Perhaps, you may say that this article’s title jumps the gun a little (perhaps, even a lot), but even with the slow and laborious coronavirus vaccine rollout currently being sporadically delivered in the U.S., you must accept that we must now begin to think “post-pandemic” – to look beyond this consuming coronavirus and all the socio-economic destruction and disruption it has wreaked here – upon the state of Massachusetts.
We must try to understand and plan for what may lie afterward, what exists there on our collective horizon, and we must do so on both a personal level, within the fabric of our own communities, and as a nation with a post-pandemic, beleaguered, and weary healthcare system.
A phrase that was popularized during the long months of 2020 was this:
The “New Normal.”
Therefore, we need to quickly dust ourselves down, and work out exactly what our own “new normal” is – post-2020, post-pandemic, and starting now.
Is it a complete re-think on how we properly reach out and assist the vulnerable people in our communities during times like these, like the recovering but constantly struggling opioid addict who can only access help through a computer screen, or is it just to pile all our fragile eggs in one basket, and hope that the necessary divergence into telehealth services and telemedicine seen last year will be enough for the vulnerable in the years to come?
Pretty much like the rest of life, there are no easy answers to difficult questions – there never are.
However, and without a doubt, the physically and mentally “at-risk” elements of our society have suffered – the diseased, the old, the poor, the homeless, the addicted, and the mentally ill – either through the COVID-19 virus itself or through its many foreseen and unforeseen effects, such as the disruption of vital and critical healthcare delivery and associated outreach programs to these very same, disadvantaged members of our society.
However you may wish to view it, something needs to change, to change fast, and it may have to do so in radical and previously unseen ways.
How Did COVID-19 Impact Massachusetts’ Drug Users?
Across the U.S., one of the demographics hardest hit by the lockdowns, the quarantines, the social isolation, and the business closures, were the drug users – the active addicts and those who were in recovery from their substance use disorder (SUD).
In fact, amid rising numbers of fatal drug overdoses during the first half of 2020, mostly opioid-related, and with the majority of those being linked directly to fentanyl or fentanyl analogs, the American Medical Association (AMA) issued an emergency brief (which they continue to update) that describes the dramatic knock-on effect of the pandemic upon the existing opioid epidemic.
Massachusetts, easily considered one of the healthiest areas of the nation, was included in the list of 40+ U.S. states that were seeing alarming rises in overdose deaths, and serious ongoing concerns about the wellbeing of those with mental health disorders and drug addiction – although, mercifully, the Bay State wasn’t suffering nearly as bad as others.
Massachusetts: Official Fatal Drug Overdoses Statistics, 2020
According to the latest “Data Brief: Opioid-Related Overdose Deaths among Massachusetts Residents,” published in November 2020, by the Massachusetts Department of Public Health (MDPH), and using both confirmed and estimated drug overdose mortality totals, there was a small yet significant increase in deaths during the first 9 months of 2020 compared to the previous year.
Furthermore, other states have used data derived from their emergency services responses to 911 call-outs to anticipate and qualify changes in the number of opioid-related incidents over time. MDPH’s version of this is MATRIS, the Massachusetts Ambulance Trip Reporting Information System – a statewide database for collecting EMS data from the state’s licensed ambulance services.
Although the system is being adjusted to reflect opioid-related incidents more accurately, the data that has emerged so far indicates that between January to June 2020, the greatest number of suspected opioid-related incidents were for males aged 25-34, accounting for 23% of opioid-related incidents with a known age and sex. Furthermore, in the first half of 2020:
- 56.9% of all opioid-related incidents were categorized as acute opioid overdoses
- 19.9% were categorized as other opioid-related incidents
- 18.3% were categorized as opioid-intoxicated incidents
- 3.4% were categorized as opioid withdrawal incidents, and
- 1.5% were categorized as Dead on Arrival (DOA) incidents
Unfortunately, the MDPH system, being in relative infancy compared to other states, is somewhat limited. Importantly, however, naloxone, the opioid overdose reversal medication, was administered in 96% of the acute opioid overdoses during those first six months.
