Addiction in the Age of COVID
By MELANIE KILGORE-HILL
Experts Discuss Challenges of Treating Addiction amid a Global Pandemic
Addiction is a lifelong battle, and it's one more Americans are fighting than ever before.
For those addicted, or struggling to stay clean, COVID-19 has created a downward spiral shaped by cancelled 12-step meetings and accountability programs, virtually removing support for a population that relies on face-to-face connection to stay clean. Nashville Medical News recently spoke with leaders of three respected recovery programs to learn how patients and providers are navigating an evolving treatment landscape.
"I hear the same story so many times a day of how the pandemic has impacted someone's substance abuse," said Chapman Sledge, MD, chief medical officer of Cumberland Heights. Sledge, who has specialized in addiction medicine for 31 years, said an increase in substance use is expected with downward economic trends, but he has never witnessed a social phenomenon impacting more people than the pandemic.
At Cumberland Heights, alcohol use disorders are still the most frequent diagnosis for residential treatment patients - a fact that hasn't changed in the pandemic. That's no surprise, given alcohol sales were up 25 percent in the first quarter of 2020. Sledge also treats ample opioid addicts and said methamphetamine use is increasingly more common - an observation confirmed by a recent nationwide review of urine drug screens that found meth was up 20 percent between March and May, fentanyl 32 percent and cocaine 10 percent.
Sledge's patients report an increase in supply chain access, with minimal increase in cost. Those with substance use disorders also report quality is down, as producers look for cost-effective ways to meet increased demand. Sledge said it's become increasingly common for illegal substances to be cut with fentanyl - cheaper to produce but far more potent.
"We see so many fentanyl analogs showing up, and the potency is even greater," Sledge said. "When most people think of overdoses, methamphetamine or cocaine usually doesn't come to mind, but they're going up because of illicit fentanyl in those substances."
Ryan Cain, president of Nashville Recovery Center, said the facility is seeing more combinations of meth, heroin, cocaine and even Xanax. "I'm not sure we've seen an uptake in meth addicts as much as an uptake in meth use by addicts," said Cain, who said it's simply easier to access in 2020 than opioids.
"Everyone understands the opioid epidemic but failed to realize that doctors and pharmacies are now so tightly regulated that it's almost impossible to get enough opioids legally if you're addicted, so they're finding alternative methods of street drugs," Cain continued. "Fentanyl and heroin are cheap and surprisingly easy to get anywhere. That means those addicted are becoming reckless with who they're buying from."
While isolation has wreaked mental health havoc across all demographics, the effect on those in recovery has been shattering. "There's a definite uptick in people in longer term recovery relapsing," Cain said. "People with multiple years of sobriety are relapsing during COVID because they're not going to 12-step meetings, having coffee with their recovery group or meeting up with sponsors. Those are everything for an addict ... and having the things that kept you sober shut down for months means people are left to their own devices, and they still have an addictive brain."
He continued, "There's an experience you have with human connection, from shaking hands to holding hands during the Serenity Prayer, and you'll never see as many people hug as you do in recovery. To have that taken away is having an impact."
Brian Haile, CEO
Economic fallout also is pushing recovering addicts over the edge, said Brian Haile, CEO of Neighborhood Health. "If you've worked hard to put your life back together, maintained a job, and been relatively healthy ... to see that fall apart because you've been laid off or become sick and your family and social support structure isn't there, it compounds underlying issues," he noted.
"Absence of employment, social support and routines makes all psychosocial and behavioral concerns really acute," he continued. "Every day our providers see people who've had significant recovery gone by the wayside." Haile added those with substance use disorders also are hypersensitive to stress, putting them at increased risk for relapse during difficult times like the current public health crisis.
Overdose deaths also are on the rise with hard-hit East Tennessee reporting a 40 percent increase in such deaths between March and May 2020 from the same time last year. That's partly because overdosing while alone is more deadly with no one nearby to call 911.
Suicide among addicts also has escalated in response to stress, economic uncertainty and isolation. A recent morbidity and mortality report issued by the Centers for Disease Control and Prevention focused on mental health, substance use and suicidal ideation during COVID-19 in the U.S. More than 5,400 participated in the study, which found young adults ages 18-24 are particularly suffering during the pandemic. In that age group, a staggering 74.9 percent reported at least one adverse mental or behavioral health symptom. Anxiety, depression, increase in substance use to cope with COVID-19-stress and suicidal ideation were most commonly reported by persons in the 18-24 age group.
