COVID19 is having an unprecedented impact on the lives of billions of people. But a robust and effective COVID19 response must not be a vehicle for denying access to essential health care services.
NHeLP is fighting to protect access to the range of critical services that people — especially low-income and historically vulnerable communities — need in order to live their lives. Yes, even in a pandemic. Especially in a pandemic.
The COVID-19 emergency presents a heightened risk for individuals with substance use disorders (SUD). These individuals are particularly vulnerable to complications related to COVID-19 because they may present decreased respiratory and lung function, which may exacerbate the impact of the disease. On top of this vulnerability, people with SUD are at risk of losing access to life-saving treatment for their condition at a time when most states across the country have ordered residents to stay at home in order to combat the spread of the pandemic.
Under normal circumstances, less than 20% of all individuals with substance use disorders (SUD) receive life-saving medication-assisted treatment (MAT). Given the COVID-19 emergency, state and federal action is needed to avoid reducing that number even further. The pandemic highlights and exacerbates the many barriers that exist for people with SUD to access treatment.
For example, federal law requires patients to receive methadone treatment for opioid use disorders (OUD) through a SAMHSA-certified opioid treatment program (OTP). Individuals in states that have implemented stay-at-home orders will find it difficult to go to an OTP to receive their medication. In response, SAMHSA has issued guidance allowing states to request an exemption for patients who are on a stable dose to receive 28 days of take-home medication and patients on a less stable dose to receive 14 days of take-home medication.
While this is a much-needed policy change in times of the COVID-19 pandemic, many barriers remain. First, methadone clinics have considerable flexibility to determine whether a patient in a less stable dose is able to safely handle the increased take-home dose. As such, clinics may continue to require certain patients to physically visit the OTP to receive the medication while risking contracting the virus. Moreover, many states have enacted additional requirements for take-home medications and not all states are eager to ease those restrictions even during the pandemic.
Federal law also limits access to buprenorphine for OUD by requiring providers to receive a waiver before prescribing the medication and by limiting the number of patients that waivered prescribers may treat in a given year. In times of provider shortages, the already low number of providers prescribing buprenorphine is likely to decrease. Moreover, Drug Enforcement Administration (DEA) regulations require providers to conduct an in-person initial assessment before prescribing buprenorphine.
SAMHSA and the DEA have issued joint guidance that allows this assessment to be conducted via telehealth (including telephone) during the COVID-19 emergency, a move that was necessary to avoid further exposing individuals with SUD. Similarly, the Centers for Medicare and Medicaid Services (CMS) have released guidelines for the use of telemedicine for SUD treatment in Medicaid. There is no doubt that this is a step in the right direction, but given the lack of SUD providers, the move should be coupled with a new approach that would allow all licensed physicians to prescribe buprenorphine without the need to receive a federal waiver.
Finally, many individuals with SUD face financial barriers to receiving care. Medicaid is the largest source of coverage of SUD treatment, but fourteen states, including states with high prevalence of both SUD and COVID-19, such as Florida and Texas, have yet to expand the program. While some individuals in those states may be able to receive SUD treatment through SAMHSA grants, they will face additional complications in the presence of a COVID-19 diagnosis.
Additionally, many states and local governments are having to prioritize funding for COVID-19 response at the expense of other programs, such as public health efforts to address the substance use epidemic and funding for SUD treatment. SAMHSA has made available emergency grants to address SUD during the pandemic and states should be actively taking advantage of this opportunity. Nonetheless, without a strong and sustainable safety net to ensure that low-income individuals with SUD have continuous access to care before, during, and after a pandemic, emergency funding will not result in long-lasting benefits for this population.