Robert Sherrick, MD, FASAM Valerie O’Connell, CQA Michael ...

Robert Sherrick, MD, FASAMValerie O’Connell, CQAMichael White, MCJAaron Ferguson, BSW

#ASAM2021

Robert Sherrick, MD, FASAM No Disclosures

Valerie O’Connell, CQA No Disclosures

Michael White, MCJ No Disclosures

Aaron Ferguson No Disclosures

#ASAM2021

Introduction – the onset of the Covid-19 pandemic in the USEffects of the pandemic on drug trade, drug use, and harm

reduction initiativesPatterns of use for alcohol, stimulants, and opioidsReview of responses from our OTPs and patient outcomesReview of Covid-19 effects in the Criminal Justice system

#ASAM2021

Understand how the Covid-19 pandemic has altered patterns of drug distribution, use, and harm reduction initiatives

Describe how use patterns have been affected for alcohol, stimulants, and opioids

Review administrative changes within Opioid Treatment Programs

Understand the impact of the pandemic in the Criminal Justice arena

#ASAM2021

https://www.asam.org/Quality-Science/covid-19-coronavirus

Everybody stay calm and…

PANIC!

Early decrease in drug precursor chemicals produced in ChinaDecrease in supply of drugs coming into US from MexicoCessation of many self-support groupsClosing of inpatient treatment programs Increase in stressors, job loss, social isolationClosing of Harm Reduction programs – syringe service

programsDecrease in media attention to SUD

8 times more likely to get COVID-1937% higher risk of hospitalization45% higher risk of deathAfrican Americans with SUD 2x more likely than Whites

with SUD to get COVID-19African Americans have worse outcomes than Whites (44%

higher risk of hospitalization, 50% higher risk of death)

Wang, Q.Q., Kaelber, D.C., Xu, R. et al. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. Mol Psychiatry (2020). https://doi.org/10.1038/s41380-020-00880-7

#ASAM2021

Issues

Stockpile Supply at Borders

Increasing Potency Based Demand

Precursor Production Shifts

Demand Driven Upward

Demonstration of Market Resiliency

https://wdr.unodc.org/wdr2020/index.html

#ASAM2021

https://wdr.unodc.org/wdr2020/en/exsum.html

#ASAM2021https://wdr.unodc.org/wdr2020/index.html

#ASAM2021https://wdr.unodc.org/wdr2020/index.html

“The reduction in air and land traffic resulting from

COVID-19 restrictions may have already led to an

increase in maritime trafficking due to decreased risk of

interception and the ability to smuggle larger quantities than

by air or land.”

#ASAM2021https://wdr.unodc.org/wdr2020/index.htmlhttps://www.cannabissciencetech.com/view/rapid-determination-24-synthetic-and-natural-cannabinoids-lcms-ms-screening-natural-products-and

#ASAM2021https://watermark.silverchair.com/clinchem0242.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAArYwggKyBgkqhkiG9w0BBwagggKjMIICnwIBADCCApgGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMRGDu_g6hXT0If3h2AgEQgIICaekwxB8Gt5LmTgFCGYzujo3cI1XtjAb1O4hMTGVGIE7vl1pmLr3bkNRgck-T8a3JUbSaWE8hY7X4lL66kOr17iz_uLUG8OulFZ06CIYHNVTDJuAMptTl3Y-4IgTsLSeBLkZJ4sj23Q8BHv4hCj9lwc5l265oM65JwEr4ja9K9NahV-WCNl_7A6Xrzy9lD4EM7D2-fbMVYqfSqZAZeZnpVxvbmzYfvlpKaai2-un1UqdeK42wGdrGXKrwlGqGWQ63DiFagsvR1tW4fU0aV9JV0x9Zx08xW2DTUolTRtmv66m4g75_N4RiCfDPCnHMXItCehldkYuQHhPZAO6CBu0HWIC4TfkGJdveyuMy8N23-x7mCuisRuP9pFgwqAbfe-rPw2Kxq3GAY17j82DYq-p82eHSrOV_1laEK9wQ9CSrlQ8BsfBSF8OAuzyij08pz6SClE5O6r8C2nO3qB_8kn_IpK6lGotCaQovk_esdUQgP3mwWrewsryUwPjxG45sHVNpGgqwVSqYNjwyoL79XWydXsHGSc3gMgDnyDCzrzMfrxxcM2yinwXVj4Q8ZpfM-dmsMye_qQ9tXUuurZJ1ToqGNBKkK6lbHvdC_VmUXmSr7nKNsfyL1oeDK82wMOTO_FBEm3nmyDoHAwW7jGU7QgU-noRnk0jgJCaoxhSNrqlTHcoIRmk1ioF99WWdSXwo3gqVNWl1DkOaWGEL_K-RRthVhgDACKfZl3VkoUCaRHtMz9mLwaNcu87jOeKvEBSOKaJvtSenTSNUtisfsYHILLI__0PEiphEekTbFcd5iu5UXOlprUqrv9HyjelE

