By Dayna Fondell, Alexandra Staropoli, and Shelby Kehoe, Camden Coalition of Healthcare Providers
Medications for addiction treatment (MAT) programs save millions of lives and are an integral component of harm reduction strategies to address problematic opioid use. In the last decade, states and localities have expanded access to MAT — including services in primary care settings — in response to rising opioid overdose deaths around the country. COVID-19 has not only exacerbated the need for MAT due to a potential rise in substance use, but has also created new roadblocks to the effective delivery of MAT services.
Through our work around the country, the Camden Coalition of Healthcare Providers has seen firsthand how a complex care approach to substance use treatment can yield positive results. This has been especially apparent while integrating MAT into primary care settings. Lessons from this work, as outlined in our toolkit, Medications for Addiction Treatment: Providing Best Practice Care in a Primary Care Setting, can inform efforts in the current COVID-19 environment.
In particular, building partnerships among MAT prescribers, their patients, and harm reduction and community organizations is critical during this time. Since February, the Camden Coalition has held biweekly MAT office hours for New Jersey providers and partners to learn from each other on topics such as federal and state policy changes during the pandemic, updates regarding community resources, and referral pathways between different levels of services. This blog post outlines opportunities we are seeing as we implement strategies from the toolkit and help providers adapt to new constraints due to COVID-19, many of which are relevant to stakeholders across the country.
The Current State of Medications for Addiction Treatment in New Jersey
In recent years, New Jersey invested in a robust opioid treatment infrastructure, including an emphasis on expanding access to MAT in ambulatory clinical (non-behavioral health) settings through the Office-Based Addiction Treatment (OBAT) model.
While New Jersey’s investment also expanded access to other harm reduction services, like naloxone, statutory and regulatory barriers in every state have historically prevented more widespread access to these services, particularly in clinical settings. Stigma and long-standing mistrust between medical providers and people who use drugs have also impeded the open conversations necessary for harm reduction strategies to succeed around the country.
The COVID-19 pandemic is changing how individuals access MAT and other harm reduction services and is also heightening the need for these services. In some instances, the pandemic has expanded access to support harm reduction strategies in clinical settings, while in others, access has been limited by the shutdown of in-person services. As the pandemic continues, there is widespread concern about a rise in problematic substance use and overdose deaths.
As the Camden Coalition continues to support the expansion of MAT access during COVID-19, delivery of care for individuals on MAT is changing in two primary ways: (1) access to MAT; and (2) access to community-based harm reduction services. These themes from our experiences in New Jersey, described below, can potentially inform stakeholders in communities across the nation.
Access to MAT
Relaxed federal and state regulations governing telehealth for MAT providers have expanded some access to MAT for Medicaid beneficiaries. One important change increased access to the initiation of buprenorphine treatment through a telemedicine visit, which had not been possible before. Because of these changes, many MAT providers have maintained services for their existing patients while also taking on new patients throughout the pandemic.
Some providers have expanded their availability outside of regular business hours to hold appointments late in the evening or at other times when it is convenient for patients who have jobs, families, and other responsibilities that make standard office hours difficult to attend. Other providers are reporting the benefit of telemedicine for patients with transportation barriers. Thanks to the efficiency of telemedicine, some providers who we work with are able to provide MAT more quickly and are operating without a waiting list for the first time in years. However, barriers still exist for many potential MAT patients because of inequitable access to the internet and technology platforms.
Because of COVID-19, many providers have also reduced the frequency of or paused routine urine drug screens (UDS). This disruption has prompted some providers to reflect on whether routine UDS are necessary. Harm reduction philosophy acknowledges that clinicians may need to collect UDS to adjust the treatment plan, but ideally, this should be done in collaboration with patients. Unfortunately, some programs practice zero tolerance policies, using positive UDS results as cause to discharge individuals from treatment. ASAM guidance focuses on using drug testing to build a therapeutic relationship and warns against using UDS in a punitive way. While providers fall along a spectrum of how they are using UDS, COVID-19 has certainly accelerated the use of a more harm reduction-informed approach.
These changes to MAT access have long-term implications for how providers will operate past the immediate crisis of COVID-19. There is already a growing push from providers to maintain flexible MAT telehealth regulations. Lessons from the pandemic may inspire providers to evaluate their clinical workflows, operating hours, and screening policies now that they have seen the potential for success using more patient-centered and harm reduction strategies.
Access to Community-Based Harm Reduction Services
The social distancing practices implemented in response to COVID-19 require community-based harm reduction centers — organizations that provide services and supplies such as syringe access, fentanyl test strips, testing for hepatitis C and HIV, and links to treatment — to adapt how they deliver services. Some centers closed or reduced their hours amid shortages of personal protective equipment for staff and other related obstacles. With already limited access to these services, further reductions in naloxone or sterile supplies can have significant implications on people who use drugs.
Fortunately, new pathways of support are emerging during this time. For example, a newly formed harm reduction organization is now offering mail order naloxone at no cost to people who may be at risk of relapse and overdose. Additionally, some New Jersey counties are investigating new ways of distributing fentanyl test strips.
These changes in community-based harm reduction services may alter their delivery in the long term. In the same way that telemedicine increases flexibility for patients, similar considerations should be given to increasing the avenues patients can use to access harm reduction services. Programs may shift to systems that do not require participants to access a central location for services and supplies. While the pandemic has facilitated access to naloxone via mail, a good next step would be to offer sterile supplies and syringes by mail as well.
We hope that the innovations, partnerships, and changes to the patient-provider relationship that evolve during this time are able to continue after the COVID-19 pandemic is over. In the meantime, MAT providers can align their practices’ internal policies with a harm reduction framework in order to reduce risk for their patients.
- Medications for Addiction Treatment: Providing Best Practice Care in a Primary Care Clinic – This toolkit shares comprehensive practical information for establishing MAT programs in primary care settings.
- Harm Reduction 101 – This video provides a primer on harm reduction.
- Resources for drug use and COVID-19 risk reduction – This resource center contains guidance documents, government advisories, and tools for people who use drugs and stakeholders likely to engage with people who use drugs.
- COVID-19 Resources for People Who Use Drugs and People Vulnerable to Structural Violence – This website provides COVID-19 resources for people who use drugs.
- COVID-19 Resources – This resource provides guidance on addiction treatments for providers treating patients with substance use disorder.
- Practicing Harm Reduction in the COVID-19 Outbreak – This website provides resources on how to practice harm reduction during COVID-19.
This Better Care Play is part of a series developed in partnership with the Camden Coalition of Healthcare Providers to share practical lessons in serving complex populations.
- Related Play: Implementing a Harm Reduction Approach to Medications for Addiction Treatment in Outpatient Settings - This Better Care Play provides steps to help providers in outpatient settings identify and implement harm reduction approaches to minimize patients' risk of relapse and overdose.