Struggling With Recovery From Opioids: Who Is at Risk During COVID-19?

OBJECTIVES: Individuals in recovery from opioid use disorder (OUD) are vulnerable to the impacts of the COVID-19 pandemic. Recent findings suggest increased relapse risk and overdose linked to COVID-19-related stressors. We aimed to identify individual-level factors associated with COVID-19-related impacts on recovery. METHODS: This observational study (NCT04577144) enrolled 216 participants who previously partook in long-acting buprenorphine subcutaneous injection clinical trials (2015-2017) for OUD. Participants indicated how COVID-19 affected their recovery from substance use. A machine learning approach Classification and Regression Tree analysis examined the association of 28 variables with the impact of COVID-19 on recovery, including demographics, substance use, and psychosocial factors. Ten-fold cross-validation was used to minimize overfitting. RESULTS: Twenty-six percent of the sample reported that COVID-19 had made recovery somewhat or much harder. Past-month opioid use was higher among those who reported that recovery was harder compared with those who did not (51% vs 24%, respectively; P < 0.001). The final classification tree (overall accuracy, 80%) identified the Beck Depression Inventory (BDI-II) as the strongest independent risk factor associated with reporting COVID-19 impact. Individuals with a BDI-II score ≥10 had 6.45 times greater odds of negative impact (95% confidence interval, 3.29-13.30) relative to those who scored <10. Among individuals with higher BDI-II scores, less progress in managing substance use and treatment of OUD within the past 2 to 3 years were also associated with negative impacts. CONCLUSIONS: These findings underscore the importance of monitoring depressive symptoms and perceived progress in managing substance use among those in recovery from OUD, particularly during large-magnitude crises.

Feasibility and Short-Term Effects of Low-Threshold Opioid Substitution Treatment during the COVID-19 Pandemic in Hamburg, Germany.

INTRODUCTION: After rapidly opening up a low-threshold clinic to support heavily opioid-dependent persons at the beginning of the COVID-19 pandemic in April 2020 in Hamburg (Germany), this non-interventional study evaluated the feasibility and short-term effects of opioid substitution treatment (OST). The low-threshold concept was customized for the pandemic situation and is the first of its kind in Germany. METHODS: Patients who had already begun treatment were questioned in two assessments, at T1 shortly after beginning treatment and at T2 6 months later. The primary outcome criterion was their quality of life using the OSTQOL. Secondary criteria included retention rate, their mental and physical health (measured by the BSI-18 and the OTI Health Scale), social situation, drug use, COVID-19 status, and satisfaction with treatment. RESULTS: Out of 84 patients included in the study, 51 participated in both assessments, resulting in a 6-month retention rate of 60.7%. 27.5% were females, and 72.5% were males. The feasibility question of the low-threshold OST clinic can clearly be answered positively. During the course of the study over 6 months, the situation mainly remained stable regarding quality of life, physical and mental health, and days of drug consumption. Patients significantly reduced the time they spent on the drug scene from 8.5 (SD = 7.56) to 6.1 (SD = 6.71) hours a day between the beginning of OST and T2 (p = 0.020). While 56.9% answered to be homeless at the beginning of OST, only 33.3% answered not to have found an accommodation by T2 (p = 0.012). The number of patients having contact to social workers increased from 51.0% to 74.5% (p = 0.004). Almost 2 fifths of the patients took part in PCR testing for COVID-19 (that only being done if they had symptoms), and none of the tests were positive. DISCUSSION/CONCLUSIONS: Overall, the low-threshold OST clinic has been successfully implemented in order to help a vulnerable group of people navigate through a global pandemic and support the public health sector. Further conclusions on effects are limited by the short study period and the small number of patients, which calls for further research studies in a larger setting.

Effects of Unemployment on Opioid Use Treatment Trajectories: Impact of the COVID-19 Pandemic.

