Vaping, Opioid Addiction Accelerate Coronavirus Risks, Says NIDA Director

Dr. Nora Volkow, who heads the National Institute on Drug Abuse, details how emerging science points to added challenges for these patient populations and the public health system.

In 2018, opioid overdoses claimed about 47,000 American lives. Last year, federal authorities reported that 5.4 million middle and high school students vaped. And just two months ago, about 2,800 cases of vaping-associated lung injuries resulted in hospitalizations; 68 people died.

Until mid-March, these numbers commanded attention. But as the coronavirus death toll climbs and the economic costs of attempting to control its spread wreak havoc, the public health focus is now dramatically different.

In the background, though, these other issues — the opioid epidemic and vaping crisis — persist in heaping complications on an overwhelmed public health system.

It is creating a distinctly American problem, said Dr. Nora Volkow, who heads the National Institute on Drug Abuse.

Volkow spoke with Kaiser Health News about the emerging science around COVID-19’s relationship to vaping and to opioid use disorder, as well as how these underlying epidemics could increase people’s risks. Her remarks have been edited for length and clarity.

Q: We’ve already been experiencing two epidemics at once — vaping and the opioid crisis — and now we’re in the midst of a third. Does that change the nature of addressing the coronavirus in the United States?

It makes a different kind of situation than we see abroad. It forces us as a country to be urgently multitasking, to focus on the urgent needs of COVID while not ignoring the other epidemics devastating America. That’s certainly challenging.

Q: What is the evidence around the relationship between vaping and the coronavirus?

Because of the recency, there’s no data to show if there are differences in outcomes between people who vape and people who do not vape. There’s no reported scientific evidence. We will start seeing it.

We know from all the cases of acute lung injury that vaping, particularly certain combinations of chemicals that were related to vaping of THC, actually led to death. The cause of death was pulmonary dysfunction. We know from animal experiments that vaping itself — not even giving any drugs with it — can produce inflammatory changes in the lung.

We already know for COVID that, with comorbid conditions — particularly those that affect the lungs, the heart, the immune system — [patients] are more likely to have negative outcomes.

One can predict an association. In the meantime, because of the data that already exist, we should be very cautious. The prudent thing is to strongly advise individuals who are vaping to stop.

Q: Young people so far appear to have lower risks of COVID complications. Does vaping change that?

We know there have been fatalities among young people. One very important area of research is to try to understand the specific vulnerabilities among young people.

Why would you want to risk it when you already know vaping produces inflammatory changes in the lungs? We know in medicine, a tissue that has suffered harm is more vulnerable.

The big centers where you are observing the rise in COVID-19 cases, that’s where you are more likely to see the comorbidity of vaping.

It’s young people that are mostly vaping, but also older people, many of whom otherwise would be smoking tobacco. [Smoking] also raises the risk. Even though the samples have not been large enough, overall, smokers have done worse than nonsmokers when they have COVID.

Q: Let’s talk about opioid use disorder. What kind of comorbidities are we starting to see between opioid use disorder and COVID-19?

People who have opioid use disorder are also likely to be smokers. Smoking itself increases harm to your lungs.

We do know that opioids actually are immunosuppressants. This has been extensively studied. Nicotine also can disrupt immunity and actually impair the capacity of the cell to respond to viral infections.

One of the things opioids do is they depress your respiration. If it’s severe enough, they stop breathing. That’s what leads to death.

Whether you overdose or not, when you are taking opioids, the frequency of your breathing is down, and the oxygen in your blood tends to be lower.

The [COVID] infection targets the respiratory tissues in the lungs. It interferes with the capacity to transfer oxygen into the blood.

If you get COVID and you are taking opioids, the physiological consequences are going to be much worse. You’re not only going to have the effects of the virus itself, but you’ll have the depressive effects of opioids in the respiratory system [and] in the brain that lead to much less circulation in the lungs.

Q: What about other supports for people in recovery?

