The coronavirus pandemic overshadowed a long list of other problems that suddenly seemed less urgent in the wake of a deadly virus and its economic destruction.
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Included at the top of that list: the opioid epidemic. That crisis is still raging in Colorado and predicted to get even worse thanks to the stress, isolation and financial devastation of the coronavirus.
Medical professionals, therapists and others are expecting a “wave,” or an aftershock, of substance abuse and overdose deaths because of the pandemic. And if it comes, Colorado will have fewer resources to handle it.
That’s because Colorado stripped at least $26 million for substance-abuse prevention, awareness and treatment from next year’s state budget, part of billions of dollars in cuts due to the economic shutdown and skyrocketing unemployment rate. A host of bills aimed at helping people recover from addiction — including medication-assisted treatment programs for jail inmates — were discarded as lawmakers whittled down their agenda to instead deal with more immediate problems.
“People of course are paying attention to COVID-19. I am too, but the opioid crisis was still a major thing in and of its own, and it wasn’t showing much sign of abating anyway,” said Rob Valuck, executive director of the Colorado Consortium for Prescription Drug Use Prevention. “We have to keep one eye on each.”
One program gutted by state budget writers would have trained doctors and nurses to screen their patients for substance abuse and refer them to treatment. The $1.5 million program was stripped to $500,000 in funding.
Other programs were not just reduced, but eliminated.
One program would have added more workers at the Colorado Crisis Services hotline to help provide “warm handoffs” to treatment, instead of just telling people where to call to get help for opioid addiction. A $5 million cut puts sober living homes in rural Colorado, particularly in the northeast and southwest parts of the state, in jeopardy of closing. And a $750,000 cut eliminated a public-awareness campaign to promote the overdose-antidote naloxone, a drug that, when kept on hand and given quickly after an overdose, can save someone’s life.
Budget writers also scratched $735,000 from a program helping former inmates continue substance-abuse treatment after their release from jail. Inmates often get medication-assisted treatment, such as Suboxone, while in jail. If they are released without it, they have a risk of overdose that is 120 times higher than if they keep taking their prescription, according to the consortium.
A delay in the “single biggest thing” to expand opioid treatment
A big slice of the $26 million in cuts, though, came by delaying a long-awaited change in policy that would mean the state Medicaid program would cover in-patient and residential treatment for drugs and alcohol addiction.
The government insurance program, for low-income Coloradans and others who qualify, has only ever covered out-patient programs for substance abuse, at least for adults.
Thanks to coronavirus, the new policy won’t take effect until January, instead of in July as previously planned. The six-month delay saves the state $8.5 million.
The delay is a blow to the Coloradans who are wait-listed for opioid treatment. Still, even the most outspoken advocates for expanding substance-abuse treatment admit the holdup — announced this spring by the Colorado Department of Health Care Policy and Financing — makes sense. Hospital systems are too busy dealing with coronavirus pandemic to handle the program expansion this summer.
Advocates have asked for the expansion for years, and 2017 legislation pushed the state department to ask for a federal waiver to change the Medicaid policy. The state will pay 28% and the federal government 72% for the residential treatment, when it begins in January.
“It will be the single biggest thing we have ever done in Colorado to expand treatment,” Valuck said. “It will take a big bite out of our treatment gap.”
Colorado overdose deaths rose to 1,062 in 2019, and the number of deaths because of fentanyl doubled from 2018 to 2019, according to the consortium. Statistics about drug overdoses and opioid-treatment lag by several months, as local health departments gather their data and report it to the state. But other clues point to an uptick in drug use during the pandemic.
Across the country, there was a sharp increase in prescriptions for anxiety drugs, including Xanax, Ativan and other benzodiazepines. Use of the drugs spiked 34% this spring. That’s troubling, Valuck said, because it means anxiety levels are rising and some people will manage their anxiety with substance abuse.
Even before the coronavirus, Colorado was not reaching 68% of people who need substance-abuse treatment — a calculation by state behavioral health officials that estimates 1% to 2% of the population needs treatment for addiction. That was an improvement from 85% a few years ago, but still a long way from success, Valuck said.
“All of a sudden we are going backwards,” he said. “This really peels a lot of that back. We have been playing a lot of catchup over the last few years.
“And nobody is saying that the budget is ever going to look good for the foreseeable future.”