ABSTRACT: Living with an opioid use disorder (OUD) can make finding and sustaining employment a significant challenge and is only expected to get worse in the COVID-19 environment. For most individuals in OUD treatment, being employed is an important part of their recovery journey. Employment has several benefits, including reductions in preoccupation with symptoms, social isolation, risk of suicide, hopelessness, and economic instability, which if not addressed often result in homelessness. Therefore, employment is an important social determinant of health, especially among those with OUD. Employment success and OUD, however, may vary based on race, age, gender, and socioeconomic status. Return to work support as states begin to reopen will be critically important to improve treatment outcomes for individuals with OUD in a post-COVID-19 environment, requiring utilizations of evidence-based interventions. Nurses, particularly psychiatric mental health and addiction nurses, should routinely screen for employment needs of their patients with OUD and connect them to the necessary support services. Finally, nurses should advocate for regulatory reform that allows for employment support services to be billable and integrated in psychiatric and behavioral health services just like other mental health services.

Trajectories and Individual Differences in Pain, Emotional Distress, and Prescription Opioid Misuse During the COVID-19 Pandemic: A One-Year Longitudinal Study.

Recent studies suggest that the COVID-19 pandemic can serve as a unique psychosocial stressor that can negatively impact individuals with chronic pain. Using a large online sample in the U.S., the present study sought to investigate the impact of the pandemic on the trajectories of pain severity and interference, emotional distress (ie, anxiety and depressive symptoms), and opioid misuse behaviors across one year. Potential moderating effects of socio-demographic factors and individual differences in pain catastrophizing, pain acceptance, and sleep disturbance on outcome trajectories were also examined. Adults with chronic pain were surveyed three times across 1 year (April/May 2020 [N = 1,453]; June/July 2020 [N = 878], and May 2021 [N = 813]) via Amazon's Mechanical Turk online crowdsourcing platform. Mixed-effects growth models revealed that pain severity and interference, emotional distress, and opioid misuse behaviors did not significantly deteriorate across one year during the pandemic. None of the socio-demographic factors, pain catastrophizing, or sleep disturbance moderated outcome trajectories. However, individuals with higher pain acceptance reported greater improvement in pain severity (P< .008, 95% CI: -.0002, -.00004) and depressive symptoms (P< .001, 95% CI: -.001, -.0004) over time. Our findings suggest that the negative impact of the pandemic on pain, emotional distress, and opioid misuse behaviors is quite small overall. The outcome trajectories were also stable across different socio-demographic factors, as well as individual differences in pain catastrophizing and sleep disturbance. Nevertheless, interventions that target improvement of pain acceptance may help individuals with chronic pain be resilient during the pandemic. PERSPECTIVE: Individuals with chronic pain overall did not experience significant exacerbation of pain, emotional distress, and opioid misuse across one year during the COVID-19 pandemic. Individuals with higher pain acceptance showed greater improvement in pain severity and depressive symptoms over time during the pandemic.

Improving methadone access for rural communities in the USA: lessons learned from COVID-19 adaptations and international models of care.

CONTEXT: The COVID-19 pandemic led to several changes to methadone treatment protocols at federal opioid treatment programs in the USA. ISSUE: Protocol changes were designed to reduce transmission of COVID-19 while allowing for continuity of care, but those changes also demonstrated that many policies surrounding opioid use disorder care in the USA cause unnecessary burdens to patients. In this commentary, we describe how current policies create and maintain fatal barriers to methadone treatment for people in rural communities who have opioid use disorder, and highlight how COVID-19 adaptations and more flexible methadone models in other countries can better allow for effective and accessible care. Reasons and ways to address these issues to create lasting solutions for rural communities are discussed. LESSONS LEARNED: We focus on three lessons: (1) methadone dispensing and take-home schedules during COVID-19, (2) telehealth services during COVID-19, and (3) international models in use prior to COVID-19. We then outline recommendations for each lesson to improve access to methadone treatment long term for rural communities in the USA. There is an urgent need to implement recommendations that maintain flexible approaches and address methadone treatment barriers in the rural USA. To achieve lasting health policy change and combat stigma about addiction and methadone treatment, there is a need for advocacy efforts that give voice to rural residents impacted by inequitable access to methadone treatment and rural-tailored educational initiatives that promote the evidence base for methadone. We hope opioid treatment program directors, regulatory authorities, and health policymakers consider our recommendations.

Contextual risk and psychosocial profiles of opioid-using mothers: A mixed-methods study.