While most people struggling with addiction don't willingly admit they need help, Sledge said front line providers are essential in screening patients for addiction. Although motivation to see treatment typically stems from a family member or employer, Sledge said it also comes from a relationship with a trusted provider.
"Until the wheels completely fall off, it's a disease people don't typically ask for help for because of stigma, shame and guilt associated with addiction," he said. "A primary care provider can open that door and do basic screenings for addiction (i.e. elevated liver enzymes) and make appropriate referrals for support," Sledge continued. "Ask how patients are responding to stress these days. If substance use is one of those mechanisms, we need to encourage them to reach out."
Cain said physicians often detect when a patient is abusing alcohol or drugs but may not recognize their need for inpatient rehab. "You can raise the bottom up for someone if you make them aware of care options available," he said. "If everyone would collectively recognize the problem and take action earlier, we'd have far less fatal situations."
In an effort to ensure better overall health through the pandemic, Neighborhood Health recently announced the decision to make flu and pneumonia vaccines available to patients on a sliding fee scale. "We're doing everything we can to keep patients alive through this and making sure we're vaccinating against respiratory illness since there's an overlapping risk of opioid overdose at a time of COVID exposure," Haile said. "Individuals who are addicted and come in contact with COVID or a respiratory disease have a higher risk of mortality, so we want to provide all the support we can."
Sledge said getting people into residential treatment at the start of the pandemic was a challenge. "People didn't trust the idea and asked why they'd go into residential with a bunch of strangers," he said. "We've put forth great effort to maintain integrity of the campus as a safe place for patients."
At Cumberland Heights, patients are screened ahead of time and again at check-in, when they're tested immediately and kept in quarantine until results are back. But that process, combined with social distancing mandates, has created fewer beds and a bottleneck for treatment facilities nationwide, and waiting lists aren't uncommon.
In an era where inpatient care may not be an option, Haile hopes more steps will be taken to increase availability of medically assisted treatment, particularly among indigent care patients. "Hope comes from action, and this is a moment where we as provider organizations should view action in the form of direct care and patient support, which is absolutely vital," he said, noting the need for more advocacy at a state level to fill gaps in outpatient MAT programs.
"We need to do more than try to prevent overdose," Haile said. "We need to expand treatment to move someone from opioid use disorder to where they're free from ongoing reliance to opiates. We need to move from bailing water to rowing forward."
He also encourages providers to take advantage of NARCAN® prescribing, now covered by CoveRx. The nasal spray is FDA-approved for the treatment of known or suspected opioid overdose. "We're giving out more than we have in the past since TennCare has been very forward thinking in terms of making it available through CoveRx," said Haile. "That's been incredibly important, and TennCare leadership should be lauded for driving those positive changes."
While in-person appointments are strongly preferred in addiction medicine, telehealth has become instrumental in maintaining relationships with patients. "Across the board in the world of medicine we've been able to serve more with technology and maintain a better connection with patients outside a residential setting," Sledge said. "In general people with addiction have a difficult time developing trust over a screen, but it's been especially beneficial for our older, long-term recovery patients who still shouldn't be at meetings face-to-face."
Despite ongoing challenges of addiction treatment in 2020, providers are still finding the positives. "When you're working in a setting where you can engage people over a continuum of treatment, from the first time they walk in the door to outpatient and supportive aftercare, seeing them get better is extremely gratifying," said Sledge.
Cain wants providers and the community to know resources are available, and that those struggling with addiction aren't alone. "There's no stigma or shame," said Cain, who often counsels families on how to approach someone they love about addiction. "Loved ones often fail to take action because they're afraid of the response, which means they'd rather watch them slowly die than offend them about addiction. Don't wait. Get help early," he stressed of taking the first steps towards recovery.
For Haile, the determination of those who've maintained the course despite setbacks is awe-inspiring for providers, who are often moved to tears by patients' determination amid hardship. "For those who've maintained the course, it's a fundamental testament to their strength and resilience," he said. "Patients bring such strength when they maintain treatment, often helping family members whose employment is stressed and having kids out of school. These folks are there to help when other family members are facing a lot of stress, so it's important to remember that successful treatment is providing strength for entire family systems. When we talk about treatment success, we talk about family success."