How COVID-19 Exposed the Gaps in Substance Use Care

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: we examine the pandemic's impact on access to treatment for pain and substance misuse, leading to an increase in opioid overdoses in Tennessee. We'll also look at the state's response to the crisis, and opportunities to make temporary policy reforms permanent.

DR. KELLY CLARK:
When it comes to issues of pain management and of addictive disease, the old way was a gross failure.

We do not have in place, currently, the infrastructure we need to appropriately manage chronic diseases, including chronic pain as well as addictive disease. And this, right now, is the opportunity to utilize the emergency energy that is out here and some of the relaxations—including funding coming from the feds—to build an appropriate and evidence-based system rather than throwing money at what had been used in the past but was not working.

DR. LISA PIERCEY:
Now that we have the opportunity to have a hard reset and to go forward, it's pretty difficult to say, "You know, I am going to go back to a system that I know was flawed, that I knew had difficulties," and we as leaders can't do that.

And yes, it's going to be more painful to change it going forward, but that is an imperative for us, and certainly our opioid and substance use disorder response is no different.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, people with substance use disorders and those who depend on opioids for pain management are the latest to suffer the pandemic's wrath. Access to care has been severely diminished, if not eliminated, in some parts of the U.S.—the resulting damage all too real. In Tennessee, an increase of opioid overdose cases statewide: up 26% through the end of May when compared to the same period a year ago. In the Knoxville metro area, cases are up nearly 84%.

Stories like this have state health leaders acting fast. They're responding to the new case load with a ground game, and they're thinking long term about ways to hold on to pandemic-inspired policy changes beyond their expiration dates.

Dr. Kelly Clark is an addiction medicine physician, a psychiatrist, and the immediate past president of the American Society of Addiction Medicine. She is along later with a list of areas ripe for policy reform.

But first, we visit with Dr. Lisa Piercey, a child abuse pediatrician and former hospital administrator, now on the job 18 months as commissioner of the Tennessee Department of Health.

PIERCEY:
In our typical opioid response, we're very focused on barriers—barriers to access to care, and barriers to recovery, long term recovery for those with substance use disorder.

So, that became one of our central points of focus when this first happened, is how do we continue allowing for access to care and removing barriers to successful recovery in the long term?

You know, the other one that we saw—and continue to see in facing the opioid crisis, that we knew would be an even more acute need in this COVID environment—is that of societal factors and socioeconomic factors, and how those very heavily influence not only access to pain management but specifically substance use disorder and its treatment.

And, you know, unfortunately, we have seen that. And here in Tennessee, we have seen an increase in our opioid overdoses just over the last 90 days or so. And you can look back and clearly see the relationship between those and, obviously, the societal and economic factors that are at play.

JOHNSON:
An increase in opioid overdoses since the pandemic began?

PIERCEY:
Yeah, absolutely.

So, our fatal overdoses in Tennessee through the end of May are up 26% over what they were this time in 2019, and we have seen pockets of that even much higher than the 26%, right—even upwards of 84% in our Knoxville metro area. And so, it's something that is incredibly concerning to us.

We've also seen a commensurate increase in nonfatal opioid overdoses, so keeping a close eye on that and waiting to see how that plays out, even despite our ramped-up efforts

JOHNSON:
What is your plan to try and get those numbers under control to try and help folks through this?

Because we're clearly not out of the woods on the pandemic.

PIERCEY:
We are not, absolutely. And so, we've taken a multifaceted approach.

One of the quickest things that we did and that we were able to mobilize are what we call our ROPS—regional overdose prevention specialists—to really enhance our distribution of naloxone. Because you look at the factors at play here and, you know, with reduced access to legitimate prescriptions and with an alteration of supply of what's on the street, we're seeing more adulterated product; and that, in the face of somewhat of an infused amount of money with stimulus checks and others, people are going out and buying more dangerous product. And so, having naloxone on hand, having more education and support on the ground, it's something that we've done pretty quickly.

You know, another thing that we've done is really ramp up our wraparound services because people are finding themselves, just like all over the nation, more issues: with unemployment; with housing; even with basic needs like food and clothing. And so, really ramping that up and increasing our support in order to reduce some of this stress and, quite frankly, also some of the isolation that we think is driving some of this.

JOHNSON:
Let's talk about those specialists.

What are they do? How are they doing it?

