Drug overdoses surged during the pandemic. Providers are thinking outside the box to combat the opioid crisis

U.S. opioid epidemic
The U.S. is in the midst of a “poly-substance crisis,” said Sheila Vakharia, deputy director of the department of research and academic engagement at the Drug Policy Alliance, and it’s important to acknowledge that drug use patterns and combinations are different than they were in the past. (Stuart Ritchie)

While the U.S. was grappling with the COVID-19 pandemic in 2020, there was another growing health crisis. Public health officials and providers have sounded the alarm about a surge in drug overdose deaths since the pandemic began.

At least 93,000 people died of drug overdoses in the U.S. in 2020, according to the Centers for Disease Control and Prevention (CDC), a nearly 30% increase from 2019. And while deaths from natural and semi-synthetic opioids stayed relatively flat, overdose deaths from synthetic opioids, primarily fentanyl, rose 43%, driving the bulk of all drug overdose deaths, according to the CDC data.

Experts are alarmed by the high jump. The U.S. is in the midst of a “poly-substance crisis,” Sheila Vakharia, deputy director of the department of research and academic engagement at the Drug Policy Alliance, told Fierce Healthcare.

And, she noted, it’s important to acknowledge that drug use patterns and combinations are different than they were in the past. "Sometimes we get stuck in certain framings and certain understandings,” she said, noting they usually lag years behind hard data. Those who are most affected are changing, too; West Virginia had the highest opioid overdose death rate (PDF) of any state among the Black community in 2018, and that same year drug overdose deaths rose among Hispanic and Black populations while falling among the white population. The same trend appeared in 2019 in states like Missouri and in Massachusetts in 2020.

Under the Biden administration, Congress has appropriated billions of dollars toward addressing the opioid crisis. “The truth is that hundreds of millions of dollars of that just cannot be spent because we do not have an evidence-based treatment infrastructure through which to deploy those dollars,” said Kelly Clark, M.D., a psychiatrist and addiction medicine specialist, as well as a member of the steering committee of the National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic.

“We never built a treatment system for addiction in the U.S.,” she said, explaining that only about 40% of programs make medications for addiction treatment available to patients when it should be at the core of long-term care. 

RELATED: Industry Voices—We need to fully fund our public health infrastructure. Not just for COVID-19, but for opioid epidemic

The emergency scheduling of fentanyl-related substances, a Trump-era policy, is set to expire this October after the Biden administration extended it earlier this spring.

More than 140 medical groups have urged the administration to let it expire, arguing that it limits medical research and contributes to worse substances being developed on the black market, mass incarceration and further stigma around prescription opioids. In September, the Biden administration proposed its recommendations to Congress on how to tackle the policy moving forward.

When it comes to treatment for opioid use disorder, the more options available, the better, many industry experts say.

“It’s not about taking anything off the table or turning anything into a one-size-fits-all approach, but it’s about: how do we create as many options as possible in the menu of possibilities?” Vakharia said.

“It’s not that our systems aren’t working,” Vakharia added. “They’re just not working for everyone.” 

Health systems, providers and startups are all trying to revolutionize drug addiction treatment and recovery, with some taking a tech-driven approach.

Aiding recovery remotely

Bicycle Health, true to its name, aims to be a vehicle for supporting patients in recovery and improving treatment access. A virtual care platform for opioid use disorder, it was conceived after founder and CEO Ankit Gupta worked at a pain clinic in northern California and observed the stigma that kept many from accepting necessary treatment. He cited research from Johns Hopkins Bloomberg School of Public Health that found 80% of people with opioid addiction are not receiving treatment. With telemedicine, Gupta told Fierce Healthcare, it was possible to make the process more anonymous, which helped break down the barriers to seeking help.

The virtual platform not only facilitates quick delivery of care but also helps monitor patients to ensure continuity of care, Gupta noted, something many experts agree that providers without proper technology struggle to do.

Bicycle Health has teams of clinicians who apart from prescribing and overseeing treatment are available by chat and can offer additional behavioral health resources to patients like psychotherapy. Bicycle Health also engages with pharmacies on behalf of patients to make sure their prescription is affordable and available for pickup the same day, and also maintains a database of what pharmacies are reported to have stigmatized or shamed patients.

Gupta highlighted the benefits of seeing a provider online; the appointments with providers are not only longer, but also more focused, patients report. Physicians are also reportedly less distracted and more comfortable during their appointments, Gupta said. And, he added, the services are better personalized, which keeps patients engaged and leads to better outcomes.

