Robert Sherrick, MD, FASAM Valerie O’Connell, CQA Michael ...
Transcript of Robert Sherrick, MD, FASAM Valerie O’Connell, CQA Michael ...
#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
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
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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
#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
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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
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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/
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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
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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/
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
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
#ASAM2021
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.
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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: