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

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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... [MUSIC PLAYING] 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.
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