The Coronavirus Disease Pandemic Continues to Challenge Patients in Need of Buprenorphine for Opioid Use Disorder

Dear Editor:

We thank Strout et al¹ for their well-written and comprehensive review “Understanding ED Buprenorphine Initiation for Opioid Use Disorder: A Guide for Emergency Nurses” in this journal. Patients with opioid use disorder (OUD) are vulnerable, and we think their review should be read by all involved in clinical ED care, not just by nurses as mentioned in their title.

We write to highlight one area not mentioned in their well-written review: how the prolonged coronavirus disease 2019 (COVID-19) pandemic has challenged treatment of patients with OUD and their access to buprenorphine. The example at our institution is generalizable to others and important for all to recognize as the pandemic continues.

At Cook County Health, the largest public health hospital serving the Chicago area since 1857, we care for a large diverse population of patients with OUD. We have a busy medication assistance treatment (MAT) clinic and team of recovery coaches who provide rapid linkage to the MAT clinic from the emergency department and our outpatient and inpatient facilities. Unfortunately, access to our MAT clinic and the affiliated continuity clinics has been disrupted by the pandemic; therefore, patients have needed to use the emergency department for care and refills of medication for OUD. We have tracked our prescriptions for buprenorphine-naloxone in our health system pharmacy and have seen a significant change in medication for OUD prescribing since the onset of the pandemic.

The Illinois state “shelter-in-place” order took effect on March 21, 2020. Compared with the 3-month period before that order, in the following 3 months the total number of prescriptions dispensed for buprenorphine-naloxone decreased almost 30%; however, the average quantity of tablets per prescription significantly increased by 60%, and there was a 22% increase in new prescriptions originating from the emergency department. Before the pandemic, patients were referred directly to a clinic or treatment center from the emergency department, but if there were delays to immediate referral eg, night, weekend, or treatment center at capacity) our emergency department provided 3 days of buprenorphine-naloxone with linkage to in-person treatment during that time. Now, during the pandemic, our ED procedure is to prescribe a full 30-day course with the understanding that linkage to an addiction specialist may not happen during that period. We know that medication alone is not sufficient treatment for OUD. In 2020, Cook County set a record for opioid deaths in the midst of a pandemic.² We do not know if this occurred primarily because of limited access to addiction specialists, if this was linked to the increased supply of buprenorphine-naloxone available on the streets from larger prescriptions, if this was associated with increased depression as a consequence of the pandemic, or if there were other reasons.

Some experts have labeled the problem of OUD during the pandemic as a “crashing of the crises,” and we think it deserves more attention.³ The pandemic has amplified known risks or unmasked new challenges to the health and well-being of patients with OUD. We need to advocate for multipronged collaboration among health care providers, elected officials, first responders, pharmacy companies, and community leaders. Although we were thrilled to see that more prescriptions originated from the emergency department during this pandemic following the guidelines described by Strout et al,¹ fewer came from the health system’s outpatient treatment clinics. Our experience highlights the challenges faced by this cohort of patients, and we worry that there is a direct association with the increased number of overdose deaths reported during this same period when more buprenorphine-naloxone tablets were dispensed per prescription. How telehealth availability, increased ED traffic, and other health access strategies can enhance substance use disorder treatment during a pandemic warrants priority attention in these pages and by policymakers. This is an issue for frontline emergency nurses and all others who care for patients in any setting during this pandemic.