Community support systems like syringe exchange programs are closing. Methadone clinics are closing. If they’re not closing, they’re unable to process the same number of patients — because the staff is getting sick or the place where the methadone clinic was does not allow for so many people. Public transportation is not available for people to attend their methadone clinics.

We’re also hearing from our investigators they have observed a significant reduction in the capacity of the health care system to initiate people on medication for opioid use disorder — especially buprenorphine. Many of the buprenorphine initiations were done in health care facilities that are saturated with COVID.

Q: What’s happening to address those problems?

If in the past, if you were a physician or a nurse practitioner and you wanted to initiate someone on buprenorphine, the laws were that you needed to see that person physically. That’s changed. It’s now possible you can initiate someone on buprenorphine through telehealth. That’s incredibly valuable.

There’s extended reimbursement for telehealth, which expands access to treatment. There are also apps that have been created that provide individuals who have addiction [access] to mentors or coaches, as well as access to therapies and group therapies.

That is one of the aspects that has actually been accelerated by the COVID crisis. These may facilitate treatment into the future, even when COVID’s no longer there.

Coronavirus Crisis Opens Access To Online Opioid Addiction Treatment

Under the national emergency, the government has waived a law that required patients to have an in-person visit with a physician before they could be prescribed drugs that help quell withdrawal symptoms, such as Suboxone. Now they can get those prescriptions via a phone call or videoconference with a doctor. That may give video addiction therapy a kick-start.

[UPDATED on April 28]

Opioid addiction isn’t taking a break during the coronavirus pandemic.

But the U.S. response to the viral crisis is making addiction treatment easier to get.

Under the national emergency declared by the Trump administration in March, the government has suspended a federal law that required patients to have an in-person visit with a physician before they could be prescribed drugs that help quell withdrawal symptoms, such as Suboxone. Patients can now get those prescriptions via a phone call or videoconference with a doctor.

Addiction experts have been calling for that change for years to help expand access for patients in many parts of country that have shortages of physicians eligible to prescribe these medication-assisted treatments. A federal report in January found that 40% of U.S. counties don’t have a single health care provider approved to prescribe buprenorphine, an active ingredient in Suboxone.

A 2018 law called for the new policy, but regulations were never finalized.

“I wish there was another way to get this done besides a pandemic,” said Dr. David Kan, chief medical officer of Bright Heart Health, a Walnut Creek, California, company. It has recently started working with insurers and health providers to help addicted patients get therapy and medications without having to leave their homes. He said he hopes the administration will make the changes permanent after the national emergency ends.

For years before the emergency regulations, Bright Heart — along with several other telemedicine counseling providers — began offering opioid addiction treatment and counseling via telemedicine, even if they couldn’t prescribe initial medication for addiction. Patients can renew prescriptions for drugs to deal with withdrawal symptoms, get drug-tested and meet with counselors for therapy.

When Nathan Post needed help overcoming a decade-long drug addiction, he went online in 2018 and used Bright Heart Health to connect to a doctor and weekly individual and group counseling sessions. He said the convenience is a big benefit.

“As an addict, it was easy to have excuses not to do stuff, but this was easy because I could just be in my living room and turn on my computer, so I had no reason to blow it off,” he said.

Post, 38, a tattoo artist who recently moved from New Mexico to Iowa City, Iowa, was addicted to Suboxone, the drug he was prescribed in 2009 to deal with an addiction to opioid pills.

Officials with the insurer Anthem said using Bright Heart’s telemedicine option has helped increase medication-assisted treatment for members with opioid drug abuse issues from California and nine other states from 16% to more than 30%. While fewer than 5% of Anthem patients seeking addiction treatment use telemedicine, the company expects the option to become more common.

Bright Heart Health officials say one barometer of the effectiveness of the care is that 90% of patients are still in treatment after 30 days and 65% after 90 days — far higher than with traditional treatment.

Several insurers — including Aetna, and Blue Cross and Blue Shield companies like Anthem across the country — have begun covering the telemedicine addiction service.

Dr. Miriam Komaromy, medical director of Boston Medical Center’s Grayken Center for Addiction, said there are some downsides to virtual care.

