The COVID-19 vaccine won’t solve major substance use disorder treatment gaps

As if COVID-19 weren’t bad enough during the pandemic, another public health crisis – substance use disorder (SUD) – has gone from bad to worse, while access to behavioral health services is shrinking.

As of September, more than half (52%) of community behavioral health organizations have seen an increase in demand for services, and half of those that offer SUD services saw their demand jump in the previous three months. At the same time, due to lack of revenue or pandemic-related restrictions, 65% have had to cancel programs, reschedule, or turn patients away. Nearly 40% of these organizations reported they may not last six months, given the revenue shortfalls.

The recent announcements that several highly effective COVID-19 vaccines are on the horizon are encouraging. With widespread vaccine distribution, behavioral health organizations will resume more treatment services for patients in need. Even if such services return to pre-pandemic levels, medication-assisted treatment (MAT) services will not be sufficient. As vaccination distribution ramps up, access to behavioral health services and prevention efforts must also expand to help stem growing overdose incidents.

Fortunately, some states and national organizations have taken the initiative to put collaborative, multi-stakeholder programs in place. These programs help people determine whether they need help for substance use and locate MAT and other services in their communities.

Opioid epidemic strengthens

Although the pandemic has exacerbated many Americans’ substance use due to impeded access to treatment, this public health crisis showed new strength well before COVID-19 was a household name. With increased social isolation and economic uncertainty, the problem of substance use is now exponentially greater. Preliminary data from the Centers for Disease Control and Prevention estimates 72,732 drug overdose deaths in 2019, breaking the previous record set in 2017.

Numerous studies and other data indicate that 2020 is on pace to break that record again. For example, the U.S. has seen an 18% spike in overdoses through May of this year, a finding echoed by the American Medical Association which reported more than 40 states have experienced increases in opioid-related mortality. Illicit fentanyl and heroin use appear to be fueling these increases.

A study of urine drug tests from this year show positivity rates increased by 35% for non-prescribed fentanyl and 44% for heroin during the pandemic. Non-prescribed fentanyl was also found in people tested for amphetamines, benzodiazepines, cocaine, and other opiates. Meanwhile, non-fatal opioid overdose visits to a large urban emergency department (ED) doubled from March through June 2020 compared to the previous year, although total ED visits decreased by more than 10,000 in that period.

The need for improved access to care, and other resources, for treating substance use disorder is greater today than ever before.

Challenges locating treatment

Although providers increasingly are short-handed locating available SUD treatment during the pandemic, access to treatment was not much better before, considering only 11% of eligible patients received such services and even fewer received MAT. With so many community-based organizations discontinuing services this year, access to effective treatment has likely been increasingly curtailed.

Faced with in-person treatment obstacles, many Americans have turned to telehealth services, including behavioral health and SUD. Overall, telehealth utilization has skyrocketed during the pandemic by as much as 3,500% in August compared to the previous year, with nearly half of the claims attributed to mental health services. Numerous mobile apps and websites have also recently emerged specializing in behavioral health/SUD, but data on their efficacy is limited or non-existent, especially for treating SUD. Furthermore, these solutions will not fill the gap if more community-based behavioral health/treatment facilities close or reach capacity. In addition, many patients lack the necessary infrastructure, such as reliable internet and mobile phone minutes, to access remotely delivered care. Treatment providers do not have the resources to provide their clients with the necessary infrastructure.

Expand preventive measures

Along with treatment, prevention is crucial in fighting this public health crisis. Providers who are not specialized in treating SUD do not have tools available. Checking their state’s prescription drug monitoring program (PDMP) database, for example, can help them identify high-risk patients who may have several controlled substance prescriptions from multiple physicians. Clinicians can then deliver point-of-care screenings and validated assessments based on the insights from the PDMP data and other medical records.

Eight states have recently launched behavioral health initiatives to help clinicians locate available inpatient and outpatient SUD and mental health treatment. In addition to tapping vetted behavioral health provider networks, these programs provide decision support and enable clinicians to send digital referrals to close the loop.  This eliminates the need for clinicians and support staff to spend hours on the phone, mass-faxing and waiting to find available treatment options for patients in crisis.

Preventive tools are also publicly accessible. In September, the not-for-profit group Shatterproof, the American Society of Addiction Medicine (ASAM) and OpenBeds, announced the availability of a 13-question SUD assessment to help individuals assess their need for treatment and determine which type and level of care is most appropriate. The assessment is accessible via a free internet portal where individuals can anonymously search for local treatment providers and submit confidential online referral inquiries.

More help to access behavioral health care is on the way. Beginning in 2022, Americans with suicidal thoughts will be able to dial 988 on their phone to be linked to a mental health crisis counselor. Although not exclusively focused on SUD, given substance use’s strong association with mental health disorders such as depression and anxiety, this access-to-care expansion will certainly help save more lives and improve outcomes, regardless of the contributing factors.

Beyond the vaccine

Everyone across the world is looking forward to the widespread distribution of a COVID-19 vaccine. However, no similar single solution is available to solve the country’s substance abuse and mental health epidemic. The solution will require a collective effort of providers, public health officials, governments, philanthropic organizations, families and patients to help expand access to effective treatment and strengthen prevention efforts.

Nishi Rawat is a critical care and emergency physician.

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