With overdose deaths spiking to new records during the COVID-19 pandemic, telemedicine has quickly become a lifeline for patients in treatment for opioid addiction.
“These are some of the unnamed victims of the pandemic,” said Jennifer Sharpe Potter, Ph.D., MPH, director of the Texas Medication for Opioid Use Disorder (TxMOUD) initiative at UT Health San Antonio, a statewide network of opioid use disorder providers that cares for about 1,800 patients. “Just like with other chronic diseases, when you lose your natural structure, it places a person at risk for a relapse.”
Quickly scaling up telehealth capacity was vital in the early days of COVID-19, Potter said, especially since opioid addiction is a life-threatening condition and so many of the pandemic’s domino effects — isolation, fear, anxiety, stress, job loss — exacerbate the factors that contribute to relapse and make it considerably harder to treat and manage the condition. Also critical: New, though temporary, federal rules that let providers prescribe and initiate buprenorphine, a medication that suppresses addiction symptoms and is one of the most effective treatments for opioid use disorder, by telephone or video.
Potter said she “can’t emphasize enough” how essential medications such as buprenorphine and methadone are to preventing overdose and hospitalization due to opioid addiction, adding that without the relaxation of telehealth prescribing rules, overdose deaths would have likely spiked even higher last year. The pandemic-induced telehealth boom, she said, is quickly proving its ability to bridge the gap between those who need opioid use disorder treatment and the number of providers able and willing to provide it. According to the TxMOUD initiative, in Texas, more than 90% of people who want to access substance use disorder treatment report being unable to do so.
“One of the biggest challenges is access — we can’t expect someone to recover if we can’t treat them,” said Potter, also a professor in the Department of Psychiatry and vice dean for research at UT Health San Antonio Long School of Medicine. “Low-barrier buprenorphine treatment is increasingly becoming the standard of care, so relaxing these rules while we monitor for consequences seems to be one of the more hopeful things that can come out of this.”
Expanding treatment access is just one of the ways Texas hospitals and health systems are confronting the opioid addiction and overdose crisis, with responses ranging from changes in clinical practice to community events aimed at preventing opioid misuse in the first place. According to the Texas Department of State Health Services (DSHS), opioid use is the primary driver of overdose deaths in the state, with the rate of opioid overdose death increasing nearly threefold in Texas between 2000 and 2016. More than 15,000 Texans died from an opioid overdose in that period. Nationwide, drug overdose deaths have quadrupled since 1999, driven mainly by opioids.
“One of the biggest challenges is access — we can’t expect someone to recover if we can’t treat them.”Jennifer Sharpe Potter, Ph.D., MPH, Director of the Texas Medication for Opioid Use Disorder Initiative
Provisional data from the Centers for Disease Control and Prevention reported more than 81,000 drug overdose deaths in the U.S. in the 12 months ending in May 2020, representing the highest number of such deaths ever recorded in a 12-month time span. In Houston last year, local first responders received an average of 90 calls per month related to opioid overdoses — peaking at 116 calls in June — and marking a considerable increase over 2018 and 2019, according to data from the UT Health School of Biomedical Informatics’ Center for Health System Analytics.
“The opioid epidemic is an ongoing problem that’s only been exacerbated by the coronavirus pandemic,” said John Harvin, M.D., an attending trauma surgeon at the Red Duke Trauma Institute at Memorial Hermann-Texas Medical Center in Houston.
The institute — one of the busiest Level I trauma centers in the country — treats overdose patients, it has also been at the forefront of research and practice aimed at reducing opioid exposure in health care settings, as overprescribing is a known factor in the diversion and misuse of opioids. Historically, Harvin said, opioids were part of the center’s pain management strategies. However, in 2013 in response to the opioid addiction crisis, he and his surgical colleagues implemented a new multimodal pain regimen designed to manage acute pain while minimizing opioid exposure. At the time, it was a “controversial” move, said Harvin, also an associate professor of surgery at McGovern Medical School at UT Health.
“We had always used opioids as pain management — it’s what we knew,” he said. “And we didn’t know if these other medications would be as effective.”