“They’re both focused on each other,” he said, “and it’s just a much better engagement.” 

The model is also easily scalable, Gupta reported. Before the pandemic, Bicycle Health, which began accepting patients in 2019, had about 100 patients out of a northern California clinic. With the onset of the COVID-19 pandemic and with a rise in demand for services, the startup opened its offerings to the entire state and was “blown away” by the reception. That’s when it decided to go even bigger. 

And with changing regulations in light of COVID-19 restrictions, Bicycle Health was able to transition completely online, whereas before, in-person physical exams were still required. That has escalated its enrollment period from four days on average to now between 24 and 48 hours.

Serving more than 7,000 patients across 22 states, Bicycle Health hopes to launch in half a dozen more by the end of the year. It partners with most major commercial health plans, Gupta said. 

Virtual rehab is on the rise, boosted in part by the shift to telehealth during the pandemic. Lionrock Recovery, licensed in 47 states, offers private treatment through video conferencing technology. Groups Recover Together is available in 11 states and offers both in-person and online care. Another startup, Ophelia, uses telemedicine to provide medication-assisted treatment and raised $15 million in fresh capital in April. Quit Genius recently raised $64 million for its telehealth addiction treatment.

RELATED: Getting Ahead of the Opioid Crisis: Lessons Learned From COVID-19

Like Vakharia, Gupta doesn’t see any one solution to the crisis. It’s just one more option. More than 20% of Bicycle Health’s patients come from rural areas, many of which have no local provider able to prescribe medication-based treatment. Most patients connect with Bicycle Health through their phone, whether over wifi or service.

Many rural communities have low or nonexistent broadband access, and Gupta acknowledged there is more work to do to improve access to care in those areas.

“I believe the way that we are most able to scale access to appropriate treatment is through the private sector,” said Clark, the addiction medicine expert, who also serves as a clinical advisor to Bicycle Health. Clark also is the founder and president of our own company, Addiction Crisis Solutions.

Taking a tech-based approach to change prescribing practices 

Since the onset of the opioid epidemic, there has been strong attention on opioid prescribing practices in the outpatient setting, Adam Ackerman, M.D., told Fierce Healthcare. But overprescribing can exist in the inpatient setting, too. 

For that reason, Yale New Haven Health System introduced its Opioid Stewardship program in 2018, co-directed by Ackerman, the physician lead. The program is about recognizing that “touching healthcare is a risk factor for addiction,” he said.

The program’s goal is to standardize care across the entire health system, which has five hospitals in two states plus outpatient care. Since its inception, it has focused on reducing the utilization of opioids, particularly those with increased risk of adverse effects. 

The first thing Ackerman and his team did was examine the way the health system prescribed opioids to inpatients. They found that oral opioids were less likely to cause adverse effects than injectable forms of opioids, but that an IV was the default order entry in the system’s electronic health record (EHR). To help standardize the use of oral opioids, they removed the IV default option. Besides re-educating clinical staff on the new approach, they also relied on the environmental reinforcement that came from making the change in the ordering system. 

To date, the program has reduced IV opioid administration systemwide by two-thirds and reduced total opioid exposure by half. And, the health system has reduced by roughly 300,000 the number of opioid tablets distributed every year to patients discharging from the hospital, the health system reported.

Treatment programs are critical. But sometimes, patients’ overall drug regimen gets too complex, and unforeseen drug interactions can occur.

Tabula Rasa Healthcare, a health tech company, created software to monitor patients for adverse drug reactions (ADEs), taking into account patients' medical history and risk factors to help optimize providers' prescribing, according to Robert Alesiani, PharmD, the company’s Chief Pharmacotherapy Officer. 

The software, called MedWise, can also take into account patients’ genomic background to determine whether their body produces particular metabolic enzymes, Alesiani explained, which are necessary to activate some opioids. Certain other drugs, like blood pressure or seizure medications, compete for those enzymes—and therefore leave a high risk of drug interactions. If a patient’s body does not produce the necessary enzymes, they won’t feel the drug’s effects no matter how much the dose is increased, leading to a risk for an accidental overdose.  

“If a patient is on one of these drugs that will block that activation of the opioid, we will make a recommendation as to when’s the best time to take the opioid so there’s no risk of that cross interaction,” Alesiani said. For patients who are high-risk for an ADE, MedWise works with their provider to equip their home with Naloxone as a precaution.

Its technology has been found to improve annual healthcare costs, hospitalizations and mortality in Medicare beneficiaries.