Emergency response systems must not overlook people with substance use disorders

When the storm unofficially known as Winter Storm Uri barreled across much of North America last year, unprecedented cold and record-breaking snowfall overwhelmed emergency response systems as well as regional and municipal infrastructure, leaving households and critical public safety services without electricity, heat, or potable water.

Health care delivery was substantially disrupted, with devastating consequences for vulnerable groups such as young children, the elderly, and people with chronic diseases reliant on medications, medical devices, or life-sustaining procedures.

Lost in the emergency response effort were people with opioid and other substance use disorders, many of whom found themselves cut off from crucial treatment and harm reduction services as the systems in place to support them faltered.

Texas was among several hard-hit states. In Austin, the state capital, many pharmacies, outpatient treatment services, and harm reduction programs were forced to close or drastically reduce operations. Resulting interruptions in access to medications that treat addiction, behavioral health treatment services, and naloxone, which can reverse overdoses, put thousands of people at increased risk of myriad health complications including withdrawal, return to substance use, and overdose.

The state of Texas identified illicit substance use as a contributor to or underlying cause of 5% of deaths due to hypothermia during the storm, and about 3% of all storm-related deaths.

In a commentary on the storm for the National Academy of Medicine, faculty members of the Dell Medical School at The University of Texas, Austin, along with state and local partners, describe challenges encountered during the emergency response while attempting to sustain addiction treatment services in the city and surrounding areas. “As the storm ravaged our community,” they wrote, “patients were in the terrible position of standing by while a stressed system struggled to adapt.”

Their experience echoes that of other cities and towns affected by this storm and earlier disasters. The struggle faced by U.S. addiction treatment systems to adapt during disaster is a direct result of their involuted, unwieldy nature.

Take opioid use disorder and its treatment as one example. FDA-approved medications for opioid use disorder, such as methadone, buprenorphine, and naltrexone, are highly effective but difficult to access. With limited exceptions, methadone must be obtained from a special dispensing facility called an opioid treatment program, often every day. Buprenorphine can be prescribed only by a provider who has obtained what’s known as an X-waiver from the U.S. Drug Enforcement Administration and who has not already reached their patient cap, which can range anywhere from 30 to 275 patients depending on how long the prescriber has held the waiver and whether they have met certain training requirements. Naltrexone can be costly and, depending on the format, may require the use of a specialty pharmacy and direct administration by a prescriber.

The nearest opioid treatment program may be several hours’ drive away, and the local pharmacy may not stock or dispense buprenorphine. Almost 25% of people in the U.S. must travel 30 minutes or more to access one or more of these medications. Medications for opioid use disorder are particularly inaccessible in suburban and rural localities.

In addition, most people receiving any of these medications must complete regular urine drug testing for so-called inappropriate substance use in order to continue treatment.

This veritable labyrinth of stipulations and barriers contributes to a stark addiction treatment gap. In 2019, just 10% of people with any type of substance use disorder in the U.S. were receiving treatment for it. When disaster strikes, sustaining these convoluted systems becomes nearly impossible.

The Covid-19 pandemic provides another, more proximal example.

In the first year of the pandemic, many people with opioid and other substance use disorders were cut off from treatment and harm reduction services. Overdose deaths rose exponentially. Individuals testing positive for Covid-19 faced especially limited options for initiating or maintaining addiction treatment. For others, accessing care meant risking infection. This was a particular problem for people receiving methadone at opioid treatment programs that require in-person dosing.

Swift action prompted important policy and practice transformations that have helped sustain and expand access to treatment for opioid use disorder during the pandemic. Allowing people to receive multiple doses of methadone they could then take at home loosened the “liquid handcuffs” imposed by having to travel to a clinic every day. Reduced X-waiver training requirements made it easier to get waivers to prescribe buprenorphine, and expanded permissions for the use of telemedicine along with increased insurance coverage of telemedicine services have made it possible to initiate and manage buprenorphine remotely. Relaxed urine drug testing requirements are facilitating care more attuned to patients’ needs and goals. These reforms are coupled with increased investment in evidence-based harm reduction interventions, such as supervised consumption sites recently opened in New York City, which have so far reversed more than 100 overdoses.

These changes, which were sought after long before the pandemic, enable more accessible, compassionate care and, equally important, more adaptive, resilient treatment systems. They should not be temporary measures but remain standard of care. Unfortunately, some are already being rolled back.

As the U.S. confronts the health effects of climate change and related hazards, it is urgent that government agencies, policymakers, and medical and public health professionals include the needs of people who use substances and those with addiction in their preparedness planning. It isn’t necessary to reinvent the wheel. Personal emergency preparedness planning resources already exist for other health conditions such as diabetes, epilepsy, and cancer. These can be adapted for substance use and addiction. Analyses of prior disasters, such as those prepared by Austin-Travis County and the city of Austin after Winter Storm Uri, offer valuable insights into what is needed to bolster the resiliency of addiction treatment systems.

A good place to begin is building upon what has already achieved in terms of expanded access to treatment for opioid use disorder:

• Increase and diversify methadone access points by expanding take-home doses, as well as dispensing it in community pharmacies and mobile units.
• Enable prescribers with the proper waiver to provide buprenorphine to more patients by eliminating caps on the number of patients a clinician can manage.
• Ensure that people who use substances have what they need to stay safe by funding and implementing low barrier harm-reduction programs that offer naloxone, safer use supplies, supervised consumption, and other evidence-based interventions.

These efforts cannot begin and end with opioid use disorder. Maintaining a narrow focus on opioids ignores the realities of the current fentanyl-driven overdose crisis. Fentanyl and other adulterants are increasingly present in supplies of illicit stimulants and benzodiazepines, and stimulant-involved overdoses are on the rise.

The needs of people with alcohol use disorder must also be addressed. During Uri, 13.9% of individuals who died of hypothermia had a history of alcohol use disorder or were actively drinking during the storm.

These efforts should be just one part of a broader approach to reducing the disproportionate impact disasters have on socioeconomically marginalized communities, including people of color, the uninsured, undocumented, and unhoused. During Winter Storm Uri, treacherous conditions and inability to access addiction treatment and harm reduction services posed a dual threat to Austin’s unhoused residents with opioid and other substance use disorders, perhaps reflected in the number of substance-involved hypothermia deaths.

As currently designed, U.S. addiction treatment systems are costing lives every day. Structured to simultaneously provide care for people with substance use disorders while surveilling, criminalizing, and stigmatizing these disorders and the people who have them, they are cumbersome, inflexible, and unprepared for the next emergency. People who use substances and those with addiction, whether or not they are in treatment, deserve our time, resources, and direct partnership to ensure they are protected, whatever lies ahead.

Emma Biegacki is the program manager of the Yale Program in Addiction Medicine.