Over time, however, the new regimen proved its value, effectively managing patients’ pain while reducing opioid exposure at Red Duke by 31% in the following years. Still, the regimen — a cocktail of multiple drugs, including intravenous acetaminophen and the narcotic tramadol — was expensive, not easily accessible and insurers might not cover it. Those drawbacks led Harvin and colleagues to launch a new study comparing the multimodal regimen to a more generic and affordable one known as MAST (Multi-Modal Analgesic Strategies in Trauma), which includes just one drug that requires a prescription.
“The opioid epidemic is an ongoing problem that’s only been exacerbated by the coronavirus pandemic.”John Harvin, M.D., Trauma Surgeon at the Red Duke Trauma Institute
That study, published earlier this year in the Journal of the American College of Surgeons, found that patients randomly given the more affordable MAST regimen experienced less opioid exposure per day, were more likely to be discharged without an opioid prescription, and reported no clinically significant difference in pain scores. Harvin was surprised.
“Honestly, I thought the original regimen would work better,” he said. “It just goes to show how we’re continuously learning more about acute pain and opioids.”
The MAST regimen is now standard practice at Red Duke Trauma Institute, including in the burn unit, where Harvin said MAST has also resulted in fewer opioid prescriptions at discharge with no differences in patient pain scores. Whether and by how much the prescribing changes impact longer-term opioid use outcomes is harder to measure, he said, noting that Texas law doesn’t allow for using data from the state’s Prescription Drug Monitoring Program for research or quality improvement purposes.
“It’s important to remember that this regimen is just a starting point and every patient is different — it’s a strategy,” Harvin said. “Before, we were hitting people upfront with lots of medications, including opioids, and then de-escalating. Now, instead of a de-escalation strategy, we have more of an escalation one.”
“The bottom line is that we can treat acute pain in an opioid-minimizing way after injury,” he said, “and opioids shouldn’t be considered the mainstay of therapy.”
In addition to clinical practice changes, many Texas hospitals are also taking a community role in educating about and preventing the diversion and misuse of opioids. Last October in north Texas, four Medical City Healthcare hospitals — Medical City Arlington, Medical City Dallas, Medical City Denton and Medical City Fort Worth — hosted day-long, drive-thru drug take-back events. They collected more than 1,200 pounds of medications for safe disposal, according to Joseph Parra, M.D., chief medical officer at Dallas-based Medical City Healthcare, which has 16 hospitals in the region. The events were part of nationwide “Crush the Crisis” opioid take-back days hosted across HCA Healthcare, Medical City’s parent company, that overall collected about 13,500 pounds of medication, doubling its haul from the previous year.
“[Crush the Crisis] raises awareness and makes it very convenient for people to discard of their medications safely so they’re not sitting around at home where someone, unbeknownst to them, can take them,” said Parra, who described people driving up to the take-back events with garbage bags filled with unwanted prescription and over-the-counter drugs. “We had heard from many people who wanted an opportunity to do this… so it was also one way we could give back to the community.”
2020 was the first year the four North Texas hospitals hosted Crush the Crisis events, but ongoing safe disposal efforts started a year before when 13 Medical City hospitals put out permanent safe drug disposal boxes for the public. Clinically, Parra said Medical City has also shifted to a pain management approach to minimize opioid exposure, with a significant decline in surgery-related opioid use across the HCA system.
Like other parts of Texas, the Dallas-Fort Worth region has also experienced a rise in overdose emergency room visits during the pandemic, reported Parra, who said that caring for patients with problems related to opioid addiction is a near-daily need.
“If we’re going to combat this [opioid] crisis, we have to do several things,” Parra said. “But one thing we can do as health care experts is if we don’t need to prescribe opioids to control pain, we can try an alternative medication first.”
Back in San Antonio, TxMOUD — the statewide network of opioid use disorder providers — just launched a new program known as SHOUT, or Support Hospital Opioid Use disorder Treatment, which trains providers to identify opioid use disorder and initiate buprenorphine treatment during acute hospitalization and then link patients to outpatient addiction care. Potter said SHOUT, which has been successful at encouraging patients to enter treatment after discharge, started at three hospitals this year.
“Regardless of circumstances, this is a group of people who were already underserved,” Potter said. “Right now, hospitals and other health care systems are in a unique position to have more resources than ever before to confront opioid use. We have treatments that work — now it’s just a matter of deploying those resources appropriately in our communities.”