Naloxone & The Vulnerability of the Solitary Opioid Addict
Like the majority of other states, the MDPH runs a naloxone provision program, designed to assist those who suffer an opioid overdose by the use of the reversal medication, and called “Stop an Overdose with Narcan®.”
The program has a dual purpose: (i). to provide syringe service programs (SSP) in multiple locations across the state, where users can get sterile needles and safely dispose of used ones, and (ii). to provide naloxone rescue kits from the majority of pharmacies across the state, with or without a prescription.
However, as highly valuable as these services are (the lives saved run into thousands), they sadly do not help the vulnerable, solitary opioid user, who may suffer a potentially fatal overdose, and has no one with them to assist them. As Sharon Walsh, from the Center on Drug and Alcohol Research at the University of Kentucky, recently stated, “The risk when someone uses opioids alone of dying is greater than if they are using with somebody else. And that person, if somebody overdoses, they can call 911 or if they have Naloxone, they can use it.”
The situation has been made undoubtedly worse by the proliferation of the synthetic opioid fentanyl, as well as its many analogs, into virtually every drug on the illicit drug market. Walsh continued, “It’s very easy to overdose on. The other thing is that it’s finding its way into other parts of the drug market. So people are overdosing unintentionally when they use methamphetamine or cocaine because it’s also laced with fentanyl.”
Telehealth: Lifesaving Service or Cheap Substitute?
The coronavirus pandemic created a unique and difficult scenario – vulnerable residents, like recovering drug addicts and those with mental health disorders, were requested to socially distance themselves, at a time when they undoubtedly needed more free and direct access to their support mechanisms, such as:
- Addiction treatment services
- Family physicians
- Counselors and therapists, and
- Their support meetings, such as 12-Step programs like narcotics Anonymous (NA) and other group-centered contacts
The answer to this unique and difficult situation was a relatively simple one: telehealth (also known as telemedicine), where patients could access their medical healthcare services online from the virtual safety of their own socially distanced homes.
For many patients, it has proven entirely successful. Mothers can attend appointments while keeping an eye on their stay-at-home children, poorer people don’t have to spend on travel (as long as they can still pay for internet access), those in “at-risk” groups can feel confident they won’t catch COVID through their PC screen, and so on.
For the healthcare providers, it ticked another box – the important box of “cost.” Compared to placing patients face-to-face and in-person in front of a qualified medical professional, eg. a doctor or clinician, telehealth has proven so much cheaper.
However, nothing in life is ever that simple, surely? Sadly, not. Some critics say that it should be essential for behavioral clinicians to actually see substance use patients, and drug test them if they deem it necessary.
Furthermore, for all its advantages – the important one being the early indications that telehealth does work – there is with one crucial proviso – it has to be done correctly, in accordance with the definition of telehealth.
Telehealth: Not Just a Quick Phone Call
A recent report by the eminent RAND Corporation, a nonprofit health policy research organization, published only this month has highlighted a fundamental concern about how available online, “video telehealth” actually is delivered to all Americans, regardless of their income. Unfortunately, it found a clear disparity when it came to low-income patients, who were left to rely on audio-only communication – in other words, a simple phone call.
Telehealth has become a vital component of healthcare during the pandemic, with a range of medical appointments moving online. For the clinics that serve the low-income demographic, it allowed them to maintain access to healthcare when many organizations were temporarily forced to “shut up shop” – such as residential addiction rehabs.
