State reports of increased opioid-related mortality continue to increase
News accounts of increases in opioid-related mortality continue to increase during the COVID-19 global pandemic, according to an updated AMA issue brief.
There now are reports from more than 40 states about ongoing concerns for those with a mental illness or substance use disorder about the need for access to evidence-based treatment. The AMA urges all states to take action, including removing barriers to evidence-based treatment for opioid use disorder and improving access to harm reduction services, including naloxone to help save lives from opioid-related overdose, as well as access to sterile needle and syringe services programs.
Telehealth bridges gaps created by location and socio-economic status
District of Columbia physician Edwin Chapman, MD, understands that "innovation" is not a buzz word only conjuring up advancements such as stem cell research or cancer-curing treatments, but also includes using telephones and video to help vulnerable patients during the COVID-19 pandemic. In recent months the use and coverage of telehealth, once thought of as a tool to increase access in rural areas, has expanded his ability to continue care for hundreds of patients with a substance use disorder within Washington, D.C.
"When I started treating patients with buprenorphine 20 years ago, I was being sent patients by parole officers and was asked to treat their addiction, but these patients needed mental health services, primary care and psychiatry. Treating only the addiction wasn't going to completely rehabilitate them," said Dr. Chapman. "You have to treat everything."
What his patients needed was an integrated care model, and integrating meant updating. Dr. Chapman digitized his patients' records, equipped every exam room with a microphone and a webcam and transitioned to telemedicine. His patients could come to one office but do multiple consultations with social workers, primary care physicians and psychiatrists, allowing them to turn what might have been multiple bus trips and hours' worth of childcare into one visit at one location—one-stop shopping.
"Telemedicine was originally only seen as something appropriate for a rural practice, as a way to help patients who might not have a physician nearby," said Dr. Chapman. "But the socioeconomic reality for many is that even when a medical office is closed, there are childcare costs, time off work, multiple bus and train fares to contend with–telemedicine is useful in bridging those gaps, too."
Doing in-office consults allowed his patients access to a whole host of specialists and services. Dr. Chapman has helped his patients with not just addiction, but with chronic conditions like diabetes, Hepatitis-C, HIV, hypertension and cancer. He says, "Telehealth has helped one of my long-term patients for at least 15 years now, and this model has helped him to stabilize his life."
"Dr. Chapman and I have a relationship that's honest," said Dr. Chapman's patient "Bill," who asked the AMA not to use his real name. "My life was using drugs, I destroyed my marriage, and it wasn't until my second or third time trying medication with Dr. Chapman's help that I was able to start feeling better. The people who know me say I look good, but I still have ups and downs sometimes. Dr. Chapman helps me prioritize my feelings and emotions. I wish there were more Dr. Chapman's out there."
Bill is one of about 260 patients Dr. Chapman sees.
"Treatment is about benefits that reverberate across the entire community," said Dr. Chapman. "Beyond the health care savings of keeping patients with chronic conditions and comorbidities out of hospitals, there's a reduction in criminal activities and homelessness. It's helping my patients get back on their feet, find housing and jobs. It's an economic model that shifts money from just housing these patients in jails, to the social services that allow them to regain control over their lives. Bill has been with me for 15 years, and in that time he hasn't been incarcerated or gone back to the emergency room. He got his life back, and in doing so we have decreased reliance on medical services. For too long in the African American community, incarceration was seen as treatment, but that's never worked. We have to change the model because medical treatment provides widespread social benefits and economic savings."
Dealing with the effects of COVID-19 is helping to break down the stigma among providers when it comes to expanding access to telemedicine, but Dr. Chapman isn't waiting for the slow realization of its benefits—he is actively putting his foot on the pedal to accelerate wider adoption. In an effort to expand professional education and reduce provider stigma, Dr. Chapman has put on some Project ECHO sessions with the Howard University "Urban Health Initiative," and they recently initiated a fellowship program in addiction medicine. Dr. Chapman also serves as an adjunct assistant professor in their Department of Behavioral Health and Psychiatry.
When asked whether there are additional policies and practices other than telemedicine that would help his patients, Dr. Chapman pointed to several "overly strict" regulatory structures that hamper addiction treatment, exacerbate health risks and impose harmful barriers to care.
Areas where Dr. Chapman would like to see improvements include how Medicaid does not allow two services to be billed on the same day, prior authorization requests that delay care for patients that do not have time to wait, and eight-hour training and waiver limits that prevent some physicians from wanting to treat patients with opioid use disorder.
"Increasing the use of telemedicine removed 10 years of challenges," said Dr. Chapman. "We still have a long way to go to remove the stigma of opioid use disorder, help those who are homeless and get more people trained to provide treatment for opioid use disorder in urban areas like mine. And we need to do it soon."