INTRODUCTION: There is an increase in cases of mothers using opioids during pregnancy in the United States but research investigating mothers' psychosocial environments along with individual variability among this high-risk group of women is scarce. METHODS: This mixed-methods study aims to examine the complex interplay of contextual risks and experiences of opioid-using mothers. A sample of 50 opioid-using biological mothers of infants diagnosed with neonatal opioid withdrawal syndrome (NOWS) were studied using a set of standardized and open-ended questions, along with medical records extraction. RESULTS: A high-risk subgroup of 36 mothers was identified using cluster analysis, characterized by a distinct profile of psychosocial risk. Thematic content analysis revealed four themes: (1) barriers to communication and mistrust of health professionals, (2) limitations of access to health care and the amplification of disadvantages related to COVID-19, (3) lifelong consequences of adverse childhood experiences (ACEs), and (4) intimate partner violence and its influence on drug use. CONCLUSION: Our findings highlight important information toward health services provision for opioid-using women of childbearing age. Efforts to reduce opioid usage in mothers need to consider psychosocial and contextual risks.

The Impact of COVID-19 on Access to HIV Prevention Services Among Opioid-Dependent Individuals.

The COVID-19 pandemic has necessitated restrictive orders and programmatic changes that may be associated with disruptions in services, including those for opioid-dependent people who inject drugs (PWID). This study aims to assess the impact of COVID-19 pandemic on access to and utilization of various HIV prevention services among PWID with opioid use disorder (OUD). We interviewed 110 PWID enrolled in medication for opioid use disorder (MOUD) treatment (e.g., methadone) between May and October, 2020 to identify if this sample experienced changed in access to the following services due to the COVID-19 pandemic: (a) HIV or sexually transmitted infection (STI) testing, (b) pre-exposure prophylaxis (PrEP) services, (c) HIV counselor or doctor appointments, and (d) clean injection equipment. A majority of the sample reported that COVID-19 had not changed their access to HIV testing or access to STI testing. Almost half of the sample reported that getting an appointment with a doctor decreased due to COVID-19. Participants reported that access to a lab or blood testing, access to injection equipment, and sessions with a case manager or counselor decreased. One-fourth of the 32 participants who were taking PrEP before the onset of COVID-19 reported that they had trouble getting their PrEP prescription due to COVID-19, and some reported that they had difficulty getting the PrEP prescription filled at their pharmacy. Our results indicate that PWID did not experience reduced access to HIV or STI testing, but difficulties in obtaining appointments with HIV counselors or doctors and limited access to PrEP were presented. Innovative strategies are needed to reduce the adverse effects of COVID-19 on HIV prevention among PWID.

Conceptualizing the effects of the COVID-19 pandemic on people with opioid use disorder: an application of the social ecological model.

The COVID-19 pandemic has resulted in unparalleled societal disruption with wide ranging effects on individual liberties, the economy, and physical and mental health. While no social strata or population has been spared, the pandemic has posed unique and poorly characterized challenges for individuals with opioid use disorder (OUD). Given the pandemic's broad effects, it is helpful to organize the risks posed to specific populations using theoretical models. These models can guide scientific inquiry, interventions, and public policy. Models also provide a visual image of the interplay of individual-, network-, community-, structural-, and pandemic-level factors that can lead to increased risks of infection and associated morbidity and mortality for individuals and populations. Such models are not unidirectional, in that actions of individuals, networks, communities and structural changes can also affect overall disease incidence and prevalence. In this commentary, we describe how the social ecological model (SEM) may be applied to describe the theoretical effects of the COVID-19 pandemic on individuals with opioid use disorder (OUD). This model can provide a necessary framework to systematically guide time-sensitive research and implementation of individual-, community-, and policy-level interventions to mitigate the impact of the COVID-19 pandemic on individuals with OUD.

Perceived risk, attitudes, and behavior of cigarette smokers and nicotine vapers receiving buprenorphine treatment for opioid use disorder during the COVID-19 pandemic.

