In the 10th edition of our Talking Treatment™ podcast, AZZLY® had the honor of hosting a very esteemed guest: the Honorable Andrea Barthwell, M.D., DFASAM.
Dr. Andrea Barthwell is Senior Advisor and Strategist to AZZLY. Dr. Barthwell previously served as Deputy Director for Demand Reduction in the White House Office of National Drug Control Policy. She also served as President of the American Society of Addiction Medicine.
Dr. Barthwell spoke to us about the challenges facing opioid use disorder providers and patients in the age of COVID. Continue reading, or click here to listen to the full podcast.
The Challenges Facing a Patient with a Substance Use Disorder (SUD) During COVID
Dr. Barthwell first spoke about being a patient in the “twin epidemics” of the opioid overdose epidemic in the United States as well as the COVID-19 pandemic. “I think the biggest challenge to a patient right now is staying alive…”, she began.
Dr. Barthwell described how COVID has created challenges including substance use and showed how fragile our healthcare system is. Between the number of people who have left healthcare and the fact that people are expected to socially distance, getting help for a substance use disorder is difficult right now.
You can also see a correlation between COVID and substance use itself. By any metric, the substance use problem has worsened in the U.S. since COVID-19 began. People are day drinking more often, more teenagers are drinking at home, there are higher rates of depression, and more people are using drinking and drugs to self-medicate mental illnesses.
Dr. Barthwell describes in particular how COVID creates difficulties in preventing opioid overdoses. Before the pandemic, when emergency medical technicians (EMTs) arrived at the scene of an overdose, they could transport the patient to the emergency room (ER), where the overdose would be reversed. Once at the ER, the patient would then be referred to addiction treatment services so they could begin treatment.
Under the social distancing protocols of COVID-19, however, EMTs are under pressure not to bring more patients into the highly contagious atmosphere of an ER—not to mention that many ERs are already overpacked with patients anyway. EMTs may then choose to reverse the overdose at the site the patient was found, where there are not as many regulations as there are in an ER. Additionally, by reversing the overdose onsite, there is no handoff to addiction treatment professionals, so the onset of treatment is delayed, if the patient even elects to pursue treatment at all.
The Challenges to the Treatment System Today as a Result of COVID
Dr. Barthwell next discussed the difficulties of the pandemic from the perspective of a healthcare provider. First and foremost, providers needed to figure out how to protest themselves. Many treatment centers were shut down, and in the early days of COVID they had little access to personal protective equipment (PPE).
Fortunately it was declared that healthcare workers were essential workers and they received PPE and were allowed to stay open. In a climate of social distancing, providers and patients enjoyed many months where there were exemptions to previously existing regulations. For example, before COVID, a provider may have only been allowed to treat a patient in the same state. With the exemptions granted during social distancing, providers could offer telehealth/telemedicine services to their patients in nearby states.
Now, these exemptions are disappearing for many providers, and again they must provide in-person services only or treat patients in the same area through telehealth to be reimbursed by Medicare/Medicaid.
Worse, this is occurring when COVID is still surging. In fact, in several states the rate of COVID cases is as high as it has ever been. Many healthcare professionals have comorbidities that put them at greater risk of serious illness due to COVID, and they are being asked to compromise their health to continue treating their patients. Dr. Barthwell said that it must be ensured healthcare professionals are protected.
How Providers Should Treat Opioid Use Disorders
Dr. Barthwell then discussed how providers can, and indeed should, treat patients with opioid use disorders (OUD), keeping in mind other factors such as co-occuring mental illnesses or substance use disorders.
Medications for Opioid Use Disorder
The Drug Addiction Treatment Act of 2000 (DATA 2000) increased physicians’ ability to prescribe the medication buprenorphine, which aids opioid users in their recovery by reducing the side effects of withdrawal. In the past this was referred to as medication-assisted treatment (MAT), and more recently as medications for opioid use disorder (MOUD).
DATA 2000 provided for OUD patients to receive psychosocial services in addition to medication, but now only 10% of patients who are entered for MOUD ever receive comprehensive care.
Often even if a treatment center wants to provide psychosocial services, this would require separate licenses and reviews in their state that they would not need to get if they were only providing medical services. Additionally, it may not be covered by Medicare/Medicaid.
Some believe that MOUD in itself (even without therapy) is useful in recovery from opioid use disorder, but as Dr. Barthwell put it, “I’ve rarely met someone with a substance use disorder that wouldn’t benefit from some talk therapy in addition to medication.”
Treating People with OUD as Well as Other Substance Use Disorders
Dr. Barthwell stated it is rare to see someone who uses opioids and doesn’t use anything else. And if they have a substance use disorder involving another substance than opioids—such as benzodiazepines, cannabis, or alcohol—then the administration of buprenorphine is not going to address their withdrawal symptoms from these substances.
“Some treatment is better than none, more treatment is better than less…” By all means, if this person has OUD, they should enter the program, but the healthcare professionals must know any substances they are using.
This is also an instance where psychosocial services, not just medications for opioid use disorder, can be important in recovery.
Treating OUD in a Patient with Alcoholism
Alcoholism presents challenges at the outset because you require a medically monitored or managed system. Alcohol withdrawal can be deadly if it is not monitored. This can present issues for a residential facility with not enough beds or a detox facility without enough spots. And if you’re trying to avoid COVID, an ER is not a safe place to be.
Treating OUD in a Patient with Another Mental Disorder
Mental disorders can come before or after a substance use disorder. If it precedes the SUD, they may be using drugs to self-medicate. And if someone is using drugs to self-medicate, and you make them quit, that mental disorder will become unmanageable.
Providers have to assess any and all mental disorders, because they can also become a problem in recovery from substance use disorder. If someone has anxiety and enters a residential treatment facility, they may have a difficult time if their anxiety is not addressed. Or if they enter a 12-step program, they may be too anxious to go. If their mental disorder is not treated, they may not be set up for success in their SUD recovery.
Why Behavioral Healthcare and Addiction Treatment Providers Should Use AZZLY
Finally, Dr. Barthwell described why, as someone who has used a number of electronic medical records / electronic health records in her practices over the years, she chose to support the AZZLY system.
In her words, the thing that won her over about AZZLY was our attention toward providers offering MAT/MOUD services. “If you were a practitioner with the X waiver for buprenorphine, then The AZZLY system was designed to accommodate the way in which you practice.”
There are other electronic health records that work with doctors in their offices but don’t worry about the regulations that come with treating OUD. There are other electronic health records that do not take into account how a treatment provider does her work.
“The AZZLY system decided to take that on, was the first in its class to take that on, and does it quite well,” said Dr. Barthwell.
“I like AZZLY because it recognized how I had to modify my practice in order to treat medications for OUD. They took that on when a lot of people wouldn’t take that on. They’re first in class.”
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Talking Treatment™ is a podcast by and for people who are passionate about ending the stigma around treatment. Every episode we speak with a guest expert from the behavioral health and addiction treatment industry to learn their story. Listen to this podcast to hear their personal perspective on treatment, best practices, and industry trends. AZZLY® is proud to host this effort to destigmatize treatment and educate listeners.