Looking out of her office window, Sally Thoren, an administrator at an addiction treatment center in Chicago, can see what’s known as the “heroin highway,” a major expressway along which runs an illegal drug market. To Thoren, it’s a constant reminder that the opioid crisis never lets up, even during a global pandemic.
Chicago is one of many American cities that has battled the nation’s opioid epidemic in recent years. Cook County saw the number of confirmed opioid deaths rise about 10 percent in 2019 from the year before. But now, in the shadow of COVID-19, officials are expecting this year’s opioid-related deaths to double 2019’s total.
For essential workers like Thoren, the pandemic means adapting to new realities and adopting new methods to provide treatment for drugs and alcohol.
One of the challenges at Thoren’s residential facility, part of the Gateway Foundation, has been capacity limitations. Because patients stay for three or four weeks, the facility is admitting a lower number of people to adhere to social distancing guidelines. All patients are screened for COVID-19 symptoms, and placed in a “semi-quarantine” while awaiting results. Thoren said that while her treatment center previously admitted 10 or 12 people a day, it is now admitting four, and there is a waitlist for treatment.
There have been reports of similar challenges across the country at addiction treatment facilities: growing waitlists, reduced hours, or facilities completely shut down because of the coronavirus.
“Are people dying in our care? No,” Thoren said. “The people who are dying are the ones who are not in care here, or at other agencies.”
Early on during the pandemic, a reduced staff at the facility meant Thoren’s own role temporarily expanded to include housekeeping tasks and helping patients get meals. Now months into the pandemic, technology is also playing a larger role to compensate for limitations at in-person treatment facilities.
The opioid resurgence is not unique to Chicago. Last month, the American Medical Association expressed its concern that states across the country were reporting an increase in opioid-related fatalities, particularly from fentanyl. However, the true degree to which the novel coronavirus is affecting the opioid crisis won’t be known for months — preliminary national data for 2019 from the Centers for Disease and Control was just recently released.
But doctors who spoke with the PBS NewsHour said reasons for an increase in deaths could be multifactorial. For one, the number of visits to hospitals and clinics are down, as people have tried to avoid catching COVID-19 from medical settings. Isolation, anxiety and other added stresses during stay-at-home orders, or due to economic hardship, could also have an impact. And as health care systems come under increasing financial strain, funding for addiction services is being cut.
Another factor, noted by Cook County Board President Toni Preckwinkle last month, is how racial inequality in the U.S. has compounded the dual public health crises, through disinvestment of communities, lack of access to care and poverty. Like COVID-19, the opioid crisis has also taken a devastating toll on people of color in Chicago. While African Americans make up under 24 percent of the county’s population, they account for half of all opioid deaths in the county this year, according to a statement from Preckwinkle’s office.
U.S. border closings have disrupted illegal drug trafficking, doctors say, leading to higher concentrations of synthetic fentanyl to make up for heroin “shortages” and potentially causing inconsistencies in what is sold and used on U.S. streets. Some drug users might seek out new sources, a risky choice if other suppliers have more potent substances.
The coronavirus “just totally scrambled the life of someone with an opioid addiction,” said Dr. Charles Reznikoff, who specializes in addiction medicine at Hennepin Healthcare in Minneapolis, Minnesota. However, he cautioned that the most recent CDC data from 2019 pointed to a record number of overdose deaths in the U.S. that predates the coronavirus outbreak, making it difficult to know what is happening in 2020.
One solution to address the gaps in care during the pandemic is telehealth services, which utilizes videoconferencing, texting and mobile apps. Back in Chicago, the Gateway Foundation has transitioned all of their outpatient services to virtual care, and Thoren believes it is a better model to safely offer support in the time of COVID-19.
To address reports of rising opioid deaths around the country, the AMA issued a set of recommendations for increasing access to treatment during the COVID-19 pandemic. The list includes pushing for states to adopt temporary rules from the Drug Enforcement Agency that say patients can be prescribed medication to treat addiction without an in-person visit first, a previous barrier to telehealth services.
Although some doctors were using telehealth long before the pandemic, there is a growing consensus in the medical community that it is a valuable way to treat in the age of social distancing, and not just for opioid use. Teletherapy for mental health services, for example, has been very popular throughout the pandemic, and according to data from the nonprofit FAIR Health, individuals are also turning to telehealth to treat chronic diseases, like diabetes.
For the time being, many private insurance companies are opting to cover telehealth services in light of COVID-19, with some even waiving costs, and Medicare is temporarily expanding its coverage for virtual visits.
President Donald Trump signed an executive order on Aug. 3 aimed at improving telehealth access in rural communities. That order also included a plan to test an incentive for rural hospitals to provide higher-quality care in exchange for more predictable Medicare payments. The administration said they would also propose regulations to extend the temporary measures offered during the public health emergency.
For telehealth to become a regular option for people in both cities and rural communities, Congress would have to pass legislation. So far, a bipartisan bill has been introduced in the Senate to make the DEA waivers permanent for states.
In March, the nation’s largest organization specializing in substance use disorders, the Hazelden Betty Ford Foundation, rolled out its virtual care program to address gaps in opioid care arising because of COVID-19.
Hazelden Betty Ford had been exploring telehealth before social distancing and stay-at-home orders, in an effort to eliminate barriers completely outside of the anxieties that come with living through a global pandemic. Not only was it a way to access those who can’t make it into a brick and mortar facility, but it may reduce stigma that some might feel by seeking help in a public or group setting.
“I think people haven’t thought about telehealth as a real option. Only as an adjunct to some other care,” said Dr. Joseph Lee, a medical director at the nonprofit. “But I see things are turning around pretty fast.”
Telehealth does not cover those without a cellphone, computer, or access to the internet, who may be adversely affected by the transition to telehealth during the pandemic if they are unable to seek help in-person.
Dr. Kurt DeVine and Dr. Heather Bell are physicians who have been training other clinicians all over the state of Minnesota to treat opioid addiction. It’s part of a program called Project ECHO, connecting rural providers to central medical centers. Because of COVID-19, they have been using a hybrid treatment of both telehealth and in-person visits.
Bell said that some patients preferred the support of the staff from in-person visits, as well as the accountability that comes with taking drug tests. But they see the benefits of reaching people virtually, like those who live far away, have inadequate transportation, are afraid to go to a rehabilitation center out of fear of getting sick — or are sick with COVID-19 symptoms themselves.
”I think being in a room with a patient is always, in my opinion, going to be a better experience,” DeVine said. But even after COVID-19 has passed, he thinks telehealth may continue to be utilized and paired with in-person visits because of its convenience. “I think the response was great and I think people are just happy to connect.”