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Opioid Addiction During a Public Health Crisis

October 1, 2021 . 614 views . View Full Issue (Volume 11, Issue 1) . Print this page

By: Anjali Rana, PharmD Candidate c/o 2025 and Katharine Russo, PharmD

              The Coronavirus disease 2019 (COVID-19) pandemic continues to pose challenges, both nationally and worldwide. Many countries that were facing public health crises prior to COVID-19 have subsequently seen a worsening of these crises, as much of the funding and attention previously available has been diverted and directed towards addressing COVID-19. Opioid addiction is one such public health crisis demanding of our attention. Addiction is a disease of uncertainty, isolation, and anxiety.1 These are feelings that can oftentimes be the precipitating factors that push folks to clinical manifestations of addiction that include alterations in behavior, mental status, appetite, physical appearance, as well as increased substance tolerance.1 The emotional strain caused by isolation during quarantine has, in many instances, led to folks looking for ways to cope. Pharmacists play an essential role in caring for patients who are struggling with opioid addiction. In order to provide optimal support, pharmacist should be knowledgeable of local, state, and federal efforts being made to address the opioid epidemic, as well as the numerous resources available to help support those in need.

COVID-19 has led to an increase in overdoses and deaths, with 596 overdose deaths being confirmed in New York City (NYC) during the first quarter of the 2021 calendar year.2  Numerous states across the United States (US) have reported an increase in overdoses and fatalities, with those numbers expected to increase as the pandemic continues.2,3,4 Brad Anderson, MD, Chief of addiction medicine at Kaiser Permanente Northwest in Portland, Oregon reiterates, “addiction thrives in isolation and dies in community — but this is a conundrum during the pandemic, because every day we’re being reminded to keep our distance and stop connecting in our usual ways.”5

  To address the current opioid epidemic, outside of the confounding global pandemic, New York State (NYS) is utilizing tools to educate the community on how to combat substance abuse. With the creation of tools such as the Substance Use Disorder Educational Resource flash drive toolkit, schools will have the resources necessary to facilitate discussions and stay abreast of the latest changes implemented by the state during COVID-19. It is essential to educate students on how prescription drug abuse can be dangerous when individuals are using medications more frequently than prescribed.6

Outside of the classrooms, New York continues to push for medication-assisted treatment (MAT) and limits for prescribing of substances carrying the potential for addiction.7  MAT’s involve the use of medications in conjunction with counseling therapies to treat opioid use disorders (OUD’s), aiding in the recovery process. In 2016, NYS enacted a law stating that practitioners can prescribe no more than a 7-day supply of schedule II, III, and IV opioids for acute pain. The law defines acute pain as pain that the practitioner reasonably expects to last only a short period of time. This applies to the initial prescription of opioids for acute pain. The law later goes on to identify certain exceptions to this rule; prescriptions for chronic pain, pain being treated as a part of cancer care, hospice or other end-of-life care, or pain being treated as part of palliative care practices.20 By limiting the initial amount of prescription opioids being dispensed to the patient, there is the potential to reduce the incidence of addiction. Prior to enacting this law, practitioners oftentimes inappropriately prescribed large quantities of opioids to patients with acute pain, resulting in many patients developing addiction. As an additional safety measure against irresponsible prescribing practices, prescribers are required to complete three hours of course work or training on pain management and addiction every three years per NYS law. 8

Enacted into NYS law in 1984, the 911 Good Samaritan Law was put into place in an effort to protect those involved in an opioid-related medical emergency.23 This law ensures that if an individual witnesses signs of an overdose (slow, weak breathing, chocking or gurling, discolored, cold or clammy skin), they can call 911 without fear of retaliation for being in possession of illicit drugs themselves or being underage in the presence of alcohol use, for example. There are exceptions to this law, however. The Good Samaritan Law does not protect individuals from a felony possession charge for possession of substances over 8 ounces, sale or intent to sell controlled substances, individuals found to be in violation of probation orders, or those having an open warrant for arrest.9

Methadone, buprenorphine, and naltrexone are Food and Drug Administration (FDA)-approved MAT’s for OUD. These medications help minimize the risk of withdrawal symptoms oftentimes seen in patients suffering from opioid addiction. Signs of withdrawal include nausea, vomiting, diarrhea, anxiety, hyperthermia, tachycardia, sweating, high blood pressure, and muscle aches.24 Methadone is available through maintenance clinics and opioid treatment programs.13 Methadone acts as an opioid agonist which binds to mu-opioid receptors, altering the brains response to pain.10 As a schedule II narcotic, methadone clinics limit patients to a one-day supply of medication, meaning that the patient must present to the clinic daily. This is meant to deter misuse of the opioid medication, as the patient will be less likely to exceed the maximum daily amount. Buprenorphine is a partial agonist at the mu opioid receptor. This enables for an alteration in the brains response to pain sensations, but at a weaker strength.11 Buprenorphine is available at outpatient pharmacies when prescribed by a physician in an office-based setting, unlike methadone which must be dispensed in a narcotic treatment facility (NTF). Naltrexone is classified as an opioid antagonist which means that it competes with opioids for opiate receptors, displacing opioid drugs and thus reversing their effects.12

