Overdose and the COVID-19 Pandemic: Dr. Chinazo Cunningham and the Challenges Of

JHU Oﬃce of External Aﬀairs | BONUS: Overdose and the COVID-19 Pandemic: Dr. Chinazo Cunningham and the Challenges of...

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JOSHUA Welcome to season two of Public Health on Call, a podcast from the Johns Hopkins SHARFSTEIN: Bloomberg School of Public Health. I'm Joshua Sharfstein, Vice Dean for Public Health Practice and Community Engagement and a former secretary of Maryland's Health Department.

Our goal is to bring scientiﬁc evidence and experience to the public health news of the day through informative interviews with scientists, community leaders, policy experts, public health oﬃcials, clinicians, and more. If you have ideas or questions for us to cover, please email us at [email protected]. That's [email protected] for future podcast episodes.

Today, as part of a periodic series on overdose and the pandemic, Dr. Brendan Saloner, a Bloomberg Associate Professor of American Health, speaks with Professor Chinazo Cunningham of Monteﬁore Medical Center. They discuss the challenges of providing patient-centered treatment for opioid use disorder in the midst of the COVID-19 pandemic. Let's listen.

BRENDAN We're joined today by Dr. Chinazo Cunningham. Dr. Cunningham is a Professor of SALONER: Medicine at the Albert Einstein College of Medicine and the Associate Chief in the Division of General Internal Medicine at Monteﬁore Medical Center. She works at the forefront of providing care, developing programs, and conducting research

focused on marginalized populations, including people who use drugs with or at risk for HIV infection. So, Dr. Cunningham, welcome.

CHINAZO Thank you so much. CUNNINGHAM:

BRENDAN You're both a proliﬁc researcher and a practicing doctor of addiction medicine. Can SALONER: you tell us about the population that you treat for substance use disorders at

Monteﬁore?

CHINAZO Sure, so I am a primary care physician, and I work in a federally qualiﬁed health

CUNNINGHAM: center in the South Bronx. I've been there for 22 years, and I treat people really from the surrounding community. And that community has really been devastated by addiction for decades.

And so most of my patients are poor. Most of them are Black or Hispanic. And most of them have opioid use disorder with, also, a substantial proportion also with cocaine use disorder.

BRENDAN So we sometimes talk about low-barrier treatment. What are some of the ways that SALONER: your practice makes treatment easier to access for these people?

CHINAZO Yeah, so, since we initially developed our buprenorphine treatment program, we, CUNNINGHAM: certainly, did that with an eye towards trying to really improve access to care for people. And so the way in which we've structured care deﬁnitely addresses that.

So, for example, we have a buprenorphine coordinator who is either a pharmacist or a nurse who's like a nurse care manager who is a point person so that people sort of don't bounce around the system trying to ﬁgure out who is that buprenorphine prescriber. So they go to one person. It's a central process.

And that person really has availability, often, within the same day, to reach out to the patient, talk to them about what treatment would be like, make sure that they have some of the most basic things that would make them eligible for treatment like insurance. I mean, we take most insurance plans, nearly all of them, except for maybe like one. We want to make sure that, for example, they're not on high doses of methadone or other things that might make treatment with buprenorphine just

very challenging.

And so, once we do that, we then schedule them for an appointment, usually, within

48 hours. And that's a very diﬀerent process than what it looks like for sort of other

people who are seeking treatment for the ﬁrst time in our clinic who are just

seeking it for primary care.

And so the waits for other people might be in the range from two weeks to six weeks

in order to get a primary care appointment, whereas, for people who have opioid

use disorder, that would happen in like two days. So that's a huge diﬀerence. And,

again, we've really worked with our leadership in our clinic, and we really developed

the program with an eye towards being able to get people access to care when they need it.

BRENDAN Well, why is it so important that people not wait two weeks or four weeks to get into SALONER: treatment?

CHINAZO Well, we want to take advantage of the time when people are ready and interested CUNNINGHAM: in treatment. Really, we want to grab them during that time. We've deﬁnitely seen that, if we wait, and we have a lot of barriers that people have to overcome, then they can lose interest. And that's the time when they, certainly, could be at risk for opioid overdose death. So, as soon as they make themselves interested, we really want to jump on that opportunity and link them to care.

BRENDAN Great, and you were talking just a moment ago about buprenorphine. SALONER: Buprenorphine, of course, is one of the three FDA-approved medications to treat opioid addiction. I wonder if you could just say a little bit about why getting medications is so important for patients who have opioid use disorder.

CHINAZO Right, well, medications are lifesaving. I mean, that's the simple answer, right? We CUNNINGHAM: know that medications reduce the risk of overdose death by at least 50%. And so medication is treatment.

We also are fortunate at Monteﬁore. We have ﬁve methadone programs. And, actually, one of the methadone programs is, literally, across the street from my clinic. And so we also coordinate with them and make sure that patients have the right treatment that matches their needs.

And so that's really a big plus that, if people-- if methadone is really a better

treatment for the patient, we can, literally, walk them across the street. Or, vise

versa, if someone shows up to our methadone program, and buprenorphine is a better treatment option, they can also walk them across the street. So it's really

wonderful to be able to provide options to our patients and to get the best ﬁt for them.

BRENDAN Great. So, practicing in New York City, your patients were amongst those most SALONER: immediately in peril when COVID cases started to rise last spring. So tell me a little

bit about how your clinic adapted to the pandemic. CHINAZO So I would say, in the Bronx, we were in the epicenter of the epicenter. I, personally, CUNNINGHAM: was deployed to provide treatment in our hospital in March, which was at the really

point of the surge of COVID. It was really, incredibly overwhelming. The whole city of New York shut down. The entire health care system changed on the dime. And many of us who were buprenorphine providers were deployed to work in the

hospital.