BACKGROUND: Cigarette smoking may increase the risk of COVID-19 complications, reinforcing the urgency of smoking cessation in populations with high smoking prevalence such as individuals with opioid use disorder (OUD). Whether the COVID-19 pandemic has altered perceptions, motivation to quit, or tobacco use among cigarette smokers and nicotine e-cigarette vapers with OUD is unknown. METHODS: A telephone survey was conducted in March-July 2020 of current cigarette smokers or nicotine vapers with OUD who were stable on buprenorphine treatment at five Boston (MA) area community health centers. The survey assessed respondents' perceived risk of COVID-19 due to smoking or vaping, interest in quitting, quit attempts and change in tobacco consumption during the pandemic. RESULTS: 222/520 patients (43 %) completed the survey, and 145 were asked questions related to COVID-19. Of these, 61 % smoked cigarettes only, 13 % vaped nicotine only, and 26 % were dual users. Nearly 80 % of participants believed that smoking and vaping increased their risk of COVID-19 infection or complications. Smokers with this belief reported an increased interest in quitting (AOR 4.6, 95 % CI:1.7-12.4). Overall, 49 % of smokers and 42 % of vapers reported increased interest in quitting due to the pandemic; 24 % and 20 %, respectively, reported attempting to quit since the pandemic. However, 35 % of smokers and 27 % of vapers reported increasing smoking and vaping, respectively, during the pandemic. CONCLUSIONS: Most patients with OUD believed that smoking and vaping increased their vulnerability to COVID-19, half reported increased interest in quitting, but others reported increasing smoking and vaping during the COVID-19 pandemic.

A clash of epidemics: Impact of the COVID-19 pandemic response on opioid overdose.

Coronavirus disease 2019 (COVID-19) will have a lasting impact on public health. In addition to the direct effects of COVID-19 infection, physical distancing and quarantine interventions have indirect effects on health. While necessary, physical distancing interventions to control the spread of COVID-19 could have multiple impacts on people living with opioid use disorder, including impacts on mental health that lead to greater substance use, the availability of drug supply, the ways that people use drugs, treatment-seeking behaviors, and retention in care. The degree to which COVID-19 will impact the opioid epidemic and through which of the possible mechanisms that we discuss is important to monitor. We employed simulation modeling to demonstrate the potential impact of physical distancing on overdose mortality.

COVID-19, mental health, and opioid use disorder: Old and new public health crises intertwine.

The United States is facing both the coronavirus disease 2019 (COVID-19) pandemic and an ongoing epidemic of opioid overdose. Opioid use disorder is associated with other mental health problems, trauma, and social and health disparities. While the United States has acted to improve access to treatment for mental health and opioid use, research will be needed to understand the effectiveness of new policies in the context of COVID-19. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Opioid Use Disorder and COVID-19: Crashing of the Crises.

: The COVID19 crisis has created many additional challenges for patients with opioid use disorder, including those seeking treatment with medications for OUD. Some of these challenges include closure of substance use treatment clinics, focus of emergency departments on COVID-19 patients, social distancing and shelter in place orders affecting mental health, bystander overdose rescue, threats to income and supply of substances for people who use drugs. While the initial changes in regulation allowing buprenorphine prescribing by telehealth are welcomed by providers and patients, many additional innovations are required to ensure that additional vulnerabilities and hurdles created by this pandemic scenario do not further fan the flames of the opioid epidemic.

Innovation During COVID-19: Improving Addiction Treatment Access.

: During the COVID-19 pandemic, many addiction treatment and harm reduction organizations have had to reduce their hours and services for people with substance use disorders, placing these individuals at increased risk of death. In order to address restricted treatment access during COVID-19, guidance from the Substance Abuse Mental Health Services Administration, the US Drug Enforcement Administration, and the US Department of Health and Human Services has allowed for use of audio-only telehealth encounters for buprenorphine induction without requiring an in-person evaluation or video interface. This has enabled innovations in order to try to meet the needs of the most vulnerable among us during the current pandemic. In this new regulatory environment, we established the Rhode Island Buprenorphine Hotline, a phone hotline which functions as a "tele-bridge" clinic where people with moderate to severe opioid use disorder can be linked with a DATA 2000 waivered provider who can provide an initial assessment and, if appropriate, prescribe buprenorphine for unobserved induction and linkage to outpatient treatment. In this correspondence we briefly share our experience developing this common sense approach to addressing the complex problem of access to treatment only now permissible due to regulatory changes during COVID-19.