key: cord-317538-i6amqpmt
authors: Krawczyk, Noa; Fingerhood, Michael I.; Agus, Deborah
title: Lessons from COVID 19: Are we finally ready to make opioid treatment accessible?
date: 2020-07-06
journal: J Subst Abuse Treat
DOI: 10.1016/j.jsat.2020.108074
sha: 
doc_id: 317538
cord_uid: i6amqpmt

nan

J o u r n a l P r e -p r o o f COVID-19 has devastated Americans across many communities, bringing unprecedented challenges to our economy, our healthcare system, and our way of life as we knew it. Like many historical moments and life-changing events, the COVID-19 pandemic has forced us to look inward and reflect deeply on our existing systems, shining a painful light on profound inequities and shortcomings of our healthcare and social support structures. The addiction treatment system is no exception. While there is growing recognition among experts that opioid use as a leading public health problem, addiction treatment programs remain siloed from the healthcare system and burdened with protocols based on punitive ideologies rather than evidence-based practices. Despite overwhelming evidence for methadone and buprenorphine, two opioid agonists that substantially reduce overdose risk (Sordo, Barrio, and Bravo, et al, 2017) , these medications remain highly controlled and inaccessible to most individuals in need of treatment for opioid use disorder. Strict regulations on the provision of such medications, often upheld as necessary to promote safety and avoid illicit diversion, are deeply embedded in a culture of stigma and criminalization that instead limit their use (Doernberg, Krawczyk, Agus, and Fingerhood, 2019) . This approach has generated treatment programs that prioritize adherence to rules, whether or not they are rational and effective, rather than promoting inclusion and retention. Like most patients failed by our current health system, those who suffer the most are the same vulnerable groups that will likely be hardest hit by COVID-19: Those who are victims of poverty, trauma, and discrimination and who frequently suffer from co-occurring conditions, such as depression, heart disease, HIV, and other illnesses.

Yet this restrictive approach has dramatically changed overnight, not because the paradigm has suddenly changed, but because the COVID-19 health crisis emerged. In just a matter of weeks, swift modifications in our opioid treatment regulations that the Substance Abuse and Mental Health Administration announced in March 2020 have revealed an alternative reality by which patients with opioid use disorder in the U.S. can now access treatment. Longer take-homes for methadone-which previously were only allowed after a patient completed years of daily visits to clinics-are now considered standard. Buprenorphine treatment initiationpreviously requiring a lengthy evaluation process by a waivered physician followed by frequent monitoring-can now be done over a simple phone call. Mandates for supervised urine drug screens and in-person behavioral counseling sessions have been largely relinquished or adapted to be remote. At the same time, the drive to prevent the spread of COVID-19 in detention centers J o u r n a l P r e -p r o o f has led to the unprecedented dismissal of thousands of low-level drug charges, which would have otherwise led to the incarceration of many drug users with minimal or no access to effective treatment.

These changes are a reaction borne out of necessity to prevent a disastrous surge of COVID-19 cases and a simultaneous surge in relapse and overdose deaths (Becker and Fiellin, 2020) . Social distancing policies and quarantine orders made requirements for numerous inperson visits and high vigilance of patients unrealistic and unsustainable. The truth, however, is that these requirements were never realistic or sustainable. Years of research have shown that requiring frequent visits, heavy monitoring, and mandatory participation in adjunct services to be eligible for life-saving medications created unnecessary barriers to accessing care (Krawczyk, Buresh, Gordon, Blue, et al, 2019) . Obstacles, such as long transportation times, difficulty managing appointments around work and childcare responsibilities, and the stigma associated with waiting in long lines to access treatment or provide urine drug tests under supervision, impede initiation and retention in treatment (Reisinger, Schwartz, Mitchell, et al, 2009 ). These barriers have not only resulted in limited utilization of available treatment programs but have likely helped to sustain an illicit market of buprenorphine that allows opioid users to access treatment and reduce overdose risk more easily than enrolling in a formal treatment program (Carlson, Daniulaityte, Silverstein, Nahhas, 2020) . Similarly, the health risks associated with crowded jails and cycling in and out of the criminal justice system did not begin with COVID-19: For decades, incarceration has created devastating outcomes for public health (Wildeman and Wang, 2017) , increasing risk for overdose, trauma, homelessness, and reduced access to healthcare.

The current morass and devastation of COVID-19, therefore, offers an opportunity to adopt a much-needed revision to the status-quo and create a more sustainable, equitable, and harm reduction-oriented system. Existing models for services both in the U.S. and other countries exemplify the potential for offering opioid treatment through more accessible mechanisms (Krawczyk, Buresh, Gordon, Blue, et al, 2019; Calcaterra, Bach, Chadi, et al, 2019) ,

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Methadone matters: What the United States can learn from the global effort to treat opioid addiction

Unintentional drug overdose: Is more frequent use of non-prescribed buprenorphine associated with lower risk of overdose?

Demystifying buprenorphine misuse: Has fear of diversion gotten in the way of addressing the opioid crisis?

Expanding lowthreshold buprenorphine to justice-involved individuals through mobile treatment: Addressing a critical care gap

Decriminalization: Different models in Portugal and Spain. In: Dual Markets: Comparative approaches to regulation

Premature discharge from methadone treatment: Patient perspectives

Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies

Mass incarceration, public health, and widening inequality in the USA