The Effects of COVID-19 on Substance Use
By Samantha Cart
In 2020, while the world was reacting to the global COVID-19 pandemic, West Virginia was simultaneously responding to its own ongoing epidemic: widespread substance use disorder (SUD) and subsequent overdose deaths.
In 2016, West Virginia led the nation in overdose deaths with a rate 162% higher than the national average, and in 2017, the Mountain State had a record number of overdose deaths—1,019.
Over the past five years, a multitude of state agencies, nonprofit organizations, private businesses and community initiatives have been working to address the drug epidemic with new prevention, education and treatment options. This work led to a decrease in fatal overdoses in 2018 and 2019. However, when the COVID-19 pandemic hit, the state—and the country as a whole—began to see an uptick in substance use and related deaths.
More than 100,000 people in the U.S. died of overdoses between April 2020 and April 2021. In West Virginia, 1,147 people fatally overdosed on drugs between August 2019 and August 2020, according to the Centers for Disease Control and Prevention.
Matthew Christiansen, M.D., MPH, director of the West Virginia Department of Health and Human Resources Office of Drug Control Policy (ODCP), is one of the state leaders working to reverse this trend. According to Christiansen, for West Virginians who were either in recovery or actively struggling with SUD, the increased isolation, instability, barriers to treatment, reduction of services and unemployment issues brought on by the pandemic may have been too much to bear.
“Addiction is fundamentally a disease of unaddressed pain and suffering, and there is no doubt the pandemic exacerbated that for many,” he says.
Taking Charge
“Early on, the ODCP understood the effects COVID-19 had on the treatment and recovery landscape,” says Christiansen. “Measures necessary to prevent the spread of COVID-19 also severely impacted people’s ability to enter into treatment and long-term recovery. At the same time, however, the ODCP began to see the impact of the incredibly potent opioid fentanyl in the drug supply. From 2019 to 2020, fentanyl-related deaths increased by nearly 87%. When coupled with the stress of the COVID-19 pandemic, this created a perfect storm that exacerbated the existing crisis.”
The ODCP is responsible for coordinating a statewide addiction response, recommending evidence-based programs to reduce substance use rates, observing best practices used in other states and making policy recommendations to reduce substance use. Christiansen’s office maintains the overdose data dashboard and treatment and recovery map, looks at new ways to use data to inform response and works with a multitude of partners—including law enforcement, corrections, Medicaid, physicians, behavioral health providers, educators, quick response teams (QRTs) and emergency medical services—to ensure all citizens have equal access to quality addiction services.
“In response to the COVID-19 pandemic, the ODCP took several approaches to mitigate the damage caused by reduced human connection, an important part of long-term recovery,” says Christiansen.
These approaches included:
- Working proactively with treatment providers and recovery residences to develop and implement policies and procedures around preventing the spread of the COVID-19 virus
- Working as a liaison between recovery residences, treatment providers and other state agencies to ensure timely and transparent communication
- Coordinating the implementation and tracking of Governor Jim Justice’s Council for Substance Abuse Prevention and Treatment state plan
- Reaching out to specific high-risk groups, such as individuals in recovery residences, treatment providers, office-based medication-assisted treatment programs, outpatient treatment programs, QRTs and crisis stabilization units, to ensure they had naloxone for those that did have a recurrence of drug use
- Working with Medicaid and managing care organizations to educate providers and increase awareness of the new guidelines around how telehealth could be utilized
- Working directly with state hospitals as well as the correctional system—two areas with high rates of contact among individuals with SUD—to ensure people are being screened for SUD, given naloxone at discharge and being referred to treatment with appropriate follow up
- Establishing seven action counties—Berkeley, Cabell, Kanawha, Logan, Monongalia, Raleigh and Wood—to aggressively support naloxone distribution, identify high-need areas and focus on transitions of care for people who have SUD to ensure they are receiving screening, treatment and naloxone at discharge
“Initial analysis of overdose fatality data led to the identification of several counties in West Virginia with higher overdoses and overdose fatalities,” says Christiansen. “These eight counties—11%—account for almost 60% of the total overdose burden for the state. They also rank highly as counties with some of the highest overdose numbers per capita. All action counties are regularly monitored for overdose activity and changes in causal substances. The ODCP has directed a record amount of naloxone to these counties and prioritized them for evidence-based addiction programs such as treatment and recovery programs, as well as law enforcement assisted diversion programs, quick response teams and prevention programming.”
In November 2021, Dr. Rahul Gupta, drug czar for President Joe Biden’s administration and former West Virginia state health officer, stated that the increase in the severity of the drug crisis has prompted the administration to focus more efforts on harm reduction strategies, including the distribution of naloxone.
A statewide standing order for all formulations of naloxone was expanded in November 2020, which allows individuals to access naloxone at any pharmacy without a prescription and gives community groups and members the ability to train and distribute naloxone to those at high risk of an opioid overdose.
“The West Virginia Drug Intervention Institute is now offering online naloxone training. After training is complete, naloxone is shipped to the address provided,” says Christiansen. “This allows people with barriers or difficulty accessing naloxone an opportunity to carry the life-saving medication. It also offers a level of anonymity for people who may not be comfortable letting others know they have this need.”
Making Strides
The ODCP tracks the completion of the objectives in the 2020 to 2022 West Virginia Substance Use Response Plan.
“In 2021, more than 85% of the key performance indicators are either done or in progress, and although COVID has slowed some progress, the ODCP is still making strides in reaching goals of expanded treatment and recovery services throughout the state,” says Christiansen.
There are currently 1,240 addiction treatment beds and 53 West Virginia Alliance for Recovery Residences certified recovery residences in the state, with 55 more in progress. The ODCP has distributed more naloxone than ever in 2021, with more than 30,000 kits distributed and 21 counties participating in naloxone distribution events. The West Virginia Board of Pharmacy reports 10,814 naloxone kits were dispensed between January and September 2021. QRTs now cover the entire southern part of the state and can be found in 30 counties, with teams currently under development in four additional counties
“West Virginia also faces unique challenges to treatment and recovery such as a lack of transportation, low workforce participation, lack of access to broadband, high poverty rates and other gaps in resources for people with SUD and mental illness that we are looking aggressively to fill,” says Christiansen. “It is truly an honor to see so many people in many different industries across West Virginia dedicated to helping their fellow West Virginians.”
Maintaining Momentum
In 2017, Cabell County was known as the epicenter of the national drug epidemic. That year, 1,831 people overdosed, resulting in 132 deaths in a county of only 96,000 people.
According to Huntington Fire Chief Jan Rader, overdose death numbers are going up everywhere, but in Cabell County, they have not come close to the 2017 peak. Rader has been working to help change the tide in her community for several years as a member of the Mayor’s Office of Drug Control Policy.
“We are probably faring better than most counties in the state—our partnerships and collaborations have helped us,” she says. “We’ve lost ground, but we haven’t lost everything. COVID-19 isn’t the first bump in the road for those suffering from substance use disorder, but it does show you that collaboration and having programs in place helps tremendously. We just have to keep our foot on the gas.”
Huntington’s QRT and harm reduction program are well-known and have been used as models on a national level.
“All of our programs are working together, and I think it says a lot about what we’ve been able to achieve. Hopefully we will continue to move forward,” says Rader. “Our job is to work together to save lives and do what is best for our community. That is what we do in Cabell County.”
Looking Forward
As new variants emerge and West Virginians continue to adjust to life with COVID-19, both Christiansen and Rader agree that the most important thing individuals can do for those suffering with SUD is to let them know they are cared for.
“It is more important than ever to reach out and tell them recovery is possible, and there is a path out of addiction,” says Christiansen.
As more and more resources emerge, West Virginians in Cabell County and across the state will continue to work to take care of each other.
“As we look toward the future, I hope we have moved passed this and gotten back on track with doing bigger and better things for those suffering,” says Rader. “Reaching 100,000 deaths in a year is beyond sad and so unnecessary. But I’m an optimist, and I think we will come out of this stronger and find even better ways to help those suffering.”
False Claims Act and Rehab Accreditation
Eliminating Kickbacks in Recovery
By Brock Malcolm
While many West Virginians have encountered unique struggles during the COVID-19 pandemic, those suffering from addiction appear to have been hit particularly hard. According to the Centers for Disease Control and Prevention, 13% of Americans reported starting or increasing substance use as a way of dealing with the stressors of the pandemic. Similarly, the American Medical Association has reported higher rates in overdoses and opioid-related fatalities since the onset of the pandemic. Given that West Virginia has historically shown higher rates of substance use and overdose than national averages, it is likely that the percentages are even higher here in the Mountain State.
Alongside these sharp increases in the number of substance users, West Virginia continues to see increases in its numbers of drug and alcohol treatment facilities and inpatient beds. While the increase in treatment options may seem like a good thing on the surface, this flood of new facilities has many concerned. In fact, in February 2020, Delegate John Kelly announced his intention to introduce legislation to require such facilities to obtain the approval of the West Virginia Health Care Authority before opening or expanding.
Currently, treatment facilities must be licensed by the West Virginia Department of Health and Human Resources, but they are considered exempt from review under the state’s Certificate of Need (CON) program, which seeks to ensure there is an existing need for health care services within a targeted population to avoid the unnecessary duplication of limited resources. To be eligible for the CON exemption, the facility must establish that its program utilizes an opioid agonist other than methadone. Methadone programs are subject to CON review, but West Virginia Code §16-2D-9 bars the Health Care Authority from granting CON approval for the development of additional programs. While the legislature did not pass a bill requiring CON review for drug treatment programs in 2021, there may be some renewed call for this additional scrutiny during the 2022 legislative session.
Meanwhile, the increases in treatment facilities across the nation inspired Congress to take action to prevent abuses aimed at patients suffering from substance use disorders. For instance, the Eliminating Kickbacks in Recovery Act (EKRA) was passed in 2018 and seeks to prevent the making of money off patient referrals by prohibiting clinics, labs, recovery centers and others from providing or accepting remuneration, or kickbacks, for such referrals. The penalties associated with EKRA violations are very steep and include fines of up to $200,000, imprisonment for no more than 10 years or both for each occurrence. Furthermore, EKRA is broader than the more familiar Anti-Kickback Statute (AKS) in that it is not limited to federal and state health care programs. Lastly, EKRA has fewer statutory safe harbors and, unlike AKS and the Stark law, no regulatory safe harbors. As such, providers of treatment and recovery services should obtain legal advice before executing contracts with laboratories or other sources of potential referrals to ensure compliance with EKRA and other applicable laws.