#ASAM2021https://wdr.unodc.org/wdr2020/en/exsum.htmlhttps://www.unodc.org/LSS/Announcement?type=NPS

Every year roughly 500 NPS are found on the national markets of UN Member States.

Opioid NPS accounted for just 2% of the number of NPS identified in 2014, but by 2018 that figure rose to 9%.

Squeezes on drug markets cause increase in analog use

#ASAM2021https://www.google.com/url?sa=i&url=https%3A%2F%2Ftwitter.com%2Fnormalnorway%2Fstatus%2F1007922995359305729%3Flang%3Dda&psig=AOvVaw0XgxTmrxlL9HOn693LnADj&ust=1613148932845000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCPD_oJOm4u4CFQAAAAAdAAAAABAD

#ASAM2021

Opportunities

Reduction in Drug Related Arrests1

Correlating Arrests with COVID2

Increases in Jail Diversion3

Ability to Scale Pilots

Technological Innovations4

1. https://www.prisonpolicy.org/virus/virusresponse.html2. https://news.harvard.edu/gazette/story/2020/08/harvard-study-links-jailing-practices-to-covid-19-spread/3. https://drugpolicy.org/press-release/2021/02/drug-decriminalization-oregon-officially-begins-today4. https://www.sciencedirect.com/science/article/abs/pii/S1871402120302058

#ASAM2021

Issues

Using Alone has Increased

Emergency Care Utilization Decreased5

Mental Health Affects Consumption6

Safe Supply is Threatened

5. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/27759916. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7403495/

#ASAM2021https://wdr.unodc.org/wdr2020/en/exsum.html

#ASAM2021https://aspe.hhs.gov/system/files/pdf/259261/ASPEEconomicOpportunityOpioidCrisis.pdf

#ASAM2021

Opportunities

Drug User Organizing7

Innovations that Save Lives8

The Role of Technology9

Harm Reduction Prevails 7. https://filtermag.org/panda-pan-american-drug-user-alliance/8. https://nextcity.org/daily/entry/new-york-city-pilots-mobile-methadone-program-to-help-treat-addiction9. https://www.cdc.gov/mmwr/volumes/69/wr/mm6943a3.htm

#ASAM2021

Solutions

Increase Awareness of Contaminants10

Improve Communication

Foster Open Dialogue11

Preserve Frontline Staff 10. https://www.vice.com/en/article/wxebjb/40-americans-are-dying-every-month-from-taking-this-new-legal-opioid?fbclid=IwAR0PHX8HYuj7yRWk-BYMvdfkC3RMQ6Uod0Ym6Pc-7iY6aOsKExxuLNBxQtI11. https://harmreduction.org/blog/covid-19-guidance-for-people-who-use-drugs-and-harm-reduction-programs/

Millennium Labs analysis of over 500,000 urine drug screen results

Some states closed liquor stores Some states have closed bars, night clubs Some countries (South Africa, Thailand, India) banned alcohol

entirelyConcern over withdrawalsMost states included liquor stores in “essential services”

Data were collected using the RAND Corporation American Life Panel (ALP), a nationally representative, probability-sampled panel of 6000 participants age 18 years or more who speak English or Spanish; data are weighted to match a range of national demographic characteristics.

