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Opioid Use Disorder, COVID-19 and HIV: Q&A with Leigh Mathias

June 19, 2020

The COVID-19 pandemic has exposed vulnerabilities in our healthcare system, including the need for coordinated primary, infectious disease, and behavioral health services.

For healthcare providers who treat people with HIV or substance misuse, the pandemic has created huge challenges. We recently sat down with one of our experts, Leigh J. Mathias, MPH, to understand the issues and where healthcare systems can go from here.

Mathias, an associate in the Division of Health and Environment, has more than a decade of experience developing and managing clinical research programs. He has played critical roles in providing a broad spectrum of interdisciplinary support to projects at many federal agencies, including the Centers for Disease Control and Prevention (CDC), National Institutes of Health, and the Health Resources and Services Agency (HRSA). He has served as Project Director/Manager for several CDC opioid prescribing and quality improvement projects and HRSA’s Ryan White HIV/AIDS technical assistance and evaluation projects.

Substance misuse is expected to rise during the pandemic because of increased stress and anxiety. How will that affect the relationship between HIV and substance misuse?

It's only going to exacerbate the issues. We've got a perfect storm with infectious diseases and substance use and misuse exposing individual and systemic vulnerabilities, including within the healthcare system and our broader communities.

When you have stressful environments like a pandemic, we see people paying attention to greater priorities. They've lost their job. They've lost their ability to obtain food. They have children at home. They no longer have child care. They’re not addressing their HIV, and remembering to take their medication to manage their HIV just goes to the back burner.

In parallel with that, people turn to substances to help the cope with the stress. And all of this is in an environment where people are further removed from their healthcare providers as a result of social distancing. Yet the success of their care is directly correlated with the frequency and the nature of the contact that they have with their provider.

How do we work our way back?

We've seen our health system, especially in the last decade, have to be much more adaptable. In the last several years, we've seen expansion of the use of telehealth as a tool. Efforts made in the past 1-2 years to expand telehealth have made it much easier to rely  on it during the pandemic.

And also, luckily, we are operating in an environment where in the last several years substance misuse and use disorders are seen more as a disease, not just something that needs to be solved with laws and policing and regulations. We've seen recommendations  from the Food and Drug Administration. We've seen opioid recommendations and guidelines from the CDC for prescribers, and the Surgeon General’s Report on Alcohol, Drugs, and Health. So a lot of the tools are there.

But there are underlying vulnerabilities in our society at large and in our communities that are going to take a lot of work to solve. It's not as simple as solving access to healthcare for all people. It's not as if there are any immediate and quick solutions to do that, but we've been equipped with the tools and at least an acknowledgement of some of these problems before they were thrust into our faces as they are today.

What are the barriers and facilitators to success when treating people with HIV and opioid use disorder (OUD)?

The first barrier is limited patient visit time, especially in large health systems. The national median “talk time” with a primary care provider is 5.2 minutes.

For substance misuse, on average, especially for an initial counseling period, it takes at least 20-30 minutes to have any sort of impact. The pressure that a provider has to see patients and move them along really is in direct opposition to providing the detailed care that a patient with OUD needs.

Another barrier is the limited amount of pain management resources. A lot of primary care providers just don't do any pain management. They refer patients to a pain management specialist, who can design a treatment plan for patients needing long-term pain management, which may entail a large number of services including medication. Aggravating matters is widespread misunderstanding, misinterpretation, or misapplication of CDC's prescribing Guideline.

An additional barrier is billing. As more providers opt for various services, from physical therapy to controlled tapers as a treatment for OUD and substance addiction, the health system needs to develop processes for billing for such services. For example, the CDC recently developed a series of International Classifications of Diseases, including 10 codes to address COVID-19 and some underlying conditions, so that health systems were able to bill insurers for related services. The last barrier is the low number of physicians or providers authorized to prescribe medication such as buprenorphine to treat OUD patients. 

As for facilitators, the standard model for HIV treatment has shown the importance of care coordination through a network of well-informed providers of treatment and services for associated underlying conditions. The pandemic requires strong facilitators to deal with the myriad of issues that individual patients may face. Second, the identification, diagnosis, and treatment of OUD is becoming more known in healthcare and less stigmatized. Having a clear established treatment recommendation was incredibly helpful.

What are some evidence-based programs?

For HIV, test and treat is one. Within a community, you identify people at risk, and using expansive testing, immediately walk someone who tests positive to a treatment environment to meet with a provider. You’re not scheduling something a week later or a month later, a meeting that can be missed.

Another is CASCADE. This is a program evaluating a model for testing at home and providing same-day initiation of treatment, including antiretroviral treatment initiation. A third is eSTAMPS, which examines the effectiveness of distributing self-test kits via the internet to the men-having-sex-with-men community. A fourth is RAPID, which is like test and treat and CASCADE, just a different flavor and approach. And finally there’s shelter plus care. It provides apartments and rent assistance for people with HIV.

How do you think the COVID-19 pandemic and the expected increase in substance use will influence the goal of ending HIV?

Providers in communities of color have historically not received the same funding, supplies, and resources as those in white communities. They are going to really struggle to get a sufficient number of a COVID tests and a sufficient number of resources to address the needs of an HIV positive patient who may or may not be suffering from substance use/OUD as well. So because of these underlying constraints, COVID-19 really is going to exacerbate the situation, and for at least a short time, leave people living with HIV with less resources than will be ideal.

So, inevitably, I think it's going to delay our objectives to reduce the prevalence of HIV and AIDS in our communities until we get to a point where these high-need, high-contact patients can again access providers easily. We're going to see an inability to maintain viral suppression and prevent future transmissions.

Are there any hopeful signs?

We've seen a lot of resiliency and adaptability among health systems and among providers. This forced adaptability is only going to benefit us in the long term, having additional resources to be able to access and provide services to patients. This is just adding to the suite of tools providers have, for example, telehealth. Maybe I'm too much of an optimist, but anytime we're forced to adapt and shed light on some of these vulnerabilities within our health system, I think it can only help us.

Dealing with things like poverty and limited access to healthcare, and the current model of our healthcare system, not being able to serve every person in our community--these are huge issues that aren't going to be solved in a couple of months or even a couple of decades. But at least we're able to have an intelligent conversation about them, and there will be some improvements from this.

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