PIERCEY:
The regional overdose prevention specialists are out in the communities. They have relationships not only with individuals but with support groups and different providers and centers in their respective communities, and they are able to use those channels—as well as their individual relationships—to talk about, "Hey, this is what we're seeing. You really need to watch out for this, and let me make sure your distribution channels of naloxone are strengthened during this," and getting those to the people who could be at risk of overdose.

JOHNSON:
Talking about wrap around services—those are the social determinants you're addressing, correct?

PIERCEY:
That's right.

JOHNSON:
How do you do that?

A lot of coordination, I assume, with other people in the governor's cabinet who are addressing all of these other issues that aren't directly under your purview there at public health?

PIERCEY:
For sure.

You know, obviously one of our strongest partners—and actually who the regional overdose prevention specialists fall under—is our department of mental health and substance abuse services.

So, they are leading the charge along with public health; our department of human services with housing support, employment support; and then using community partners.

And that's what really gets the job done, is leveraging our community partners and providing them the resources that they need so they can support individuals in their communities in whatever culturally- or community-sensitive and appropriate methods that they have.

JOHNSON:
In the early days of the pandemic, were you worried this might happen?

PIERCEY:
I was worried about this; I was worried about suicide; I was worried about, quite frankly, domestic violence and child abuse—I'm a child abuse pediatrician by trade—and so, all of these things that are exacerbated by isolation, by a lack of interaction and connection with one another. You know, our folks, our friends over in mental health often say the phrase, "The opposite of addiction is connection," and when we're all socially isolated, you lose that connection.

And yes, we try to do it through virtual means, and we try to do it as safely as possible. But the fact of the matter is that people are isolated, and when you put that in the context of perhaps a loss of income, or even a loss of housing or other societal supports—that was something that we were pretty clearly worried about.

Fortunately, we have not seen the increase in suicides that we expected. We've had some blips and we've had increased numbers of calls to our crisis triage line and to our mobile crisis, but we haven't seen that pan out for suicides.

Unfortunately, we have seen that in overdoses—lots of factors at play here and, quite frankly, the increases even higher than I expected. It's terribly concerning.

JOHNSON:
How are you helping people dealing with these issues get the treatments they need?

How are you connecting them to counselors so that they can get the help necessary to maybe get back to where they were before all this started?

PIERCEY:

I mean, it just goes back to the cliche, "Necessity is the mother of invention," and while we didn't invent telehealth for this, we have really leveraged both virtual video visits as well as telephonic visits in a lot of different avenues that we hadn't done before. They were always amenable to that but, you know, when you didn't have a choice other than to interact telephonically or through telehealth...

That's the primary channel that we've used, and we've had to change some infrastructure to allow that. Obviously, one of them was the regulatory environment and we addressed that through executive order.

One of them was the payer landscape; and, so, we've had some commercial payers come on board and then the state as a safety net. We were able to allow that pretty readily and then just use some of our funds for the technology cost and the needs that we had.

And so, we're in a pretty good spot now, which begs the question of, "Is this a model that we can continue in perpetuity in the future?" And I think it is.

JOHNSON:
I wanted to ask you about that.

You know, eventually we'll have the opportunity—or the time, even—to look ahead, look beyond the pandemic. A lot of things have changed, as you've mentioned, a lot of policies have changed in Washington, which have flowed down to the states.

Do you see a better program when we come out of this fog?

PIERCEY:
I think we have to have a better program.

And, as I was describing earlier, sort of an inflection point that we've had—at least here in Tennessee—over the last couple of weeks where we're now moving into pandemic recovery, or, you know, planning for the future; and with every single conversation—and the one at hand is no exception—we have to ask ourselves, what is it that we intentionally want to improve? What lessons have we learned? What can we incorporate going forward on a more sustainable basis?

Because, you know, it's one thing to say in our previous world to say, "Oh, that's a really big problem or an issue that we're going to have to tackle," just didn't have the appetite, or whether that be financial or just the energy to do it, the appetite for change.

But now that we have the opportunity to have a hard reset and to go forward, it's pretty difficult to say, "You know, I am going to go back to a system that I know was flawed, that I knew had difficulties," and we as leaders can't do that.

And yes, it's going to be more painful to change it going forward, but that is an imperative for us, and certainly our opioid and substance use disorder response is no different. What have we learned? What can we do in the future that will get us to a better spot versus just returning back to a steady state?

JOHNSON:
What are you thinking about as far as the next steps on this topic?