Weekly frequency increased 14% from March of 2019 to 2020

Increases higher in women, younger adultsWomen had 41% increase in heavy drinking days 39% increase in SIP (Short Inventory of Problems) scale Represents an increase in alcohol related problems for 1 in 10

women Alcohol was consumed 1 day more per month by 3 of 4 adults

Alcohol sales in stores were up 54% in late March compared to that time last year, while online sales were up by 262%

Increase in unemploymentFinancial stressorsSocial isolation, boredomWorking from homeKids out of school Increase in domestic conflictDecrease in availability of self-help resources – AA/NA, CR,

RR, etc.

Short-term Potential impact of increased drinking at home on domestic violence and

child neglect Impact of alcohol on immune system and complications of COVID-19 Risk factor for depression and suicide Importance of SBIRT

Long-term Potential for relapse or escalation into alcohol use disorder Morbidity and mortality associated with increased alcohol consumption Social instability associated with alcohol – job loss, homelessness

ASAM recently updated guidelines on the treatment of Alcohol Withdrawal - https://www.asam.org/docs/default-source/quality-science/the_asam_clinical_practice_guideline_on_alcohol-1.pdf

Precursor chemical supply disruptedMovement of drugs into US from Mexico slowed Farmers paid less for coca cropsMTA availability decreased and price increased – up to double –

with large variations from one area to another Potential for increased drug related crimeDrug cartels clever and motivated – some making their own

precursors – new methods of transporting into US – use of fentanyl rather than heroin

NIDA web site data

NIDA web site data

Increased risk of COVID pulmonary complications Immune suppression Pulmonary damage from inhaling

Increase in high-risk behaviors – lack of social distancing/masks Increase in high-risk sexual encounters Increase in psychiatric co-morbidity and poorer treatment retention Impulsivity, cognitive impairment, anhedonia, hypersexuality, psychosis

Medical issues – weight loss, rash, dental abscesses, infections Social problems – childcare issues, homelessness, etc.

Evidenced based treatments: Contingency Management (CM) Community Reinforcement Approach (CRA) Cognitive Behavioral Therapy (CBT) Mindfulness-based treatments (MBRP) Motivational Interviewing (MI) Physical exercise Medications – none FDA approved

Bupropion, Naltrexone, Mirtazapine, Methylphenidate, Topiramate, others

MOUD, using one of the 3 FDA approved medications for this indication, is the standard of care.Methadone, buprenorphine, ER-naltrexone

All of the above noted factors affecting supply, street cost, psychosocial stressors, and decreased social interactions have combined to increase overdoses

COVID could affect access to MOUD Methadone – only available at Opioid Treatment Programs (OTPs)Buprenorphine – OTPs or office-based (OBOT)

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The Role of Medications in Treating SUDs

SAMHSA DEA Ryan Haight act State regulationsRegulatory and statutory requirementsPublic Health departmentsState Opioid Treatment Authorities (SOTAs)State Medicaid requirements

Medicare and other payers

Expansion of the use of telehealth“Blanket” exception for take-home privileges up to

28 daysAllowing for alternative person to pick up dosesAllowing for dosing patients curbside

Patients may be seen for follow up for methadone or buprenorphine via telemedicine

Patients may be started on buprenorphine without a face-to-face examination, including by telephone

Patients to be started on methadone are required to have a face-to-face examination

Patients started on buprenorphine who fail may be switched to methadone without a face-to-face examination (?)

Allowed prescribing of controlled substances without an in-person evaluation

Schedule II drugs can be called in with a written prescription to follow within 15 days

Exemption in some cases to have separate DEA registrations in every state of practice

Allowing off-site or alternative (doorstep) dispensing under certain circumstances

Changing regulations to ensure continued flow of therapeutic medications

Relaxing of 42 CFR part 2 confidentiality regulationsExpansion of Medicare payments for telehealth servicesRelaxation of rules regarding telemedicine platforms and

HIPAA

Universal precautionsManaging clinic traffic – clinic visits should not be a high-risk

exposureUse of telemedicine, telephoneContinue usual policies for UDS and medication call-backsDevelop procedures for getting doses to patients who are

positive and/or symptomaticDevelop procedures/backup for staff who are positive and/or

symptomatic

Created 148 documentsGeneral response to outbreakClinic postings Letters for staff and clients for curfewUpdated billing guidance Telehealth or email consent

Necessary to quickly pivotChanging federal guidance State executive orders with fast implementation

Worked with state authorities to ensure our staff were in healthcare population

Staff were prioritized into the healthcare population in all nine states

Continuing expanded use of telemedicine Increasing OTP discretion on take-homes within limitsAllowing for methadone intakes via telemedicine with an

appropriate remote real-time examinationFacilitating OTP data exchange with appropriate safeguardsContinue relaxed regulations concerning practicing across state

lines

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Aaron Ferguson:

1. “World Drug Report 2020.” United Nations : World Drug Report 2020, wdr.unodc.org/wdr2020/index.html.

