Last week, we discussed three noteworthy trends from the past decade in treating the opioid crisis. The first was recognizing medication for opioid use disorder (MOUD) as the standard of care. The second was formalizing an addiction medicine specialty. And the third was expanding the availability of MOUD.
This week, we’ll consider three additional trends in treating the opioid crisis: the use of MOUD in incarceration, harm reduction strategies, and the role of telehealth.
Trend 4: Incarceration and Medication for Opioid Use Disorder
The Substance Abuse and Mental Health Services Administration (SAMHSA) and American Society of Addiction Medicine say that offering medication is now the standard of care. As a result, MOUD is increasingly recognized as a medically necessary service for incarcerated persons.
Based on 2015-2016 data from the National Survey on Drug Use and Health, the chances of becoming involved in the criminal justice system are approximately three-to-five times higher for persons who use prescription and intravenous opioids. And nearly 30-45% of incarcerated persons report suffering signs of opioid dependence or addiction. These include severe cravings, withdrawal, and the inability to control their opioid use.
Further, the use of buprenorphine and methadone decreases opioid overdose deaths. Yet, 2018 data demonstrates that buprenorphine and methadone are offered to incarcerated individuals in only 14 U.S. states or territories (27% of jurisdictions).
Notably, legal standards mandate provision of evidence-based standards of medical care for incarcerated persons. This was challenged in the 1976 US Supreme Court case, Estelle v. Gamble. The court established that withholding medically necessary care from prisoners is cruel and unusual punishment, a violation of the Eighth Amendment. More recently, federal courts have held that failure to provide MOUD to incarcerated individuals violates the Americans with Disabilities Act (ADA).
In addition to reforming the criminal justice system in the U.S., which includes ending the War on Drugs, we must strive to provide MOUD in all states and territories, including in the criminal justice system (i.e. jails, prisons, probation, parole).
Trend 5: Harm Reduction and the Democratization of Naloxone
The U.S. Food and Drug Administration (FDA) approved naloxone (Narcan) for treating opioid overdose in 1971. As opioid overdose rates skyrocketed in the 1990s, some states piloted take-home naloxone kits for patients and families. The Centers for Disease Control and Prevention (CDC) estimated that more than 26,000 opioid overdoses were reversed by non-medical persons between 1996-2014. And since 2010, distribution of naloxone kits to laypersons has increased by 183%.
Other research offers convincing evidence that providing naloxone kits to laypersons saves lives. In fact, one study showed opioid overdose death rates to be 27-46% lower in communities that implemented overdose education and naloxone distribution. It is often standard practice for clinicians to distribute naloxone to patients at-risk of overdose. This includes, for example, people in substance use treatment programs and persons leaving jail or prison. In some states, naloxone is freely accessible at pharmacies.
Throughout the past decade, syringe service programs, also referred to as syringe exchange programs and needle exchange programs, have become much more widely accessible. These programs provide access to sterile syringes and help appropriately dispose of used syringes. Many also provide additional supports like naloxone distribution and referral to substance use disorder treatment programs, among other services.
The contents of opioid medications bought illegally are also concerning. Counterfeit drugs may have dangerous fentanyl-like compounds and other ingredients that may warrant a similar harm reduction approach.
Trend 6: Telehealth
The COVID-19 pandemic has ushered telehealth into an entirely new era. This includes the use of teleheath in treating the opioid crisis. Telehealth expands the opportunity for patients struggling with opioid use disorder (OUD) to find providers who meet their needs. And laws that govern telehealth and the treatment of OUD have changed in the last decade.
The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 was developed to combat online pharmacies selling controlled substances. It required at least one in-person medical evaluation before prescribing controlled substances. Unfortunately, given that buprenorphine is classified as a controlled substance, the law created barriers for patients seeking telehealth treatment for OUD.
In 2019, Representative Doris Matsui (D-CA) introduced H.R. 4131: Improving Access to Remote Behavioral Health Treatment Act. It would have allowed certain community mental health centers to prescribe controlled substances via telehealth. This bill, however, never became law.
In March 2020, as COVID-19 surged across the U.S., the Drug Enforcement Administration (DEA) temporarily waived the requirement for an in-person medical evaluation prior to prescribing buprenorphine. Also, the Department of Health and Human Services waived penalties for HIPAA violations. This allowed for online medical visits and has increased access to MOUD during the pandemic.
In 2020, Senators Rob Portman (R-OH) and Sheldon Whitehouse (D-RI) introduced S. 4103: Telehealth Response for E-prescribing Addiction Therapy Services (TREATS) Act. It would permanently expand telehealth services for OUD to allow buprenorphine treatment following a virtual medical evaluation. S. 4103 has been referred to the Committee on Health, Education, Labor, and Pensions.
Many state restrictions on the use of telehealth for OUD treatment still exist, though some states are now implementing it broadly. Early accounts of effectiveness are promising, and studies comparing telehealth to in-person care are in progress.
Conclusion
These themes in addiction medicine over the past decade position the U.S. to more robustly address the opioid epidemic. They are also decreasing stigma and shifting public consciousness to better understand that addiction is a medical condition, not a moral failure. Though the COVID-19 pandemic exacerbates the opioid epidemic, we feel hopeful. We welcome a new decade of research and clinical practice in treating the opioid crisis. Ultimately, we hope more people will regain control of their lives through recovery from opioid addiction.
Latest posts by Rebekah Rollston (see all)
- Treating the Opioid Crisis: Current Trends and What’s Next, Part 2 - February 18, 2021
- Treating the Opioid Crisis: Current Trends and What’s Next - February 11, 2021
- After COVID-19, We Must Build Back Better - August 20, 2020
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