As the president’s Public Health Emergency declaration for the coronavirus was about to expire last week, a wave of anxiety came over drug treatment clinics in Maryland.
Virus cases were again rising in the state, and clinics were depending on the federal order to continue taking unusual steps to keep workers and patients safe. Those include doing health exams and counseling online, and sending medications home with patients in bulk.
The order was extended at the eleventh hour, giving temporary relief to providers tending to a growing roster of Marylanders. But some say the new normal isn’t ideal, and safety concerns persist.
“This kind of care is normally very intimate, and emotional, and here we are on Zoom,” said Edgar Wiggins, executive director of Baltimore Crisis Response, which provides residential mental health and substance use treatment. It has relied on newly allowed telehealth appointments for many initial calls.
“We still mask up and go see people,” he said, “but if we lose the ability to also use technology, of course that exposes us to more risk.”
Providers say they have implemented a host of other changes, including cleaning and masking staff and patients as guidance surfaced. But the moves weren’t seamless, and treatment was interrupted for some. There still isn’t enough protective gear.
Few of the state’s 88 clinics closed for any time during the pandemic, as there were fresh problems with substance use. Fatal overdoses ticked back in the first three months of 2020 after dropping in 2019 for the first time in a decade. Many experts expect the increase to continue.
Some providers and local authorities say the balance between safety and care remains tenuous, placing a burden on staff that seems less recognized by the public than the burden on other health care workers.
Steve Dixon, an opioid addiction counselor, said he started work in a Baltimore clinic the day Gov. Larry Hogan issued a stay-at-home order March 30. There was “pandemonium” as he and his colleagues worked to ensure clients safely got their daily dose of methadone during a more than 12-hour day.
The clinic has more than 1,400 patients. Eventually, Dixon tested positive for the virus and was hospitalized.
“I had been issued an official letter calling me an essential employee,” he said. ”But I didn’t see any banners calling me or my colleagues heroes like other essential employees. I felt more like a forgotten employee.”
The danger is significant and it’s shared by workers and those needing treatment, said Brendan Saloner, an associate professor in Johns Hopkins University’s Department of Health Policy and Management.
The pandemic and virtual visits mean people may be alone more, increasingly stressed and prone to overdosing, he said. Drug users already were far more vulnerable to infections of all kinds, not just COVID-19.
He also said some of the stress heaped on providers was unnecessary. The nearly expired federal emergency order “pushed everything to the brink,” and that could happen when the order expires again. No expiration date was given.
So critical was the order to treatment centers, as well as hospitals and doctor’s offices tapping telehealth services, that nine of the 10 members of Maryland’s congressional delegation wrote Health and Human Services Secretary Alex Azar in a letter written a week before the expiration urging him to act.
Sen. Chris Van Hollen of Maryland called the order essential for Maryland’s front-line health care workers and patients, and said the Trump administration’s “failure to extend it in a timely manner” had caused unnecessary anxiety and disruption.
Others agreed the order has been critical for safety, and provides financial relief because providers can charge for virtual visits.
The costs of fewer people coming into the clinics, however, can’t be discounted.
Dr. Kenneth Stoller, director of the Johns Hopkins Broadway Center for Addiction, said many treatment sessions before the pandemic were done in groups of eight to 10 people but now involve only three to four people seated at a distance.
Given “the risk inherent in sitting in a room with multiple other people for upward of 10 hours per week, as our patients and some staff did pre-COVID, it will be a challenge to get back” to the same level of services, Stoller said.
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Hopkins’ Solaner said there has long been a disparity in resources between behavioral and medical health. The pandemic, he said, only further highlights challenges in funding. The substance abuse clinics get less protective gear. And additional services may be necessary for patients who lack stable housing or have other needs.
While in crisis, Solaner said, substance users may not be following pandemic-related safety orders on distancing and masking, promoting virus spread. He said the problem is tough to address when no one knows how many patients and workers have been infected.
Infections are supposed to be reported to local and state authorities. But the nonprofit agency that oversees mental health and substance use centers in Baltimore City, for example, said it has received only five such reports from treatment centers, for a total of three staff and 11 clients infected. It’s clearly underreported, said Adrienne Breidenstine, spokeswoman for Behavioral Health Systems Baltimore.
Dr. Aliya Jones, Maryland’s deputy secretary for behavioral health, said the state will continue to focus on getting people treatment, and workers guidance and protective gear.
Jones said about 32,000 people rely on the system of treatment centers in the state for counseling or the medications methadone or buprenorphine. More see a private doctor for a buprenorphine prescription.
Wiggins from Baltimore Crisis Response said he’ll be watching the suicide data and other indications the pandemic is leading more people to “self soothe” in harmful ways.
“I’ve never seen anything like this, and I’ve worked through hurricanes and lot of disasters,” he said. “They’ve all had an end in sight. This situation clearly has no end in sight.”