Denver Health saw a spike in people coming to its emergency department for opioid-related issues, including overdoses, in April — the first full month of the pandemic. What’s hard to know, though, is whether there were more overdoses or whether other clinics were closed and that pushed more patients to the emergency department, said Dr. Scott Simpson, medical director of psychiatric emergency services at Denver Health.
His department has seen fewer patients for emergency psychiatric services during the pandemic, but the patients have been sicker than usual, he said. A higher percentage have required admission to the hospital or needed physical restraints.
“Coronavirus and the pandemic aren’t going to help anybody get sober,” Simpson said. “If anything, it’s more difficult now than it was before.”
Opioid treatment in rural Colorado still lags
The $26 million in cuts does not include reductions to related programs for mental and behavioral health, according to a Colorado Sun review.
It’s always been easier for people in a behavioral health crisis to get access to alcohol and drugs than to a therapist, said Tanya Sorrell, a psychiatric and mental health nurse practitioner and associate professor at the University of Colorado College of Nursing Anschutz Medical Campus in Aurora.
And during a global pandemic — when people were isolated at home, stressed about their finances and their families, and while many therapists worked only via online chats — that was more true than ever, she said.
“It’s not just an opioid crisis — it’s a behavioral health and coping crisis,” Sorrell said. “We are even more stressed and poorer-coping now than we were four months ago, as a nation.”
Consider, too, that stores that sell liquor and marijuana were considered essential and allowed to remain open during the economic shutdown, she said.
Sorrell works with 40 clinics in 17 rural Colorado counties that provide treatment for substance abuse. The work, aimed at expanding medication-assisted treatment for opioid use disorder in rural areas, began as a pilot program in two counties in 2017 and was expanded in 2019. It is managed by CU’s College of Nursing and the Center for Prescription Drug Abuse Prevention.
Lawmakers discussed cutting funding for the program, but it was spared. It’s helped 1,100 patients in rural Colorado from 2017 to 2019.
During the pandemic, the clinics turned to telehealth and tele-psychiatric visits. Federal aid is helping pay for prepaid phones so clients can connect with counselors, as well as masks and other protective equipment for staff seeing patients in person.
State and federal rule changes brought on by the pandemic also allowed some clients receiving treatment to take drug tests, which included DNA swabs, at home instead of coming in for regular appointments. And restrictions were loosened so that patients taking medication-assisted treatment for opioid use, such as Suboxone and methadone, could get prescriptions with fewer in-person appointments than usual.
Still, the pandemic has taken a toll on that outreach. And Colorado’s rural areas were already behind in terms of meeting the need for opioid treatment and prevention.
“Unfortunately, we can never say that we’ve met the need and that’s what we are always striving for,” Sorrell said.
The legislature didn’t kill every bill related to the opioid crisis. Some progress was made, particularly on bills that did not require much money.
A measure from Rep. Brianna Buentello, a Pueblo Democrat, requires insurance companies to cover substance-abuse treatment. It says the state’s insurance commissioner must make sure that companies include coverage for medication-assisted treatment and naloxone.
“The opioid crisis didn’t go away when the pandemic hit,” Buentello said in an emailed statement.
Program for pregnant women and new moms reduced
Among the cuts was $637,000 from a program that helps pregnant women and new moms who need addiction treatment. In this case, though, the program wasn’t spending its allotted funding and had returned a portion to the state each year.
The reason was lack of beds.
State officials in charge of the program said they could not spend all the allocated funds because there are not enough treatment beds in the state, especially beds that will take pregnant women and mothers with children.
The program, called Special Connections, is for pregnant women and those with babies one year old or younger, and includes out-patient and residential treatment. While Medicaid pays for screening, counseling and other treatment services, the residential portion is covered through the state Office of Behavioral Health.
There are just 64 beds at five locations statewide, and the program can help from 150 to 200 women per year. Under rules that go back decades aimed at prohibiting mental institutions, each treatment center is allowed no more than 16 beds.
The bed shortage meant that the program has sent money back to the state every year — about $1.3 million since 2016.
Despite the budget cut, the program still will receive $1.2 million in state funding next fiscal year. The goal is to find future funding to expand bed capacity, a task made even more challenging with the coronavirus crisis, said Camille Harding, director of community behavioral health at the state Office of Behavioral Health.
“What we really need to do is increase beds,” she said.