Is there anything else you could be doing that you want to do or that you're going to be pursuing between now and the end of the year or even into next year?

PIERCEY:
I think, really, the primary focus here is more of a shift towards this virtual interaction. That does not replace in person interaction because it's extremely valuable, and for some patients that is really the only method that they prefer. But for telehealth and more virtual interactions, not only do we have to have the infrastructure setup to be able to do that, we also have to have the payment structure set up to do that.

Unfortunately, most of our payers have come alongside us and said, "You know, not only because of the pandemic, but hey, this worked pretty well." And so, we need to do that in the future.

So, getting the entire environment—the payer system, the regulatory system, and, quite frankly, the patient and provider relationship—getting that set up to make that a sustainable model is something that I think is really important and, quite frankly, I think it's doable. And so, we need to pursue that going forward.

JOHNSON:
Pandemic aside, how big of an opportunity do we have right now to make these changes that have been, essentially, thrust upon us, but we find they work well?

PIERCEY:
You know, I think that's going to be the question in every single sector—not only in our own provision of services to patients and to our citizens, but in our own workforce and in our society at large.

And so, I think the real leadership here comes from taking the lessons that we've learned and the new models that, quite frankly, we had to use because we didn't have any other choice—taking the good parts of that and using that to inform how we reopen and re-emerge from this.

Because, as I mentioned, just to go back to the way it was is not only ill-advised but, in some instances, it can be perceived as lazy or cowardly because we're not taking the information that we have and using it to change for the better. Because, you know, when things go back to normal—and they will eventually go back to normal—you get in somewhat of a state of inertia, and the barriers to change and the resistance become higher and higher with time. So, now's the opportunity to do it.

And I realize that when we're going back to somewhat of a normal state, financial considerations are even more at play now than they used to be, so it creates a challenging environment when you're talking about buying equipment or buying different technologies. But that is something that we're also going to have to refocus our efforts on: where do we spend our money to get the most bang for our buck going forward?

JOHNSON:
Thinking about all of the changes that have come in the various aid packages out of Washington: are you worried at all about any of those reforms—those abilities to issue waivers and such on some of these programs—that that will snap back and be gone when this is over?

PIERCEY:
You know, we were just talking about that yesterday when we were discussing telehealth in another public health program and, you know, the comment was, "Well, we only have approval to do this through the end of June. Should we restructure our entire approach to delivering care without the certainty that, just as you mentioned, without the certainty that these are going to go on in the future?"

And, you know, I would like to believe that while we're all going through our learning process, so are our federal partners and they're learning, "You know, that is a good way to deliver that service, and we were really nervous about trying it six months ago, and it was pretty risky. But you know what? It does work, and how can we get to a situation where we can deliver that in the future?"

And I have to say that our federal partners have been nothing but supportive. I have found them to provide us with the resources that we need, but also the flexibility that we need.

Because I think everybody agrees all of our states—although we're similar in some ways—we're all very different in many ways. And having the structure and the support and the resources, but also the flexibility to customize the program for what meets the specific needs of Tennessee, has been incredibly beneficial to us.

So, we've been very pleased with our federal partners.

JOHNSON:
What are the stakes involved in dealing with this issue and keeping this forward momentum?

PIERCEY:
I think when we emerge from this, there's going to be some pretty heavy financial and social devastation. We're already starting to see that.

And so, whatever we can do to intelligently and sustainably increase access and remove barriers—whether it is the population dealing with substance use disorder or any other public health concern—I think those are the types of initiatives that are going to get us past this, because we're already starting to see these stresses. Those stresses are not going to go away in six months, or in 12 months, or in 18 months when maybe the disease burden is lower.

The impacts of the economic crisis are going to be felt for a very long time, and we know that individual economic prosperity plays an enormous role in health. And so, that's why we've had a focus here in Tennessee of getting our economy restarted. We don't want to do it in a way that endangers health, but we also know it plays an important role in that.

And so, trying to balance the two is something that we're really focused on to create a healthier environment all around for Tennessee

JOHNSON:
The novel coronavirus has created a lot of pain and suffering for people but also, from a policy standpoint, a lot of opportunity.

Those are the words of Dr. Kelly Clark, an expert on addiction medicine with a long list of reforms she hopes states and territories will make soon before federal waivers expire and the public forgets.

