Addiction has been an ongoing struggle for many Americans for decades, and with the increase in opioid prescribing/manufacturing, the ever-growing social media culture backing the use of alcohol to cope with stress, as well as the first worldwide pandemic in 10 years; numbers are at an all-time high for such individuals vulnerable to substance use disorders (SUDs).
Addiction in the United States:
Per the National Survey on Drug Use and Health (NSDUH) in 2017, 19.7 million people in the United States were estimated to suffer from some sort of substance abuse disorder in that year alone. Less than 1 year into the COVID-19 pandemic, the CDC recognized an almost 13% increase in newly onset or worsened substance use disorders (SUDs).
COVID-19 & Substance Use Disorders:
As a pharmacist working with patients in an addiction/rehabilitation hospital setting, my experiences have been at the forefront of this worldwide crisis. While the COVID-19 pandemic has manifested discrepancies in the care and accessibility for those seeking treatment for their conditions it is my belief that this trend has had unfortunate early beginnings. Due to the stigma towards those struggling with such disorders, it is apparent that funding and access to services for these individuals seem to fall short now more than ever with resources limited to all healthcare entities.
Stigma, combined with limited access to therapy, are noteworthy treatment barriers and they will be discussed further below, but an important prerequisite is addressing what the current treatment landscape entails. A combination of medication-based and non-medication-based interventions together can help individuals throughout the additional recovery and rehabilitation process.
Common Treatment Options for Substance Use Disorders:
Seizures/delirium tremens being the most serious and fatal symptom of detoxification/withdrawal; clinically these patients may be treated with the same medications used for patients that have status epilepticus.
While benzodiazepines have traditionally been used as a medication of choice for those withdrawing from alcohol, phenobarbital has shown to provide great benefit with less risk for addiction and negative side effects (oversedation and dependence making up a large portion of negative effects experienced from benzos). A drawback to using phenobarbital, however, is the drug interaction profile as this medication may interact with many medications. A common issue that I personally have experienced are with those who are also addicted to IV drugs and may have contracted HIV as a result. These patients may be on anti-virals in which the majority of these agents are contraindicated with the use of phenobarbital. In this case diazepam, a benzodiazepine, is used as an alternative. While phenobarbital is widely used, benzodiazepines still provide benefit when assessing CIWA (Clinical Institute for Withdrawal Assessment) by pulse dosing for breakthrough symptoms.
Aside from alcohol detoxification, heroin and opioid abuse commonly touches the many Americans who suffer from SUDs. Subutex (buprenorphine) is the drug of choice at the specific facility where I see patients. Our clinicians have opted to choose Subutex over Suboxone (buprenorphine-naloxone) as it is negatively marketed to those with addiction as a “high-killer” due to the naloxone component. Naloxone may immediately reverse effects of opioids as it is a potent antagonist. Titrating patients slowly with a buprenorphine-only approach may also reduce the incidence of immediate withdrawal and provide a safer detoxification experience.
As for non-pharmacological options, patients going through detox programs may receive extensive therapy and counseling sessions within groups or on an individualized basis. The combination between pharmacological therapies and non-pharmacological therapies may increase a patient’s chances of avoiding readmission (relapse) from a psychological standpoint.
Patient’s detoxing and withdrawing may also request ice packs, heat packs, or showers to alleviate the temperature fluctuations that may come with the substances exiting the body. Making these patients as comfortable as possible during this extreme life change will increase the chances of completion of the program and encourage the patient throughout the process. The act of detoxification and seeking sober living can cause major emotional stress that may prompt the patient to become irritable and discouraged.
In Conclusion:
The unfortunate setbacks from COVID, specifically limiting the amount of patients allowed in these facilities to participate in the programs has been a major barrier for those suffering from SUD and wanting to seek treatment. Many patients are being turned away as the healthcare networks are attempting to comply with CDC guideline recommendations and limit capacities to ensure social distancing is being upheld. As far as general access to these medications, companies have still been able to provide the appropriate amounts and requested agents despite COVID.
Prior to the pandemic, the largest setback for access and these patients was insurance cost. Some insurance companies may not pay for adequate amounts of treatment days, if any at all. The astronomical costs sometimes leave these patients with no option except for unaffordable treatments, incomplete treatment periods, or worse; not treatment at all.
Prior to the COVID-19, substance use disorders were prevalent; however the stress of losing loved ones, losing jobs, and the overall stress that the pandemic has caused has increased the number of those suffering from SUDs. Aside from insurance costs and the pandemic, the stigma of having a substance use disorder also impedes on the decision to seek treatment. As a societal whole, we must do better to ensure those around us suffering feel comfortable and able to seek the appropriate treatments that may ultimately save their life.
References:
Bose J, Hedden SL, Lipari RN, Park-Lee E. Key Substance Use and Mental Health Indicators in the United States: Results from the 2017 National Survey on Drug Use and Health. National Survey on Drug Use and Health. https://nsduhweb.rti.org/respweb/homepage.cfm. Published September 2018. Accessed June 20, 2021.
ASAM Clinical Practice Guideline. (2020). Alcohol Withdrawal Management. https://www.asam.org/docs/default-source/quality-science/the_asam_clinical_practice_guideline_on_alcohol-1.pdf?sfvrsn=ba255c2_2.
Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings. Geneva: World Health Organization; 2009. 4, Withdrawal Management. Available from: https://www.ncbi.nlm.nih.gov/books/NBK310652/
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