Medication-Assisted Treatment, Part II: At-Risk Populations & Behaviors in the COVID-19 Pandemic

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Addiction Hope Medication-Assisted Treatment Interview of Dr. Mark Gold & Dr. Brian Fuehrlein – 8-17-20

In Part 2 of this 4-part series, you will read the continuation of an important and informative interview between Jacquelyn Ekern of Addiction Hope and Dr. Mark Gold and Dr. Brian Fuerhlein, two leading doctors in the addiction field, discussing the medication-assisted treatment of addiction.

In Part II of this interview, Dr. Fuehrlein and Dr. Gold explore populations and behaviors that increase the use of opioids and overdose rates in medication-assisted treatment. They continue this conversation and how the COVID-19 pandemic has impacted medication-assisted treatment, relapse and overdose rates.

Medication-Assisted Treatment, Part II: At-Risk Populations & Behaviors in the COVID-19 Pandemic

JE: For those watching, I’m sure it is challenging as the majority of viewers know someone that has died from an overdose. My 16-year-old son’s friend since Pre-K just passed away because he thought he was taking Oxycontin, and it was fentanyl. He came from a great family and was a boy that had tremendous promise, and his family has since tried to do some advocacy work to lessen the stigma of addiction.

This brings me to my next question for both of you – how do we better educate families and patients about overdose prevention and treatment to save lives?

MG: If I may refer to the Naloxone/Narcan article that we did on Addiction Hope, the data shows that people who have developed opioid use disorder are always at risk for overdose when they are out of treatment.

So, if they are in treatment with, for example, Dr. Fuerhlein, they would be in medication-based treatment with methadone, buprenorphine, naproxen, or naltrexone.

The minute they stop this treatment, they become an at-risk population. There is also the at-risk population, such as your son’s friend, which is the first-time user, occasional user, or the person whose drug supply changed.

These are major components to why overdose deaths continue to rise:

1) the drug supply has been changed. Heroin has been replaced with fentanyl, which can be manufactured in South Asia, China, India, now in Mexico, and can be sent through the US mail. They don’t need big ships or transshipments over borders. They just need a package in post-delivery.

2) The drug supply for other illicit drugs have been contaminated. Methamphetamine, cocaine, and more samples have been seen to be laced with fentanyl.

3) Patients are afraid to come to the emergency department. Both psychiatric emergency room visits and addiction visits are down even though alls to suicide hotlines and overdoses are up. People are more afraid of catching COVID-19 than they are of their disease, addiction, which is likely to kill them. This has also changed our ability to treat people on an ongoing basis. Many that were successfully treated with buprenorphine, suboxone, or injectable naltrexone have stopped going to their doctor’s offices.

These factors have all come together like a perfect storm. For this reason, I tell everyone, every time, if they know someone that has an opioid use disorder, they should carry narcan or naloxone with them or have it in the house.

Medication-Assisted Treatment can cause problems for at risk populationsBF: I do want to touch on some things with COVID because that is important. First, a couple of things regarding harm-reduction or overdose prevention.

One, if a relapse occurs following a period of sobriety or a period of abstinence, the chance of an overdose is more likely because that person has lost tolerance.

These individuals used to take a certain amount of fentanyl, heroin, or opiates then experience a period of abstinence. When they relapse, they take the same dose they used to take and had tolerance for. However, they have lost that tolerance and are more likely to die of an overdose.

As such, we do say, if one relapses, don’t pick up where you left off. This is why individuals released from incarceration are at high risk. We also see a high risk-situation if someone is in treatment for 30-days and has been sober. They should not pick-up where they left off and should try to use the same supplier, as they know how their pirates affect you.

Switching to a different supplier means you may not know how those drugs will affect you, and your risk for overdose is increased. Additionally, do not mix substances. If you are experiencing a relapse and using opiates, for example, don’t use benzodiazepines (Xanax, Klonopin, Valium, Ativan, etc.).

It is important not to take these and not to drink alcohol if you are overdosing on these drugs, as this is particularly deadly. Obviously, we want our patients to be abstinent and sober and participate in recovery and treatment, but if you are talking about harm reduction or overdose prevention, these things are important to be aware of.