2. “Rapid Determination of 24 Synthetic and Natural Cannabinoids for LC–MS-MS Screening in Natural Products and Drug Inspection Applications.” Cannabis Science Tech, www.cannabissciencetech.com/view/rapid-determination-24-

3. Initiative, Prison Policy. “Criminal Justice Responses to the Coronavirus Pandemic.” Criminal Justice Responses to the Coronavirus Pandemic | Prison Policy Initiative, www.prisonpolicy.org/virus/virusresponse.html.

4. Siliezar, Juan. “Harvard Study Links Jailing Practices to COVID-19 Spread.” Harvard Gazette, Harvard Gazette, 3 Aug. 2020, news.harvard.edu/gazette/story/2020/08/harvard-study-links-jailing-practices-to-covid-19-spread/.

5. Learning Opportunities from COVID-19 and Future Effects on Health Care System. www.sciencedirect.com/science/article/abs/pii/S1871402120302058.

6. Holland, Kristin M., et al. “Trends in US Emergency Department Visits for Mental Health, Overdose, and Violence Outcomes Before and During the COVID-19 Pandemic.” JAMA Psychiatry, 2021, doi:10.1001/jamapsychiatry.2020.4402.

#ASAM2021

Aaron Ferguson:

7. Chiappini, Stefania, et al. “COVID-19: The Hidden Impact on Mental Health and Drug Addiction.” Frontiers in Psychiatry, Frontiers Media S.A., 29 July 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7403495/.

8. THE OPIOID CRISIS AND ECONOMIC OPPORTUNITY: Geographic and Economic Trends aspe.hhs.gov/system/files/pdf/259261/ASPEEconomicOpportunityOpioidCrisis.pdf.

9. “PANDA: The Birth of a Pan-American Drug-User Alliance.” Filter, 20 July 2020, filtermag.org/panda-pan-american-drug-user-alliance/.

10. New York City Pilots Mobile Methadone Program to Help Treat Addiction. nextcity.org/daily/entry/new-york-city-pilots-mobile-methadone- program-to-help-treat-addiction.

11. “Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic - United States, January–March 2020.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Oct. 2020, www.cdc.gov/mmwr/volumes/69/wr/mm6943a3.htm.

12. Isotonitazene Is a New Opioid That Is Leading to Accidental Deaths, www.vice.com/en/article/wxebjb/40-americans-are-dying-every-month-from-taking-this-new-legal-opioid?fbclid=IwAR0PHX8HYuj7yRWk-BYMvdfkC3RMQ6Uod0Ym6Pc-7iY6aOsKExxuLNBxQtI.

13. Coalition, National Harm Reduction. “COVID-19 Guidance for People Who Use Drugs and Harm Reduction Programs.” Harm Reduction Coalition, Harm Reduction Coalition, 5 Oct. 2020, harmreduction.org/blog/covid-19-guidance-for-people-who-use-drugs-and-harm-reduction-programs.

#ASAM2021

1. Wang, Q.Q., Kaelber, D.C., Xu, R. et al. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. Mol Psychiatry (2020).

2. Millennium Health Signals Report™. COVID-19 Special Edition: Significant Changes in Drug Use During the Pandemic. Volume 2.1 | Published July 2020.

3. COVID-19 Impact on the U.S. National Overdose Crisis. Overdose Detection Mapping Application Program (ODMAP). NIDA. 2020, July 7.

4. Friedman J, Beletsky L, Schriger DL. Overdose-Related Cardiac Arrests Observed by Emergency Medical Services During the US COVID-19 Epidemic. JAMA Psychiatry. Published online December 03, 2020.

5. Pollard MS, Tucker JS, Green HD. Changes in Adult Alcohol Use and Consequences During the COVID-19 Pandemic in the US. JAMA Netw Open. 2020;3(9):e2022942.

Dr. Sherrick: