E9: Covid-19 and the Opioid Epidemic

This is OnePath with Metrohealth, your toolkit for helping to combat the opioid epidemic as a member of the medical community with empathy, mindfulness, and a big-picture perspective. I’m Libbey Pelaia, educator within Metrohealth’s department of Opioid Safety. Thanks for joining us.

Unsurprisingly, the global pandemic of Covid-19 has played an insidious role in the worsening of the opioid epidemic in the US. The early months alone of the pandemic brought an 18% increase nationwide in overdoses compared with the same months of the previous year. State by state, fatality numbers have spiked upwards: 580 people dead due to use of illicit chemicals in Oregon, a 37% spike in Meth usage in Oregon, and in our home state of Ohio, 548 individuals were lost to drug abuse in the spring of 2020, plus 481 in June and 442 in July.

Though the most-up-to-date data is still emerging surrounding the Covid-19 pandemic’s impact on opioid overdose deaths, the most recent data, reflecting September 2019 through August 2020, shows that there were 88,295 predicted deaths, 27% more deaths than the prior year.

The way things are looking, the final 2020 total of overdose deaths could exceed 90,000, solidifying 2020 as the year with the all-time highest number of overdose deaths, and the largest single-year percentage increase in the past twenty years.

All of this is incredibly upsetting. And while this data could be seen as only demoralizing and discouraging, it’s moving the office of opioid safety at MetroHealth to double down on their mission with an even deeper sense of urgency. The education team in particular has been working hard to adapt their educational content to the times.

Natalie Copeland-Traster: It is so important to us as an education team really to inform others just how common substance use disorder as well as mental health conditions are. Especially now given the huge impact of COVID-19. So many individuals really do not go and seek the help that they desperately need in a large part because of stigma. And so much of the basis of the stigma is due to all the misinformation and myths that are out there.

That’s the voice of Natalie Copeland-Traster of Metro’s Office of Opioid Safety Education Team. She shared that as a team, they are determined to change the dialogue around issues of addiction and substance use disorder.

Natalie Copeland-Traster:

The education team is developing curriculum for local school districts as well as local universities to discuss SUD, OUD. We've also created trainings that are individualized based on the needs of the audience with presentations that can go anywhere from 10 minutes to four hours and even beyond. Our audiences have varied drastically in age, educational needs. For examples, some have focused heavily on resources, stigma, harm reduction, the overlap of COVID-19 and mental health. We have hosted opioid safety grand round trainings that's open to all metro health staff. And we also train new providers and nurses in the emergency department.

Natalie Copeland-Traster:

Additionally, we've also been creating annual mandated employee education modules. We're all active members of the Cuyahoga County Opioid Task Force, the heroin and opioid action plan committee, The metro health opioid education sub committee, the Medina County Opiate Task Force, and the National Opioid Workforce Group. In addition at the Ohio means jobs, Cleveland Cuyahoga employer round table, both of those groups promote recovery friendly workplaces.

Christine Fishman is a pharmacist working out of the office of opioid safety and acts as the leader of the academic detailing program at MetroHealth. Remember the episode we did about prescriber peer review? Academic detailing hooks directly into that process.

Christine Fishman:

We have a peer review committee that consists of a peer review nurse, a case manager, nurse, and another pharmacist. And basically what they do is they review the prescribing habits of physicians. And then they provide me with some of that information and I can use that information to have conversations. I don't really target physicians or anybody who has prescriptive authority. I don't target them, but I learn from what they do, how to best address some of the gaps that clinicians may have when it comes to prescribing opioids. So I'm not going to go to a doctor and say, "You suck." But I will go talk to the doctor and say best practice guidelines say that, "The best way to prescribe opioids would be to use one of the smart sets that our electronic medical record suggests."

Christine Fisherman:

So that when you are talking to the patient it reminds you that you need to put down a diagnosis. It reminds you that you need to perform imaging or certain labs conduct a pain management panel at least once a year. It controls substance agreement if you have chronic pain patients. It gives you options like well, here are some non-opioid alternatives that you can start with, and then you can start with opioids starting with the lowest dose, and then working your way up if necessary.... It allows me to discuss with physicians so that when they're aware of the tools that are in front of them, they are better able to take care of the patients. And then hopefully we have better outcomes for everybody.

Christine shared that her team has also partnered with Cleveland’s Center for Health Affairs in creating an opioid safety tool kit to enable other hospital systems to set up similar programs to Metro’s, including peer review and academic detailing.

...They can do so easily without having to reinvent the wheel. So basically we provide them a toolkit with everything that we've done, so they don't have to do it themselves.

In addition, we're collaborating with the Northeast Ohio Medical School on a course that will be housed with the center for health affairs that will provide anyone with prescriptive authority continuing medical education regarding opioids and opioid use disorder. So if you are a prescriber who can write for medicated assisted treatment or what we'd like to refer to as medications for opioid use disorder, you have to get eight hours of continuing medical education specifically in opioid use disorder. And the goal is to have all eight of those hours available for practitioners should they choose to do them there.

The office of opioid safety is also working on an initiative to increase the number of providers who are able to prescribe the life-saving MAT option of Suboxone.

Christine Fishman:

It works very well and it prevents patients from relapsing. As you know in the past, you had to undergo training to become X wavered, or to be able to prescribe Suboxone for the treatment of opioid use disorder. Recently HHS, the Health and Human Services guidelines just came out that state that anyone with his or her own DEA number can treat up to 30 patients with Suboxone, up to 30 patients.

Christine Fishman:

All they have to do is fill out what they refer to as a notice of intent. And they fill that out and this makes this valuable drug accessible to so many more people. And I'm hoping this will help remove some of the stigma patients face when seeking treatment. So it was very difficult for patients to have access to Suboxone. Now, maybe with the relaxation of the rule that allows doctors to treat up to 30 patients without having to be X wavered, hopefully more primary care physicians will take it upon themselves to treat those patients. And the more patients we treat, then we don't have to have the horrific number of opioid overdoses that we've had in the past year, especially due to the pandemic.

Christine and her team work with prescribers to make sure they’re following best practice guidelines, but they don’t only want to do that.

I found that prescribers really, really care about their patients and they want to offer them the best possible treatment or therapy for the problems they may encounter. I like to look at my job as somebody who provides them with the right tools to do their job. Because if they find it easy to do the right thing, then it's a win-win situation for everybody.

Aside from creating an even more dire need for the work of the education team, the covid-19 pandemic has necessitated some strategic changes and increased creativity in connecting with the public.

Natalie Copeland-Traster:

...We had to learn how to educate individuals virtually, which was not something that we did very often. We were much more used to having that face to face interaction, which as I think everybody has experienced in this past year, you've had to get past that learning curve.

And this year, despite the pandemic, despite some of these challenges, we were still able to educate people throughout the community, in the MetroHealth System.

They also initiated the Project DAWN Expanded Mobile unit due to the shutdown of many services dedicated to treatment and hard reduction.

Natalie Copeland-Traster:

The project DAWN Expanded Mobile Unit, it is a harm reduction service that's in a low threshold environment and we actually opened it in April of 2020. Due in part to the massive release of incarcerated individuals that were in the Cuyahoga County Correctional Center. And at that time, we identified this huge, significant need to provide these resources and linkage to care. However, because so many services were shut down in our communities. Our project DAWN Expanded Mobile Unit realized this great need especially for syringe exchange program, safe injection supplies, et cetera.

Natalie Copeland-Traster:

And these services have been proven time and time again, to help decrease the outbreaks of HIV and HCV within communities. We're really hoping to expand this program because it has been incredibly successful and very much appreciated in the community. The staff that we have on our RV, they are building these amazing relationships with this very marginalized and very vulnerable population. Not only are they providing the syringes for them to be able to exchange, doing the testing, the safe injection supplies, linkage to care as well as resources.

The education team has found that word of mouth has been spreading throughout the community regarding the services the office of opioid safety offers-- and they’re dedicated to providing those services as consistently as they possibly can.

Natalie Copeland-Traster:

...There were a couple of days here and there that unfortunately the RV was out because of repairs and whatnot. And despite incredibly hot weather, our staff was sitting out there underneath the canopy tent, still trying to be there for their patients. And the relationships that they're developing are just absolutely inspiring and phenomenal because they're building this trust when so many of our patients, the system has failed them.

Natalie Copeland-Traster:

They are there with them the whole way and when they're ready to start treatment, they're there to help with the linkage to care. And the syringe exchange program, just within a month, one month alone, there were over 35,000 syringes exchanged.

A lot of the requests that the education team has received throughout the pandemic have been for content that explores the connections between substance use disorder, mental health conditions, and coping mechanisms.

Natalie Copeland-Traster: Because let's be honest throughout this whole pandemic there's been constant stressful news. There's been such an incredible amount of loss. Loss of life, loss of jobs, of incomes. There's been so many triggers for people that have been in recovery and how many people can honestly say that they've been thriving through this whole pandemic. Most people are struggling, not just individuals with mental health conditions and substance use disorders, but all of us.

Natalie Copeland-Traster:

We're entering a time that very few people in our society have lived through anything like this before. And with all of our educational you know programming that we've been doing, people are really, really trying to focus on that mental health piece and coping skills, self-care strategies has been huge.

Natalie Copeland-Traster:

And honestly our education team have been getting more and more requests than we have certainly throughout early 2020. And, and especially now as the communities are starting to open up and we're finding safer ways to be able to congregate. Honestly, we're getting different requests from all sorts of organizations in the community as well as all different age levels and the needs of the audience are certainly different than what they were a year ago.

Christine shared that data has emerged displaying that post-Covid patients are using more and more medications in the thirty day period after being diagnosed, and that some of the medications being prescribed may be contributing to a generally negative trend.

Christine Fishman:

Increase use of opioids, increase use of benzodiazepines to treat things like malaise and fatigue and pain, anxiety, sleep disorders. And to the effect that we're starting to see an increase in the prescribing trend of those medications and the treatment of that patient population. So that's a little bit of a disturbing trend, and I wanted to make sure that the team of prescribers treating our long COVID patients at MetroHealth were aware of that, so that they could think about that when treating their patients.

Christine Fishman:

So instead of reaching for a benzodiazepine to treat anxiety, that is usually not the first line course of recommend treatment. But other medications can be used first. And then if all of those failed, then we can consider benzos. Same with opioids. It would be a good idea for them to know that there is an upward trend of prescribing for opioids, but at our hospital, let's first consider non-opioid treatments first. And those can be both pharmacological and other different kinds of therapies that should be used with those patients.

The education team, and the entire office of opioid safety, is doing their best to encourage further understanding of this epidemic and more thorough distribution of educational and recovery-enabling resources, even in the face of intensely negative 2020 data. And even in the face of potentially even worse numbers emerging.

Natalie Copeland-Traster:

So far the information for 2021 that trend upward is incredibly disturbing. And it really it's up to us to do something about it. Just by early April of 2021, the medical examiner had issued a public health alert. And he had said that Cuyahoga county had already suffered at least 79 suspected overdose deaths just in the month of March. So again a year after the pandemic, we were already looking at that many deaths at least 79 suspected overdose deaths. And so far we really only have some of the data from the first quarter of 2021. So it's still a little too early to project with certainty how fatal the shear will be. But again, that upward trend is incredibly disturbing and we're seeing this all across the country.

Globally, mental health has taken a massive hit throughout the pandemic for all ages. The data, once again, tells a grim story, especially for young people.

Natalie Copeland-Traster:

We know that roughly 30 to 45% of adolescents, young adults with mental health disorders also have co-occurring substance use disorder. And then about 65% or more of youth with substance use disorder also have a mental health disorder. And young people have proven, especially vulnerable to mental health issues, especially related to COVID-19. Having school closures, trying to overcome the obstacles of learning an entirely different way. Learning remotely, having to isolate from friends due to social distancing have been major sources of stress and loneliness for a lot of our young people.

Natalie Copeland-Traster:

And a review of the international literature has identified incredibly high rates of anxiety, depression, as well as post-traumatic symptoms among children during this pandemic. And there was actually a report from the CDC that had showed that starting in April of 2020, the proportion of mental health related emergency room visits for children that were under 18 among pretty much all pediatric ER visits increased and actually ended up staying elevated through October.

Natalie Copeland-Traster:

And there were different students that had been surveyed at seven American universities, and they reported largely negative impacts of COVID on their psychological health, as well as their lifestyle behaviors. And we also know that anxiety, depression and adjustment disorders all exploded in the spring of 2020 in that 13 to 18 years age group. And overall it was increasing 80 to 90% compared to years prior. And unfortunately self-harm also increased about by 91% in March, so early on in the pandemic. And that self-harm increase was among youth again, in that age group of 13 to 18.

Natalie Copeland-Traster:

And then in April, it nearly doubled at 100% in comparison to the previous April. So again, as we mentioned earlier nobody has been really thriving throughout this pandemic. Our children especially were impacted immediately. Again, we saw those numbers in early March and April. And when you have to think back and reflect on, how did you feel at that time of the pandemic? There was no hope for any type of vaccines or treatments. There seemed to be no end in sight.

Natalie Copeland-Traster:

And now a little over a year later, a lot of us are still struggling with this because while there has been the hope of treatments, the fatality seem to be decreasing, vaccination access seems to be increasing. There's still that worrisome feeling about what's going to happen with variants. What's going to happen with our economy and everything. So we're really only starting to see just the tip of the iceberg of what is yet to come in the years coming down the road. And again, it doesn't matter where you're from, your level of education and everything. Mental health has been impacted and substance use disorder has been impacted. And as we know, both of those conditions do not discriminate.

The first thing that the education team has to do is make sure that they are educating people on the fact that substance abuse disorder or opioid use disorder is NOT a moral failing.

Christine Fishman:

We have to make it known that this is a chronic illness that needs to be regarded and treated like every other chronic illness out there. That people will relapse, that people will stumble, they will fall. And we need to be there to help pick them up and get them to the place they need to be. So to me, that is the most important thing we have to do. We have to normalize the care for substance use disorder, that's number one.

Christine Fishman:

We need to make sure that we offer people the care they need with respect to pain relief that include the use of opioids. We can offer alternative therapies. If medications are not working, there are definitely many modalities that can be used to help people with their pain in order to live a more comfortable lifestyle. Pain is always going to be there. ...Pain teaches you that there's something wrong and that you have to do something in order to temperate or mitigated or make yourself feel a little bit better.

Christine Fishman:

And that may include things like physical therapy, occupational therapy, using different techniques. And actually those things are offered at MetroHealth. We have Botox, we have dry needling. We have infusion therapies, myofacial release. We actually have psychologists that help with pain psychology.

There are so many different ways providers can help treat pain and teach people to live with a level of pain. Because frankly: living can be a painful experience. Turning off pain altogether is no longer the goal, but learning to manage it and cope with it is.

Christine Fishman:

So to me, it's very important to address pain, but in a healthy way, and not maybe just throw medications at it. We have to look at it from many different perspectives in order for us to be able to manage it and take care of it.

Natalie Copeland-Traster:

It's essential that we understand that substance use disorder is a chronic relapsing brain. It is not a moral failing. And actually the average American will relapse approximately seven times before they'll be able to maintain successful recovery. And increasing awareness through advocacy and education is absolutely imperative in order to combat the devastating pandemic and opioid epidemic.

There are so many variables that can exacerbate the challenges of recovery, especially in a global pandemic. With so many lives lost and so much uncertainty still on the horizon, those who struggle maintaining their mental health or sobriety have had an incredibly difficult time.

Natalie Copeland-Traster:

And even those that have not struggled as much with those problems, we have struggled many. I already said that about, how many of us can actually say that we've been thriving throughout this pandemic. And it's important to know that there is a chance to recover. There is a chance to prevent this and now more than ever, we need to remember that in a world where you can be anything, be kind. Because we truly never know what someone else may actually be going through.

Next time on One Path… we talk with Matthew Hawkins about his experience in recovery.

OnePath with Metrohealth is a production of Evergreen Podcasts, produced, written, and engineered by Hannah Rae Leach and mixed by Sean Rule-Hoffman. Special thanks to Mike Tobin, Karolyn Tibayan, Joan Papp, Joya Riffe, and the entire Department of Opioid Safety in making this show possible.