New Jersey’s opioid epidemic did not recede when the novel coronavirus invaded the state two months ago, and addiction in general may well be on the rise during these challenging times, with drug-related deaths up slightly over last year, state figures show.
As with many other aspects of health care, the landscape of treatment and risk-reduction programs has evolved significantly during the pandemic in ways that are good and bad, experts said.
Many community-based treatment programs closed when the state shuttered nonessential businesses and ordered people to stay at home in late March, concerned they could not keep clients and staff safe. Others that remained open are busier than ever, according to those involved, and are adapting to new infection-control protocols.
Variations in the supply chain for heroin and other illicit opioids have prompted an increase at some hospitals of patients who have overdosed or are facing withdrawal and need emergency care, or want help managing their addictions. At other facilities, the volume of cases has declined, doctors said.
But experts agree that the stress, longtime seclusion and economic downturn associated with coronavirus will lead more people to misuse alcohol and drugs in the weeks and months to come. “There is historic, real reason to believe substance use disorder will go up during and after COVID,” said Dr. Kaitlan Baston, who runs addiction programs at the Urban Health Institute at Cooper University Health Care, in Camden, where the addiction-disorder clinic is busier than usual.
“As long as there is an economic downturn or as long as there is an unemployment rate that’s increasing we will be seeing this issue. And with COVID we’re adding to that social isolation,” she added. “Social isolation is one of the main drivers of substance use disorder.”
More drug fatalities in 2020
New Jersey has lost more than 3,000 residents annually to drug-related deaths in recent years, a trend that had started to decline slightly. But data collected by NJ Cares, the state’s coordinated opioid response effort overseen by the Attorney General’s Office, shows higher numbers of these fatalities in each of the first four months of 2020, when compared to last year. The state had lost 1,030 residents by the end of April, versus 866 by that time last year.
While opioid addiction has been headlining health care news in the Garden State for several years, it has recently been eclipsed in public conversation by COVID-19, which has been detected in nearly 132,000 residents, including more than 8,500 who have died. The disease is particularly deadly for those with underlying conditions, which are more common among individuals with substance use disorders (SUDs) — especially if they are also experiencing homelessness, which can make it a particular challenge to manage chronic conditions and avoid new infections.
“It’s just not a stable time for anyone who is out (on the street) using substances,” Baston said. “And a lot of those patients are putting themselves at risk to have to go out into the community and get what they need.”
For some with heroin addictions, finding the drugs they need every day to avoid life-threatening withdrawal presents new challenges. Stay-at-home orders have made it hard for dealers to operate in the open, experts note, and problems with supply have led some distributors to mix their products with other potentially more deadly substances, like fentanyl.
“People are definitely struggling with that as well,” said Eddie Frierson, harm reduction manager for Hyacinth AIDS Foundation, which operates syringe-access programs in Trenton, Jersey City and Paterson. “And we are giving out a lot of Narcan kits too,” he said, which contain naloxone, the quick-acting overdose antidote.
Frierson said limits on available staff — many have underlying conditions that put them at risk of infection — and a lack of masks, gowns and other personal protection equipment, or PPE, forced Hyacinth and some of the state’s other needle-exchange programs to suspend operations for several weeks at the start of the outbreak. Hyacinth is operating again at its three locations, he said, but on fewer days than in the past and with new policies: Clients are provided gloves, mask and hand sanitizer and passed clean needles through a van window instead of face-to-face.
Demand for syringe-access programs on rise
Demand for these services is on the rise at most sites, Frierson said. He served 39 clients in three hours last week in Paterson, double the normal turnout. “The clients need us,” he said. “If we don’t give them the supplies they need we’re going to see an uprising in blood-borne pathogens.”
Cooper’s Camden clinic is also doing a brisk business with those seeking treatment, Baston said, with more walk-in clients and nearly twice as many patients referred to them from the ER after an overdose. While other programs were forced to cut back or suspend operations, this clinic was able to shift more stable patients to telehealth sessions and create space in the schedule for more patients.
Now patients are screened for COVID-19 symptoms and moved through the facility in a way that’s designed to minimize the risk of infection, Baston explained, an evolution she said has been very successful. “We were noticing a big wave of unmet need,” she said. “Patients were unable to get physically to their (treatment) program, or detox, or residential (treatment) and a lot of people were ending up in the ER.”
Federal and state regulators supported these developments by creating waivers to allow some treatment protocols to be conducted by telehealth, instead of just face-to-face, and permit stable clients to receive up to a month’s worth of prescriptions for medication-assisted treatment, or MAT — the highly controlled pharmaceuticals that are considered the “gold standard” in addiction care. New York City has even begun delivering methadone to individuals with SUDs who are in quarantine, according to several reports.
Medication home delivery, telehealth treatment
New Jersey’s Department of Human Services, which oversees most addiction programs, has also extended telehealth coverage for Medicaid members, distributed additional naloxone, and enabled certain MAT home-delivery options, among other changes, to expand access to care. It’s not clear how widely home delivery has been used but the flexibility these various changes allow is appealing to some providers.
“We’ve made a lot of progress. Maybe these are emergency actions, maybe they need to be permanent,” said Robert J. Budsock, president and CEO of Integrity House, which includes a 425-bed residential treatment facility in Newark and outpatient programs. “It’s been years that everyone’s been talking about telehealth and telepsych, and we’ve been crawling around. And then it’s like a switch was turned on.”
Integrity House, founded in 1968, had never offered telehealth before last month, Budsock said, when it moved some outpatients to virtual treatment. (Many support services, including some Alcoholics Anonymous meetings, have also been moved online, and Horizon Blue Cross Blue Shield of New Jersey, the state’s largest health insurance company, is working with health care providers to expand access to mental health and SUD assistance through telemedicine.)
Integrity House has also continued to run programs for those who want to come in, reconfiguring how they use the waiting room, scaling back group sessions to create more space, and requiring temperature and symptom checks for everyone. But they have not suspended treatment, Budsock stressed.
“Our position at Integrity House is that we are an essential service that is needed here in the community and people have depended on us and relied on us for many years. So we changed things,” he said.
Changes are particularly noticeable at the residential facility, Budsock explained, where they have restricted visitation, implemented strict screening for all staff, and deployed professionals to clean frequently touched surfaces every 15 minutes. When an employee and client tested positive early in the outbreak, Integrity secured enough tests to screen all residents and staff — regardless of any symptoms — and track the contacts of anyone who was found positive for COVID-19.
With that information in hand, Integrity could isolate those who had been diagnosed with the disease and then quarantine people who they had come into contact with for a 14-day incubation period, Budsock said. As a result, communal dining was suspended and residents were restricted to their own units — which hold between 16 and 39 people — while meals, treatment and other services were brought to them, he added.
“We want to eradicate this issue at Integrity House and we want to make sure we maintain a safe environment,” Budsock said.