“I think therapists and providers do worry whether it provides the same level of engagement with the patient and whether it’s possible to gauge someone’s sincerity and level of motivation as easily over a camera as in person,” she said.

But she predicted telemedicine service will grow because of the tremendous need to broaden access to mental health and addiction counseling. “Too often the default is no counseling for patients,” she said. “This gives us another set of tools.”

Patients can also have trouble finding a doctor who is eligible to prescribe medication to help treat addiction. Physicians are required to get a federal license to prescribe Suboxone and other controlled substances that help patients with opioid addictions and can write only limited numbers of prescriptions each month. Many doctors hesitate to seek that qualification.

A few small studies have found that patients are as likely to stay with telemedicine treatment as with in-person care for drug addiction. But no studies have determined whether one type of therapy is more effective.

Telemedicine does have its limits — and is not right for everyone, particularly patients who require more intensive inpatient care or who lack easy internet access, Komaromy said.

Premera Blue Cross and Blue Shield officials said they are partnering with Boulder Care, a digital recovery program based in Portland, Oregon, to help customers in rural Alaska. “Telemedicine is a unique way for someone to go through treatment in a discreet manner,” said Rick Abbott, a Premera vice president.

Nathan Post, a tattoo artist living in Iowa City, Iowa, used a telemedicine service to help overcome his addiction to Suboxone. “This was easy because I could just be in my living room and turn on my computer, so I had no reason to blow it off,” he says. (Courtesy of Nathan Post)

While telemedicine has been growing in popularity for physical medicine, some people may still be reluctant to use it for drug addiction.

There are also concerns that allowing providers to prescribe controlled substances without meeting patients in person could increase the risks of fraud.

“There is a fear around this that there may be some rogue providers who make a lot of money off addiction and will do it stealthily on the internet,” said Dr. Alyson Smith, an addiction medical specialist with Boulder Care. “While that is a small risk, we have to compare it to the huge benefit of expanding treatment that will save lives.”

Smith said she doesn’t notice a big difference in treating patients for drug addiction in her office compared with on a video screen. She can still see patients’ pupils to make sure they are dilated and ask them about how they are feeling — which can determine whether it’s appropriate to prescribe certain drugs. Dilated pupils are a sign of patients suffering from withdrawal from heroin and other drugs.

Dr. Dawn Abriel, who treated Post and previously directed a methadone clinic in Albuquerque, New Mexico, said she can diagnose patients over video without issue.

“I can pick up an awful lot on the video,” particularly a patient’s body language, she said. “I think people open up to me more because they are sitting in their homes and in their place of comfort.”

In West Virginia, one of the states hardest hit by the opioid addiction epidemic, Highmark, a Blue Cross and Blue Shield company, started offering telehealth addiction coverage with Bright Heart Health in January. Highmark officials say a lack of providers, particularly in rural parts of the state, meant that many of the insurer’s members had difficulty finding the help they need.

Dr. Caesar DeLeo, vice president and executive medical director of strategic initiatives for Highmark, said the insurer was having problems getting customers into care. Only about a third of members with addiction issues were receiving treatment, he said.

“We needed to address the crisis with a new approach,” DeLeo said. “This will give people more options and give primary care doctors who do not want to prescribe Suboxone another place to refer patients.”

DeLeo said patients will also be referred to Bright Heart in hospital emergency rooms.

Dr. Paul Leonard, an emergency doctor and medical director for Workit Health, an Ann Arbor, Michigan, company offering telemedicine treatment and counseling programs, said many patients who turn to ERs for addiction treatment get little help finding counseling. With online therapy, patients can sign up while still in the ER.

“We’ve built a better mousetrap,” Leonard said.

Telemedicine addiction providers said they and their patients are getting more accustomed to virtual care.

“There are always times you wish you could reach out and hold someone’s hand, and you can’t do that,” said Boulder’s Smith. “But we feel like we are more skilled at a virtual hand-holding and really connect with people and they feel well supported in return.”