Prior to COVID-19, patients receiving methadone as part of MAT were required to pick up their medication daily at their opioid treatment center.13 This process increased the patients risk for contracting or spreading infection. As of May 2020, the federal government has approved methadone deliveries during the pandemic.14 The New York Health Department and the NYS Office of Addiction Services plan to deliver 1300 prescriptions per month with staff using personal protective equipment (PPE) according to guidelines. The new change in methadone treatment regulations was largely meant to assist patients who contracted COVID-19 or were exposed to someone who contracted COVID-19, so that they can still get their medications without exposing themselves or others to illness. This change has reduced the financial burden of transportation, and greatly reduced the fear and anxiety many patients face leaving their homes during the height of the pandemic.15 Of note, there is also a push for community pharmacists to dispense the opioid reversal agent, naloxone (Narcan®). States like New Jersey partnered with 322 independent and community pharmacies in September 2020 to give away 72,000 doses of naloxone without a prescription and free of charge to help curb the increase in overdoses during the pandemic.19

New protocols have been implemented in the opioid treatment centers according to guidance set by the Office of Addiction Service and Supports of New York State (OASAS). These centers are now required to provide a COVID-19 questionnaire to individuals entering facilities, check temperatures, and inquire if the patient is experiencing any symptoms. For patients identified to be experiencing respiratory illness, they would be placed in an isolation room. In this situation, the patient can receive their prescription but should be isolated from the public area to decrease risk of disease transmission.16 Patients who have chronic medical conditions or are vulnerable to infection are given a 28-day supply of their prescription from the treatment center. This is based on risk vs benefit, taking into account the risk of diversion in comparison to risk of infection to the patient and those who they come in contact with.16

In response to COVID-19, new tools are being utilized to help patients recover from drug abuse. Telemedicine has expanded the outreach of our nation’s healthcare facilities by allowing practitioners to meet with patients remotely. For instance, “Families against Narcotics” and “National Alliance on Mental Illness” are both programs offering opportunities for patients to speak virtually with a specialist and other practitioners who deal with narcotic misuse. The goal is to continue promoting group support despite social distancing protocols put in place in light of the pandemic.17,21 Yale University has created a guide called, “Guidance for people who use substances on COVID-19″, a useful tool for individuals who may not be aware of the serious consequences associated with opioid abuse.21

New apps are additional tools that have been created in response to COVID-19 that have helped bolster community support. The Sober Grid, for instance, is a community of individuals recovering from their struggles with drug abuse. This app features live peer coaches who document and share progress with others to build support. This app encourages patients to look towards new activities and hobbies in life that are healthier than drug abuse.18 This is a free app, ensuring that folks can take part without the worry of another financial burden. WEconnect Health Management is another app that has enabled fresh advances in the lives of those struggling with addiction. Patients can stay on track with their recovery by receiving reminders from their sponsor, or by attending group sessions. This app encourages patients to develop a plan and stay focused on achieving their goals in life.

              It has been said time and time again how pharmacists are the most accessible health care providers. As the opioid epidemic continues to threaten the world, pharmacists remain an indispensable outlet for those struggling with addiction. It is essential that pharmacists be prepared to provide patients struggling with addiction the appropriate resources needed to overcome these struggles and live a healthier life. Pharmacists can encourage patients to find ways to stay connected with those in their community. Facetime, Zoom, and WebEx are some of many video conferencing platforms that have allowed the world to stay connected during times of isolation. Pharmacists can introduce patients to support groups, such as Alcoholics Anonymous and Narcotics Anonymous, which have gone virtual during the pandemic.22 Developing a routine can be beneficial to everyone, not just those battling addiction. When possible, patients should be encouraged to identify healthy routines they had prior to the pandemic, and continue them if they can be done in a safe manner.  For activities that cannot be done safely, patients should be encouraged to find new activities and hobbies. This can include staying active and exercising, for those who have not engaged in those activities previously. Finally, those struggling with addiction should be encouraged to never give up. Relapse is not a sign of personal failure. Relapse is an opportunity for pharmacists and other healthcare professionals to utilize their knowledge and training to provide better, continued support.

References:

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  2. Unintentional drug poisoning (overdose) deaths quarter 1 … https://www1.nyc.gov/assets/doh/downloads/pdf/basas/provisional-overdose-report-first-quarter-2021.pdf. Accessed January 1, 2022.
  3. American Medical Association – ama-assn.org. https://www.ama-assn.org/system/files/issue-brief-increases-in-opioid-related-overdose.pdf. Accessed January 1, 2022.
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  13. OTP Preparedness Guidelines march 24 2020. https://nj.gov/humanservices/documents/covid/OTP%20Preparedness%20Guidelines%20March%2018%202020.pdf Accessed January 1, 2022.
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  15. Smith GB. Methadone delivered direct to homeless and other isolated New Yorkers. THE CITY. https://www.thecity.nyc/health/2020/4/26/21247076/methadone-delivered-direct-to-homeless-and-other-isolated-new-yorkers. Published April 26, 2020. Accessed January 1, 2022.
  16. Arlene González-Sánchez, M.S., L.M.S.W. commissioner. https://oasas.ny.gov/system/files/documents/2020/03/covid19-otp-faqs_2_0.pdf Accessed January 1, 2022.
  17. Psychiatry. https://medicine.umich.edu/dept/psychiatry/mental-health-resources-covid-19/addiction-substance-use-recovery-during-covid-19-pandemic. Published December 13, 2021. Accessed January 1, 2022. 
  18. Sober grid – the worlds largest recovery app. Sober. https://www.sobergrid.com./. Accessed January 1, 2022.
  19. New Jersey giving away 72,000 doses of Narcan to combat … https://www.msn.com/en-us/health/medical/new-jersey-giving-away-72000-doses-of-narcan-to-combat-drug-overdoses/ar-BB19jD5S. Accessed January 1, 2022.
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  24. Authored by Leah K. Walker PD. Opioid withdrawal: Signs, Symptoms & Addiction treatment. American Addiction Centers. https://americanaddictioncenters.org/withdrawal-timelines-treatments/opiate. Published November 4, 2021. Accessed December 31, 2021.
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