CLARK:
The federal government has been very aggressive in making payment changes around telemedicine, with CMS taking the lead there; with loosening some of the restrictions on access to buprenorphine and methadone, with the DEA and SAMHSA taking the lead there. But while the federal government can say, "They may," it comes down to the local state jurisdictions to say if you really can or if you must do something else.

And that's one of the things we've been working on with ASAM, is to really engage—we're structured with state chapters—but to really engage with the single state authorities, with the SOTAs [Ed. note: state opioid treatment authorities]—the range of people within the states and local jurisdictions who may have much more restrictive regulations and requirements in place.

JOHNSON:
Are states and territories moving to take advantage of these policy opportunities?

CLARK:
It varies enormously from state to state.

In some states—I'm in Kentucky, and we acted very quickly here to normalize payment for virtual visits, by which I mean not just traditional telehealth but some of the changes that are being allowed now by CMS that we're calling telehealth but would not meet those stricter definitions. Now, those strict definitions are in place in a number of states still.

The other issues are around payment as well as policy of what you can do, because allowing it if the payment doesn't follow—it's not really going to move the dial here on what we need to happen.

JOHNSON:
Telehealth is one tactic impacted by the payer issue.

What are some of the others?

CLARK:
Yep. Multiple issues. And some of it's not just telehealth.

It's around some of the restrictions that we have in states, particularly around medication for addiction treatment, which is what we call MAT—used to be called medication assisted treatment, but insulin does not "assist" the treatment of diabetes and buprenorphine does not "assist" with the treatment of opiate addiction. So, there are some restrictions that are in place there, and because there are restrictions on how people must practice, payment is a part of that. But so are the actual regulations.

Some states still have requirements that patients see independent counselors or have independent counseling sessions to receive buprenorphine, which just continues to increase stigma. We don't require people with major depressive disorder to see a therapist in order to get Prozac or a person with generalized anxiety disorder to see a counselor in order to get a medication for that, but some states still have a stigma and require counseling to get addiction treatment.

JOHNSON:
Has Washington provided the flexibility needed to implement all of these changes?

CLARK:
Yes, and Washington has been very clear on some of these clinical issues as well, such as required counseling—as I've just said—but also issues around prior authorization—decreasing what's necessary for patients to access medications.

The use of different levels of care for treatment is extremely important. We can deliver some treatment using telemedicine for outpatient types of levels of care. But for inpatient care, we really need to use another approach.

And Washington, in making some of the dollars available; in being clear that addiction treatment is an essential health issue, so PPE should go to that; and et cetera—there are opportunities for the states to take a look at what they have on the books and what they have in practice using the guidance and the very rapid moving forward that the feds have done to make those changes in their states that are so necessary during this time when we need physical restrictions.

JOHNSON:
So, we've talked about telehealth, counseling, and medication-based treatment.

Are there other areas where we might look to make policy change?

CLARK:
Yes, absolutely.

So, one of the things that we don't have in place are clear requirements for quality around addiction treatment: each state licenses facilities independently; some do and some don't utilize the ASM criteria for levels of care; some made up their own levels of care.

But now, since there's actually a certification with ASM and CARF, taking a look at ensuring that what states are paying for—what they're actually exposing people to by their inpatient environments—are safe and are effective treatments. There's an opportunity for that right now.

There's also a major opportunity—and you'll see this, if you look at the guidance that we put up, by Googling ASM and COVID on our site—that where we are, in most communities, an initial phase of this pandemic where the population prevalence is low. If you've got 10, 15, 20% of your population that might be COVID positive, you can isolate those people. But once we get into, in the community, a stage where it's 40%, 50%, you can't isolate individuals. You need to actually build parallel types of systems for those who may be at high risk for infection and those who are not.

So, there are things that can be done right now in states looking forward to prepare.

JOHNSON:
Give us some examples.

CLARK:
Sure.

So, a simple example might be for opiate treatment programs. SAMHSA was very aggressive in giving guidance for the use of telehealth, as well as increasing the amount of time that people can have take-homes to two weeks or four weeks. But still, people need to come into the center, and people who are not stable will need to come more often.

As the population prevalence goes up, we're suggesting that programs look to, perhaps, have every-other-day dosing days—where specifically populations who might be at risk to be infectious come in, and days where people who are considered to be in a population that would be at low-risk to the infection come in—so that we can better isolate those populations as well, as an example.

JOHNSON:
What can we do to address issues impacting our homeless and incarcerated populations?