“Lower-income patients may face unique barriers to accessing video visits. These are important considerations for policymakers if telehealth continues to be widely embraced in the future.” – Lori Uscher-Pines, lead author and senior policy researcher at the RAND Corporation
While noting that there was very little telehealth use prior to the pandemic, the RAND report, after studying more than 500 clinic locations across the state of California, found that:
- Overall visit volume remained stable during the pandemic
- Approximately half of primary care medical “visits” from March to August 2020 were done via telehealth
- Of these, over 77% percent of behavioral health “visits” were conducted via telehealth during the same period
- Telehealth “visits” by type were predominantly a telephone-only service
- Among primary care medical visits, 48.5% were via telephone, 3.4% were via video, and 48.1% were in person
- However, for behavioral health, 63.3% (nearly two-thirds) were via telephone, 13.9% were via video, and 22.8% were in person
There are many definitions of what constitutes “telehealth.” However, the vast majority excludes audio-only “visits.” In fact, prior to the pandemic, it should be noted that these services were rarely reimbursed by either private insurers or government programs, eg. the federal Centers for Medicare & Medicaid Services.
Now, there are strong signals that once the pandemic is finally resolved, audio-only telehealth will no longer be covered by these insurance programs.
Massachusetts & The Way Forward
Only this month, the state of Oregon finally put into practice a far-reaching and controversial drug policy (known as “Measure 110”) that was voted for during the time of the U.S. Presidential election – the decriminalization of the possession for limited (or personal use) amounts of illicit narcotics.
In an era when the so-called “War on Drugs” has clearly failed, when fatal drug overdoses are now rising, when the end of the opioid epidemic is still but a distant hope, and nothing more, and when fentanyl and its analogs are being cut into every other hard drug going, Oregon has made history by becoming the first U.S. state to take this stand, and to move the focus of its drug policy from criminalization and prison sentences to those who are affected by drug use and to public health in general.
Kassandra Frederique, the Drug Policy Alliance’s executive director, stated at the time, “Today’s victory is a landmark declaration that the time has come to stop criminalizing people for drug use. Measure 110 is arguably the biggest blow to the war on drugs to date. It shifts the focus where it belongs – on people and public health – and removes one of the most common justifications for law enforcement to harass, arrest, prosecute, incarcerate, and deport people.”
Now, here in Massachusetts, the wheels are turning in a similar direction. Both of the cities of Somerville and now Cambridge have voted in favor of (i). decriminalizing the use and possession of “entheogenic” plants (meaning psychoactive and hallucinatory), which can be used to treat some mental health and substance use issues, and, importantly, (ii). decriminalizing all controlled substances.
Like the Somerville vote, Cambridge’s order says it should be considered a low priority for law enforcement to charge anyone for possessing the plants or any other controlled substances. The order specifically states, “Drug policy in the United States and the so-called ‘War on Drugs’ has historically led to unnecessary penalization, arrest, and incarceration of vulnerable people, particularly people of color and of limited financial means, instead of prioritizing harm-reduction policies that treat drug abuse as an issue of public health.”
To misquote a legendary 60’s folk anthem, the times – perhaps – they are a-changin’…
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- American Medical Association: https://www.ama-assn.org/system/files/2020-12/issue-brief-increases-in-opioid-related-overdose.pdf
- Massachusetts Department of Public Health: https://www.mass.gov/doc/opioid-related-overdose-deaths-among-ma-residents-november-2020/download
- Massachusetts Department of Public Health: https://www.mass.gov/doc/emergency-medical-services-data-november-2020/download
- Mass.gov: https://www.mass.gov/stop-an-overdose-with-narcanr
- Mass.gov: https://www.mass.gov/info-details/syringe-service-program-locator
- JAMA Network: https://jamanetwork.com/journals/jama/fullarticle/2776166?guestAccessKey=1cbe677e-5cda-4394-9933-078d1fcfecaf
- Ballot Pedia: https://ballotpedia.org/Oregon_Measure_110,_Drug_Decriminalization_and_Addiction_Treatment_Initiative_(2020)
- Centers for Disease Control and Prevention: https://www.cdc.gov/drugoverdose/epidemic/index.html
- Harvard Health Publishing: https://www.health.harvard.edu/addiction/substance-addiction
- Verywell mind: https://www.verywellmind.com/why-did-i-relapse-21900