also been among the hardest hit by COVID-19.
Guidance and resources
In response, North Carolina Attorney General Josh Stein and Secretary of the Department of Health and Human Services Mandy Cohen, announced the More Powerful NC initiative, which focuses on connecting North Carolinians to treatment and recovery support services. More Powerful NC offers:
The American Society of Addiction Medicine (ASAM) has also released guidance to support patients, providers, and policymakers in addressing challenges related to addiction treatment during the pandemic, including state-specific resources. The Harm Reduction Coalition, North Carolina Urban Survivors Union, and other organizations have published COVID-19-related resources and guidance for people who use drugs and treatment providers as well.
New funding
On September 14, 2020, the North Carolina Department of Health and Human Services received a $35 million State Opioid Response (SOR) grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) to continue funding the Opioid Action Plan 2.0 for two years. The Action Plan, launched in June 2019, is focused on:
Governor Roy Cooper acknowledged that the COVID-19 pandemic “has been particularly difficult for people with substance use disorders, and this funding will help us reduce overdoses in our state,” while emphasizing the importance of expanding Medicaid to increase the accessibility of treatment services to North Carolinians in need.
Potential considerations
“X the X Waiver”
Under the Drug Addiction Treatment Act of 2000 (DATA 2000), buprenorphine may be prescribed by certain providers that have obtained an “X Waiver” from the U.S. Drug Enforcement Administration. Eliminating the “X Waiver” has been proposed to increase access to buprenorphine by reducing prescribing restrictions and increasing the number of prescribers. This may be particularly important during the pandemic, when buprenorphine prescribers may be reassigned into critical care settings or become ill with COVID-19.
Telehealth
Unlike methadone, buprenorphine can be prescribed or dispensed in settings other than federally approved opioid treatment programs (OTPs) as a result of DATA 2000, the Comprehensive Addiction Recovery Act of 2016 (CARA), and the SUPPORT for Patients and Communities Act. Prior to the COVID-19 pandemic, however, an in-person medical evaluation was required before treatment with buprenorphine or any controlled substance could be initiated. To address concerns related to OUD treatment access during the pandemic, federal lawmakers have enabled exemptions to allow buprenorphine prescribing via telehealth services, including the use of telephone or audio-only technology during both initial and follow-up consultations. The TREATS Act, introduced in the U.S. Senate on June 30, 2020, would permanently expand telehealth services for buprenorphine treatment, but require the use of an audio-visual platform during initial consultations.
While the recent expansion of telehealth has supported access to health care services for OUD and many other conditions, it has exposed challenges related to digital equity. Inadequate access to technology or the internet, privacy, low levels of comfort or proficiency in using technology, and other factors have impacted the receipt of care via telehealth services. Improving internet access across the state has been identified as a crucial step by several North Carolina Institute of Medicine task forces and stakeholder groups, including the recent Task Force on Serious Illness Care. Permanently authorizing audio-only telehealth visits for both initial and follow-up consultations and encouraging prescribers to consider this modality could also address some concerns related to digital equity.
Intersectionality
New research indicates that people with substance use disorders, particularly Black people, are at higher risk of COVID-19 and adverse health outcomes related to the disease. Stigma, a significant barrier to supporting and improving outcomes among people who use drugs, also disproportionately affects Black people.
Stigma has been shown to reduce treatment access and utilization, despite extensive research supporting the effectiveness of buprenorphine and methadone in increasing patient retention in treatment, decreasing drug use, reducing infectious disease transmission, and supporting self-efficacy. In terms of the pandemic, stigma may prevent people who use drugs from seeking treatment if they become ill with COVID-19 and may result in the provision of substandard care if they do seek treatment, increasing the risk of adverse outcomes among historically marginalized populations in particular. Intersectional approaches provide an opportunity to better understand and address health disparities, and may be instrumental in developing and implementing strategies to reduce the toll of the opioid epidemic and the COVID-19 pandemic.
See more COVID-19 analysis here.