So I would say what we did is we really worked as a team of providers. So we have about 50 providers who provide buprenorphine treatment in seven diﬀerent clinics. And, while people were being deployed here and there, it was really important to

have very clear leadership in terms of the buprenorphine treatment program.

And so one of my colleagues, Dr. Tiﬀany Lu, really sort of stepped to the forefront and organized us so that we would ensure that our patients continued to have

access to treatment. And so what that looked like was that we met weekly as a team, as things were changing so quickly in terms of the policies and regulations around treatment, to make sure that we were on the same page and to make sure

that we were following within the regulations.

We oﬀered only telehealth visits. We provided buprenorphine prescriptions for a much longer period of time. So we gave people 30 days worth easily. And, for many

patients, we gave them reﬁlls. We worked with pharmacies to ensure that they would have access to their medications. And we also did mail. We also mailed medications.

We mailed naloxone kits to patients or worked, again, with pharmacies to have the

naloxone kits available when they picked it up. We stopped doing urine drug testing. So we really, totally changed the way that we provided treatment.

And what's interesting is we've looked at a sort of preliminary evaluation, and we found that the linkage-to-care rate during COVID was actually higher than pre-

COVID. And so, of those people who sought buprenorphine treatment, 2/3 of them ended up being linked to treatment, as compared to 50% of people pre-COVID.

So that's an interesting ﬁnding. And I think a lot of that has to do with how we've changed and how we didn't-- how the requirements for treatment really sort of

changed. But we are looking further into that so that we can learn a little bit more and so we can continue to make sure that we can really link people to care as best

as possible.

BRENDAN Yeah, really interesting. And you talked about the telehealth, and I want to dig into

SALONER: that just a little bit more. So how is telehealth working for your patients? And what have you learned about how to make it accessible to people who may not have

been on online platforms before the pandemic?

CHINAZO Right, so that's deﬁnitely challenging. So we take care of patients who are homeless CUNNINGHAM: and who have changing phone numbers if they have phones. And, certainly, most of them don't have internet access or data.

And that's been really challenging. I mean, I don't have the answer. I mean, for a lot

of our patients, when we talk about telehealth visits, the health care system encourages us to do video visits, which require internet access and data. And so

that is-- so, for a lot of our patients, that's not possible. And we don't care. We will do a phone visit.

I've had patients, actually, seek me out in the park while I'm walking to work because they don't have a phone, and they know my schedule. And we will-- I have

done visits in the park and then provided medications afterwards. So, any way we can work around it, we have tried to do that. It still is a challenge, and there's, certainly, a divide when it comes to technology, but we'll do anything we can.

BRENDAN Yeah, and now, to zoom out a little bit, I mean, one of the troubling things we're

SALONER: seeing nationally is a sharp increase in overdose deaths during the pandemic. What do you think is going on? And what do you think we still need to understand about

what's going on?

CHINAZO Yeah, so I don't know that we know what's going on. I think there's still a lot that we

CUNNINGHAM: need to learn about how opioid use disorder and other substance use disorders, how they've sort of evolved during this epidemic, this pandemic.

My sense is, probably, that treatment was limited, and so that certainly may have aﬀected people's ability to access their medication. And, if they couldn't access

their medication, they would go into opioid withdrawal. Then they would use whatever opioid they could get their hands on, which could contain fentanyl. That's one big way.

I think people probably also lost some of their tolerance just because the markets probably shifted, and their access to drugs probably changed. And, if they had a decrease in their tolerance, then they would be at risk for overdose if they used the

same amount that they would normally use. That's another reason.

And then I think a third reason is, certainly, with social distancing, people are more likely to be alone. And, if they're using alone, and they overdose, then there's nobody there to help reverse their overdose. So I think those are all deﬁnitely

possibilities.

I don't know that we know what the cause is, but, certainly, it's important to ﬁnd out because the pandemic is not over. And it's not even anywhere close to being over.

And there will be more pandemics in our lifetime. So I think we do need to learn from this and ﬁgure out how to try and prevent overdose deaths as much as possible.

BRENDAN One ﬁnal question, with the incoming Biden administration, what do you see as the

SALONER: most urgently needed changes in federal policy to treat addiction and prevent overdose?

CHINAZO I have a wish list. We need to change policies around widespread to make sure that

CUNNINGHAM: opioid use disorder treatment is woven into mainstream health care. We cannot have our treatment system segregated, as it has been for decades.

And so how do we get hospitals, health care providers to provide treatment? We have to incentivize them or penalize them if they don't. And so incentives that we use across the whole health care system for other conditions, like heart failure and certain infections, we know how to do that. We just need to insert opioid use

disorder or substance use disorders into that as well.

And so, once systems are incentivized to provide treatment, they will do it in 10 minutes. But, to this point, we've been sort of relying on the goodwill of individual providers, and that will get us only so far.

BRENDAN Dr. Chinazo Cunningham, thank you so much for coming on the podcast. SALONER: [MUSIC PLAYING]

CHINAZO Thank you. Thank you for having me. CUNNINGHAM:

JOSHUA Public Health On Call is produced by Joshua Sharfstein, Lindsay Smith Rogers, SHARFSTEIN: Stephanie Desmon, and Lymari Morales, audio production by Spencer Greer, Niall Owen McCusker, Cian Oatts, and Matthew Martin with support from Chip Hickey,

distribution by Nick Moran. Thank you for listening.

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