The national crisis of addiction and drug overdose shows little signs of improvement, and the pandemic only accelerated the trend. Increasingly, providers are regarding substance use disorder (SUD) as a chronic condition, approaching it with lifelong treatment and recovery support, but more needs to be done to help those with SUD.
Recent research demonstrates a rise in substance use during the height of the pandemic. Fear, financial setbacks, uncertainty, and social isolation prompted more people to turn to unhealthy and desperate measures just to make it through another day. In a national survey conducted between April and June 2020, the Centers for Disease Control and Prevention (CDC) found that 26 percent of respondents said they started or increased substance use to cope with stress or emotions.
Even more concerning is that from September 2019 through August 2020, the United States also witnessed 88,295 drug overdose deaths — a record high that is almost 19,000 more deaths than the prior 12-month period. Think of it this way: If all the people who died from drug overdoses during that time were in one place, no NFL stadium would be large enough to hold them all.
Moving forward, the healthcare community at large recognizes that this country is at a critical crossroads, in which the latest treatment modalities can help reverse the grim trend of SUD and overdose deaths. It will take time and resources, but most of all, it will take persistence.
Opioids and fentanyl are a deadly threat
Opioids are currently the main driver of drug overdose deaths, accounting for more than 70 percent of such deaths, and about 2 million Americans are estimated to have opioid use disorder. One of the (many) reasons why the crisis has been so difficult to resolve from a public health perspective is that the street supply of illicit opioids has quickly become more potent and therefore more deadly.
And this increased potency comes from the somewhat recent introduction of fentanyl — a synthetic substance that is 50 to 100 times more powerful than morphine and other opioids. Fentanyl is showing up more often on the street and causing an exponential number of deaths. In 2017, 59 percent of opioid-related deaths involved fentanyl, compared to 14 percent in 2010.
Because the pervasive opioid crisis has so many facets, solutions require a combination of medical, behavioral, regulatory, and social measures. Today’s recommended healthcare approaches include medication-assisted treatment combined with counseling and peer support. By tracking the patient’s treatment response frequently over time, care providers can adjust course to best support the journey to recovery.
Medication-assisted treatment for addiction
Buprenorphine (Suboxone) is often the preferred medication that helps people with opioid use disorder quell cravings and gain the focus they need to begin comprehensive treatment in earnest. It can be ordered by most behavioral health or primary care professionals with prescribing authority.
However, additional federal regulations associated with this particular medication have historically stifled buprenorphine prescribing. Clinicians found the imposed training requirements, certifications, and limitations on the number of patients they could treat with buprenorphine too cumbersome. No other prescription drug has ever carried such qualifiers.
But as of late April, updated rules now allow physicians, nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetist, and certified nurse-midwifes to prescribe buprenorphine for up to 30 patients at a time without completing the prerequisite training and certification. Qualified practitioners who do complete the training and certification requirements can prescribe for up to 100 patients for one year, eventually prescribing for up to 275 patients in subsequent years.
April’s change came as a direct response to the dire increase in overdose deaths that were provoked largely by the pandemic. Advocacy groups continue to fight for the removal of all special restrictions on buprenorphine prescribing to help increase access to the medication as an effective treatment for SUD.
The prevailing shortage of behavioral health providers combined with the increased need for addiction treatment — as evidenced by the recent CDC overdose data — create a perfect storm. Buprenorphine alone can be efficacious for some patients when access to additional comprehensive treatment is delayed, deferred, or simply unavailable.
One study from the Recovery Research Institute at Massachusetts General Hospital using simulated models found that buprenorphine alone reduced overdoses (fatal and nonfatal) by 22 percent. However, when contingency management, psychotherapy, overdose education, and rescue medication were also part of treatment, overdoses were reduced by 31 percent.
Addiction requires comprehensive treatment
Obviously, clinicians shouldn’t expect patients to reach the recovery stage after a short course of buprenorphine. The standard of care for opioid use disorder also includes some type of specialized addiction counseling, psychotherapy, and peer coaching or fellowship. More importantly, addiction is a chronic, relapsing condition that often lasts a lifetime.
Clinicians should screen patients for SUD with proven screening tools. Further evaluation for those who present with SUD is needed to determine the right level of treatment and to refer them to trusted specialty care when appropriate. Patients in outpatient and recovery programs also will need ongoing support to maintain their engagement with care plans.
Research on addiction shows that the reinforcing effects of drugs on the brain perpetuate the person’s craving and ongoing use of the drugs, even when the consequences of using are extreme. In other words, someone who’s addicted to opioids will seek their drug of choice at the expense of their careers, their relationships, and their health, knowingly risking their lives in the process.
With addiction, the brain structure changes over time, and the person’s capacity to self-regulate becomes impaired. That’s why early treatment response — however encouraging — is not a great indicator of long-term outcomes. Patients receiving treatment for SUD need frequent check-ins and re-evaluations of their care plans based on where they’re currently at in their recovery, including times of relapse.
It’s not unusual for someone who’s been in recovery for several years to relapse. A relapse should never be considered a treatment “failure,” no more so than a high blood pressure reading should be considered a failure for a hypertension patient. Clinicians treating individuals with SUD should have a specific plan in place to adjust care plans when relapses occur, treating the incident as a learning opportunity for the patient.
What else clinicians can do
Not every person who has SUD will seek treatment or make their condition known. In fact, just the opposite is true. About 40 percent of people with SUD who know they need treatment don’t seek it because they feel they aren’t ready to stop using, according to the National Survey of Drug Use And Health from September 2020.
That’s why it’s important for primary care, behavioral health, and other providers to screen for SUD and watch for underlying conditions and stressors that might prompt an individual to want to self-medicate with drugs or alcohol. Rely on proven screening tools that produce objective results.
Finally, creating a comfortable, convenient path to treatment can also encourage the reluctant to engage in care. For some, a telehealth offering might ease their childcare concerns or help them feel less stigmatized than walking into addiction program clinic. Providing apps or online education can also help bridge the path to treatment.
More providers must be involved in caring for those with SUD because while the opioid crisis has escalated across the U.S., treatment capacity has not kept pace. By screening patients, offering warm-handoff referrals, and offering medication-assisted treatment, providers can help turn the tide of addiction in their communities.