Last March, when the coronavirus pandemic was still in its infancy in the United States, the opioid epidemic was already mature and ravaging the country. Even prior to the pandemic, addiction treatment and harm reduction services were difficult to access for many people attempting to stave off overdose or blood-borne infections like HIV. With stay-at-home orders looming, it became clear that thousands of people struggling with addiction were going to be cut off from vital services and lifesaving medications.
To their credit, state and federal officials—with the help of addiction treatment advocates—enacted temporary changes to methadone and buprenorphine prescribing to attempt to reduce overdose deaths in the face of the mounting pandemic. Methadone, which is one of the most effective medications for the treatment of Opioid Use Disorder, is also one of the most highly regulated medications, as it is only accessible at special clinics rather than a typical doctor’s office and dispensing rules normally require patients to stand in line for their daily dose. Buprenorphine, another highly effective medication for OUD, can be accessed via a doctor’s office, but only after an in-person evaluation. Rule changes last March allowed for methadone to be prescribed for two-to-four-week take-home doses and for buprenorphine treatment to be initiated via telemedicine.
Unfortunately, these rule changes had very little impact amid the sea of Covid-related restrictions that disproportionately impacted vulnerable populations. Recent data from the US Centers for Disease Control and Prevention (CDC) shows that there were nearly 90,000 drug overdose deaths in the United States in the 12 months ending in August 2020—the highest number of overdoses ever recorded in a 12-month period in this country. New data released in Massachusetts shows that overdose deaths increased 5 percent in 2020 compared to 2019. Most concerning, overdoses by Black men in Massachusetts increased by nearly 70 percent from the previous year.
Public health experts are just beginning to assess the collateral damage from the pandemic. Overdoses are a part of that wreckage, but not all of it. People who inject drugs were largely cut off from essential harm reduction services, including syringe services (needle exchange programs), which are effective at reducing HIV transmission and at improving linkage to medical care. Even before the pandemic, these services were already in short supply and heavily restricted. Of the 220 “hot spots” identified in 2016 by the CDC as at highest risk for an HIV outbreak, only 47 had a syringe service program. Disruption of essential services as a result of the pandemic has fueled new HIV outbreaks among people who inject drugs throughout the country—not just in rural areas like West Virginia but in cities like Boston as well. And, evading rational thought, US legislators from West Virginia to Indiana to New Jersey are dismantling syringe service programs altogether.
Given the setbacks, we are now further away from ending both the overdose and HIV epidemics than we were before the pandemic. Even to get the United States back to pre-pandemic numbers, an aggressive, multipronged approach is desperately needed. President Biden’s stimulus bill contains a necessary $1.5 billion for community mental health services relating to addiction and another $1.5 billion for drug and alcohol use treatment. This infusion of cash is necessary but not sufficient. It is equally important that these dollars be spent on evidence-based treatments that are effective, not simply on increasing the number of detox beds—which does virtually nothing to prevent overdose.
In addition to this increased funding, the federal government must codify the changes made to methadone and buprenorphine prescribing that were instituted at the beginning of the pandemic. The Biden administration took an important step recently by reducing barriers to buprenorphine prescribing, but should go one step further by fully eliminating the required waiver necessary for all buprenorphine prescribers. Toward the effort of ending the HIV epidemic, the federal government must also lift the restriction on the use of federal funds to purchase needles or syringes.
Additionally, now is the time to expand harm reduction services, not shutter them. Keeping syringe services programs open is a no-brainer—and anyone attempting to do otherwise should be ashamed of themselves. But we shouldn’t stop at syringe service programs. Now is the time to sanction safe consumption sites in the United States. Also known as overdose prevention sites or supervised consumption sites, these are facilities that “allow people to consume pre-obtained drugs under the supervision of trained staff.” Sanctioned safe consumption sites operate in 10 countries around the world and have been shown to reduce overdose deaths, decrease public consumption and the number of discarded needles, reduce HIV infection, and to be synergistic with medication treatment and other overdose prevention services. One unsanctioned US safe consumption site was responsible for a substantial drop in overdose deaths. A major study noted the impact that safe consumption sites might have on six major cities. And mayors around the country have expressed support for such facilities, but no one has yet actually instituted one. Now is the time to step up and save lives.
The devastation of the coronavirus pandemic has provided us with an opportunity to build a health care system that provides lasting solutions to the drug epidemic. In the short term, this means using federal and state relief dollars to expand access to medication treatment and harm reduction services. In the long term, it means permanently lifting arcane restrictions and drug laws that were established as a result of stigma, racism, and fear. In doing so, while we near the end of the coronavirus pandemic, we could also near the end to the drug epidemic in the United States.