CLARK:
Enormous opportunities.

Opportunities around, first, funding.

One of the things we know is that when a person leaves their incarceration—just like if they leave a rehab center—their risk of dying from an overdose, if they've got opiate use disorder, is seven times higher than normal in the first month. It's an enormously increased risk. And the one thing we know—and we know this from Rhode Island—that can decrease that is getting them started on medication, particularly agonists treatment—so, methadone or buprenorphine—and following them.

So, there's funding that's out there. The decrease in restrictions around the use of the medications that the feds have done will support this, and allowing people to get into the kinds of treatment that will allow them to better integrate into society rather than come right back into the justice population.

JOHNSON:
And as it relates to the homeless?

CLARK:
Yeah, another huge opportunity. And one of the opportunities that we have right now is to learn from each other.

In this way, I would rephrase to say the work that LA County is doing and Dr. Brian Hurley—where I think he's got 4,500 addiction mental health patients who are housed in RV trailers that he's actively treating—the pivot that we need to do to population management, rather than our old individual best care for one individual, during times of disaster is a change in ethic.

It's still an ethic, but it's a change in ethic that we need to embrace, and there are people and individuals and organizations out there that are doing that. And learning from each other is something that's really imperative right now.

JOHNSON:
This is a long list.

If you were a state or territorial health official, where would you start?

CLARK:
We'll start with the understanding that, you know, you don't want to be penny wise and pound foolish, and everyone says that. But look at where you are most likely to get a return on your investment, if you will. Talk to your peers, talk to people who are doing things in different communities, and then address what is available in your community.

One of the things we know, for example, is that a hub and spoke model of doing treatment with buprenorphine in Vermont was an epic fail in LA County—like a $9 million fail—because the infrastructure, and the resources, and the culture in LA County is so vastly different. Find the best practices that are out there, adjust them to your community.

And keep in mind right now that one of the things that we're also seeing is still a cracking down on pain providers and prescribing opioids for pain. And in here in Kentucky, in particular, we had issues with, you know, the DEA coming in and closing down pain management practices. Some of those patients there were, you know, fake patients selling their medication or have opiate use disorder. But the majority, we know, are people who are simply physically dependent.

They had gotten physically dependent on higher doses—they don't have addictive disease, they don't need to be treated for addictive disease—but they are physically dependent on medication. And interacting with, getting a community ready, for that so that they're not going in and out of emergency rooms, ending up on the streets, getting opioids and et cetera, is something that communities should really take a look at aggressively.

JOHNSON:
How much time do you think states and territories have to embrace these reforms before interest in change fades away?

CLARK:
The sooner, the better, and, particularly, one of the things that you can do is to help advocate for some of these reforms to continue.

They're basically real life pilot programs, so ASAM and the AMA and other organizations are asking for, in particular, the telemedicine relaxations that have occurred during this acute stage of the pandemic to continue for one year after the emergency is declared over with so that we have a time to look at it and study and evaluate the positives and negatives of the changes that have been made, and implement—return back toward—what our new normal will be.

So, some of this is the faster you can act, the better; and the more you can strategically target continuing some of these interventions to evaluate them, also the better.

JOHNSON:
There is a concern that many of these flexibilities that have come out of Congress will expire and we'll be back to doing things the old way.

CLARK:
Right. And when it comes to issues of pain management and of addictive disease, the old way was a gross failure.

We do not have in place, currently, the infrastructure we need to appropriately manage chronic diseases, including chronic pain as well as addictive disease. And this, right now, is the opportunity to utilize the emergency energy that is out here and some of the relaxations—including funding coming from the feds—to build an appropriate and evidence-based system rather than throwing money at what had been used in the past but was not working and scaling up historic and ineffective systems.

JOHNSON:
If a state could achieve the majority of these reforms over the next year, what would be the benefit for those who need these services?

CLARK:
Well, the benefit is beyond those who need the services. It's a benefit for the totality to the community.

We have a problem in Kentucky with—we've got openings and jobs, and we can't get people to pass a drug test. This is an employer issue. We have problems with our child and family services, issues due to parents being incapable of parenting because of their active addictive disease. We have problems with our criminal justice system being overwhelmed by crime that is directly related to active addictive disease.

The benefits are societal, not just to the individual; and, if we keep that in mind, that can help guide our response.

JOHNSON:
You can find links to the resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.