The novel coronavirus will not slow down the opioid epidemic that’s gripped the United States for decades. As the Bay Area shelters-in-place, a mobile health team in Contra Costa County continues to bring prescriptions for addiction medication directly to people who are homeless and even more isolated from services.
Click the play button above to listen to this story. Find last year's report on the street medicine team here.
A few weeks ago, Dr. Joseph Mega was making the rounds with Contra Costa County’s mobile street medicine team. The team parked behind a department store in the far east side of the county. About 30 tents were lined up along a fence in a field. Soon people poured into the parking lot.
The team handed out clean needles and Narcan, a medication that can reverse the effects of an opioid overdose. Mega prescribed one person buprenorphine, a medication that can block cravings, ease the agonizing pain of withdrawal, and makes it easier for people to stop using opioids.
“A couple of people were saying, 'You need to see this person. She's got an infection on her neck,’” Mega said in a recent phone interview. When he did screen the woman, he saw an infection under her skin from injecting into a muscle or using a needle that hadn’t been cleaned off.
“And it looked pretty serious,” he remembers. “This is an example of someone who had been delaying going to the hospital because they didn't want to be going there in the context of coronavirus.”
The Health Risks Of Isolation
Mega works in the emergency room, and he’s also the medical director for the county’s Health Care for the Homeless program. Doctors like Mega are increasingly worried that people are avoiding seeking vital medical services because of concern about the coronavirus. Many of the people Mega encounters are living alone in their tents, and he worries that because of social distancing orders, people are also using drugs alone.
“Anytime someone is using alone that puts them at higher risk of overdose,” Mega says. “If people are going to be injecting or using opioids, it's probably better for them to have a single other person around them than have no one, even in the context of the coronavirus pandemic. The risk of overdose from opioids doesn't go away."
The opioid overdose rates in Contra Costa County in 2019 remained relatively stable, Mega notes, but there were significantly more fentanyl-related deaths that year than the year prior. Based on an analysis by Health Care for the Homeless, the leading cause of deaths for the homeless population in the county from 2012 to 2018 was unintentional injury, and 64 percent of those deaths were attributed to overdoses.
Because of the coronavirus, the focus of the street medicine team has also shifted. The outreach team is attempting to move quickly across the county to map where people are staying, and screen people on every site for symptoms of the coronavirus.
"The main thing we're doing when we get to a site is asking people, 'Are you feeling sick? Do you have a cough, shortness of breath?’” Mega says, noting that the team can also test people for the virus.
‘Afraid Of Getting Sick, Afraid Of Dying’
The coronavirus can spread rapidly in congregate living settings, like shelters and encampments. Homeless people and people addicted to opioids also have high rates of underlying health conditions. In San Francisco, more than 130 people living in homeless shelters or transitional housing have tested positive for COVID-19. There have been two confirmed cases among the homeless population in Contra Costa County, and over 800 confirmed cases in the county overall as of Friday.
"People are afraid of getting sick, afraid of dying. There are a lot of unknowns," Mega says. "The main thing people wish they had better access to was ways to clean their hands regularly. It's sort of a joke if I tell someone to wash their hands regularly if they don't have access to running water. We're not reaching everybody, and there's not unlimited hand sanitizer to give."
While people are sheltering-in-place, there have been signs people are seeking less medical help in general. Throughout the Bay Area, emergency room visits have dropped, and that can have dire health consequences unrelated to the coronavirus.
Emergency Visits Drop
In 2018, Mega developed a program in the emergency department at Contra Costa County Regional Medical Center in Martinez to help start patients with opioid dependency on buprenorphine. But with fewer people going to the emergency room, fewer people are also seeking this kind of help.
"People are rightfully afraid of using public transportation. Maybe they would [normally] hop on a bus and go to the needle exchange or go to a place where they can access services,” Mega says. “They're scared of doing that because they don't want to be out in the community.”
He’s worried that in a few months, experts will begin to see the health toll of people avoiding the emergency room because of the coronavirus.
Promising Signs Before The Coronavirus
As recently as last summer, there were signs that fatal drug overdoses, which had accelerated in the United States for three decades, were beginning to wane. Life expectancy in the country climbed for the first time in years as drug overdoses and cancer deaths declined. California received an influx of federal funding targeted for “medication-assisted treatment” like buprenorphine, and more physicians received licenses to prescribe the medication around the state.
But it’s unclear how many of these gains will be impacted by the pandemic. Dr. Alex Stalcup, medical director for the New Leaf Treatment Center in El Cerrito, has worked with patients with addiction for decades. That means he’s seen multiple waves of drug epidemics. Now he’s worried about patients who are feeling isolated.
"[Cities] are trying really hard, they’re putting out street teams and working with the community,” he says. “It’s just that the need exceeds the demand.”
Stalcup is also concerned the coronavirus could turn the drug supply even more volatile and lethal. While drug-related deaths have declined around the country, fentanyl-related deaths have continued to rise.
"It's really hard to support your habit during a shutdown. People are hungry. Panhandlers can't get food. Sex workers can't get business,” he says, referring to patients he’s worked with for years. “Addiction is a disease that’s remarkably sensitive to stress."
Sweeping Changes In Federal Guidelines
There have also been major policy changes on the federal level that some advocates say could bring relief. Because of orders for people to stay inside during the pandemic, the federal government has eased regulations around accessing prescriptions for buprenorphine. Now doctors like Stalcup can prescribe the medication over the phone.
"As long as we can assess their health by phone, we can phone-in, or e-prescribe, Suboxone, for people who are terrified of opioid withdrawal,” he says.
This can ease a common barrier to accessing medication for addiction. A federal report in January shows that 40 percent of U.S counties do not have any health care providers approved to prescribe this medication.
“It’s an unexpected silver lining of the COVID-19 crisis,” says Barbara Andraka-Christou, the author of "The Opioid Fix: America’s Addiction Crisis And The Solution They Don’t Want You to Have". “These are important changes that probably should have happened a long time ago.”
It’s unclear how long these new guidelines will last, or what impact loosened restrictions could have on the opioid crisis. But Andraka-Christou says this is an important, and rare, opportunity to study the impact of increasing access.
"Suddenly a lot of these barriers are being lessened,” Andraka-Christou says. “But if you think about it in the context of everything else, from relapse triggers to stress to harder accessibility of support groups, I'm not sure how those health outcomes will look.”
Back On The Streets
Dr. Joseph Mega and the mobile outreach team continue to meet with homeless people directly every week. Now the team is working to prevent both a coronavirus outbreak and to reduce the risks of drug overdoses. They screen people for the coronavirus and offer prescriptions to help people with addiction.
A few weeks ago, the team stopped by an encampment along a highway against a fence in Contra Costa County. They handed out clean needless, gave out Narcan, and answered questions about the coronavirus.
"There were probably a lot more people who needed services, but weren't around at the time," Mega says. "So we said we'd come back.”
You can access Contra Costa’s social service and health information 24/7 by calling the three-digit, toll-free number 211 from any phone. You can also contact them at their website, cccc.myresourcedirectory.com
There is also a free, confidential national helpline for individuals and families facing mental and/or substance use disorders. Their number is 1-800-662-HELP (4357).