Now, to get to Dr. Gold’s point about how COVID has impacted all of this, we are seeing a few things. First, we are seeing a dramatic decrease in presentations in March, April, and into May. This is across the board on the medical side and the psychiatric side. We suspect that people were afraid to come to the hospital at this time.

If you struggle with an opiate use disorder, you may be unknowingly, or knowingly, injecting fentanyl, and doing so is far more likely to kill you than COVID.

Hospitals are pretty safe now as all patients are tested for COVID, and all personnel have face masks and face shields. We also saw that patients lost a lot of their resources as well.

Methadone clinics had to reduce the number of days they were seeing patients. A lot of suboxone/buprenorphine providers are switching to phone only, and it was difficult for patients to engage only over the phone at the last minute. Sometimes, providers were even sick themselves and couldn’t come into work. AA and NA meetings were switched to virtual or canceled because of the risk of COVID.

As such, there were a variety of reasons why patients who were afraid to come into the hospital were also losing resources that they were counting on to stay sober in the first place.

This combination of risk of relapse joining with fear of coming to the hospital was putting our patients in a very dangerous situation. We are seeing the volume pick back up and patients returning where I am in Connecticut. However, other parts of the country are unfortunately not doing as well.

In the next part of this article series, on Medication-Assisted Treatment, we’ll take an in-depth look at the specific medications that can be used to treat substance use disorders.

Please See Part 1 of the Interview
Please See Part 3 of the Interview
Please See Part 4 of the Interview


Virtual interview with Dr. Mark Gold & Dr. Brian Fuehrlein conducted by Jacquelyn Ekern, MS, LPC, – Founder & President of Eating Disorder Hope and Addiction Hope on August 17, 2020.

About the Interviewee:

Mark GoldMark S. Gold, M.D., Professor, Washington University School of Medicine – Department of Psychiatry, served as Professor, the Donald Dizney Eminent Scholar, Distinguished Professor and Chair of Psychiatry from 1990-2014. He was the first Faculty from the College of Medicine to be selected as a University-wide Distinguished Alumni Professor and served as the 17th University of Florida’s Distinguished Alumni Professor.

Dr. Gold is also a Distinguished Fellow, American Society of Addiction Medicine; Distinguished Life Fellow, the American Psychiatric Association; Distinguished Fellow, American College of Clinical Pharmacology; Clinical Professor of Psychiatry, Tulane University School of Medicine; Professor( Adjunct), Washington University in St Louis, School of Medicine, Department of Psychiatry; National Council, Washington University in St Louis, Institute for Public Health

Learn more about Mark S. Gold, MD

About the Transcriber:

Image of Margot Rittenhouse.Margot Rittenhouse, MS, PLPC, NCC is a therapist who is passionate about providing mental health support to all in need and has worked with clients with substance abuse issues, eating disorders, domestic violence victims, and offenders, and severely mentally ill youth.

As a freelance writer for Eating Disorder Hope and Addiction Hope and a mentor with MentorConnect, Margot is a passionate eating disorder advocate, committed to de-stigmatizing these illnesses while showing support for those struggling through mentoring, writing, and volunteering. Margot has a Master’s of Science in Clinical Mental Health Counseling from Johns Hopkins University.

As a freelance writer for Eating Disorder and Addiction Hope and a mentor with MentorConnect, Margot is a passionate eating disorder advocate, committed to de-stigmatizing these illnesses while showing support for those struggling through mentoring, writing, and volunteering. Margot has a Master’s of Science in Clinical Mental Health Counseling from Johns Hopkins University.

The opinions and views of our guest contributors are shared to provide a broad perspective of addictions. These are not necessarily the views of Addiction Hope, but an effort to offer a discussion of various issues by different concerned individuals.

We at Addiction Hope understand that addictions result from multiple physical, emotional, environmental, and genetic factors. If you or a loved one are suffering from an addiction, please know that there is hope for you, and seek immediate professional help.

Published on December 1, 2020
Reviewed & Approved by Jacquelyn Ekern, MS, LPC on December 1, 2020
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About Baxter Ekern

Baxter Ekern is the Vice President of Ekern Enterprises, Inc. He contributed and helped write a major portion of Addiction Hope and is responsible for the operations of the website.