COVID-19, Mental Health, and Opioid Use Disorder: Old and New Public Health Crises Intertwine

Abstract

The United States is facing both the 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 US 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.

Before the COVID-19 pandemic, the United States (US) was facing an epidemic of opioid overdoses. As most of the country has been ordered to stay at home, a new concern is that social distancing policies could increase the likelihood of death from overdoses. Social isolation is associated with poor mental health and co-occurring mental health problems are risk factors for opioid overdose (Ataiants, Roth, Mazzella, & Lankenau, 2020). Social distancing also increases the risk of overdosing alone, preventing bystander administration of naloxone, which would prevent death (Volkow, 2020).

People with opioid use disorders also have disproportionately high rates of psychological trauma and mental health problems (Williams, Girdler, Williams, & Cromeens, 2020), the effects of which can be compounded by social isolation. Exposure to large-scale disasters has also been associated with increases in domestic violence, child abuse, post-traumatic stress disorder (PTSD), depression, and substance use disorder (Galea, Merchant, & Lurie, 2020; Tracy, Norris, & Galea, 2011). In this time of great crisis, policy makers and practitioners have moved at an unprecedented pace to innovate new strategies to deliver mental health and addiction services. The US has adjusted regulations to expand telehealth and make medication for addiction more accessible. Insurance companies, including Medicare, now cover psychotherapy and other health services (including assessment, evaluation and management) delivered by telehealth via video conferencing or telephone (Center for Connected Health Policy, 2020). The Substance Abuse and Mental Health Services Administration (SAMHSA) lifted regulations that previously limited methadone dispensing to daily in person dosing. SAMHSA now allows for take-home methadone to treat opioid addiction. The number of days of prescription doses allowed for methadone and buprenorphine has been extended to 14 or 28 days, based on patient stability (Bao, Williams, & Schackman, 2020). Regulations regarding intake and admission processes to addiction treatments have also been eased to increase access (Centers for Medicare & Medicaid Services, 2020; Substance Abuse and Mental Health Services Administration, 2020a). In some situations, prescriptions are allowed to be delivered to people’s homes through mail, treatment providers, or and law-enforcement officers (Substance Abuse and Mental Health Services Administration, 2020b). These policies facilitate social distancing, while also increasing access to mental health and addiction services.

Updated addiction and mental health treatment policies have expanded options that practitioners have for addressing increased need for mental health and addiction services. However, they have not expanded the number of practitioners (or practitioner hours) who provide services, which may be problematic as access to behavioral health services was already difficult and funding inadequate (Knickman, Krishnan, & Pincus, 2016). Professional societies have disseminated guidelines for practitioners transitioning to telehealth services (National Association of Social Workers, 2020). Guidelines addressed important issues of maintaining client confidentiality, building therapeutic rapport, fostering working alliance, and billing for services (American Psychological Association, 2020). However, barriers to telehealth implementation exist in rural areas with limited cell phone and internet coverage, and for patient groups without access to smartphones or computers (Leite, Hodgkinson, & Gruber, 2020). Practitioners are also able to leverage new technology to address service gaps. There are now nearly 10,000 apps that exist to address mental health, as well as technical startup networks to support new interventions without vast expansion of the workforce (Chang, Kessler, Pincus, & Nock, 2020).

As we move, hopefully, past the peak of COVID-19, research will be needed to guide which technologies are evidence-based and what innovative approaches to addiction and mental health treatment were successful, and therefore might be sustained beyond the current public health crisis. Research will also be needed to identify the impact that social isolation has had on mental health, opioid use, and overdoses. Understanding the disparate impact across racial and ethnic groups is also important, as there is already evidence of substantial disparities in COVID-19 diagnoses and severity among communities of color (Núñez, Madison, Schiavo, Elk, & Prigerson, 2020). It will be important to understand how exposure to psychological trauma—further compounded by co-occurring health conditions, institutional racism, and socioeconomic disparities—may have exacerbated overdoses. Identifying inequalities, as well as which innovative strategies were most effective at improving patient outcomes, will guide future policy endeavors to scale up the most successful strategies.