An Epidemic in the Midst of a Pandemic: Opioid Use Disorder and COVID-19
Authors: G. Caleb Alexander, Kenneth B. Stoller, Rebecca L. Haffajee, Brendan Saloner
Journal: Annals of Internal Medicine (2020)

Ideas and Opinions2 April 2020An Epidemic in the Midst of a Pandemic: Opioid Use Disorder and COVID-19FREEG. Caleb Alexander, MD, MS, Kenneth B. Stoller, MD, Rebecca L. Haffajee, JD, PhD, MPH, and Brendan Saloner, PhDG. Caleb Alexander, MD, MSJohns Hopkins Bloomberg School of Public Health and Johns Hopkins Medicine, Baltimore, Maryland (G.C.A.), Kenneth B. Stoller, MDJohns Hopkins University School of Medicine, Baltimore, Maryland (K.B.S.), Rebecca L. Haffajee, JD, PhD, MPHRAND Corporation, Boston, Massachusetts, and University of Michigan, Ann Arbor, Michigan (R.L.H.), and Brendan Saloner, PhDJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (B.S.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-1141 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The novel coronavirus, COVID-19, has upended all facets of American life and placed an unprecedented strain on the U.S. health care system. Extreme measures, including continued social distancing and coordinated suppression efforts, may be required to reduce catastrophic mortality (1). Although the pandemic threatens everyone, it is a particularly grave risk to the millions of Americans with opioid use disorder, who—already vulnerable and marginalized—are heavily dependent on face-to-face health care delivery. Rapid and coordinated action on the part of clinicians and policymakers is required if these threats are to be mitigated.For persons already in treatment, one of the biggest threats is disruption of care, particularly access to medications for addiction treatment. Such challenges are especially acute for patients who receive methadone through opioid treatment programs, because historically the dispensing of methadone has been tightly regulated, requiring many patients to receive no more than 1 directly observed daily dose at a time (2). Recognizing the imperative to address potentially dire disruptions in care, the Substance Abuse and Mental Health Services Administration (SAMHSA) recently released new guidance increasing the ability of opioid treatment programs to transfer as many patients as possible to take-home methadone maintenance protocols (3). To address concern that SAMHSA's new guidance might spur an increase in nonmedical methadone use, as well as to improve quality of care, persons receiving take-home methadone should be coprescribed naloxone, an opioid reversal agent that may mitigate the risks of fatal overdose among those at high risk (4).Fortunately, patients receiving buprenorphine, another medication approved by the U.S. Food and Drug Administration for opioid addiction, face fewer access barriers, because 30-day medication supplies are routinely dispensed through retail pharmacies. Public and private payers should nevertheless reduce barriers further in the coming months by temporarily shortening buprenorphine refill windows, eliminating prior authorizations, and granting exemptions to face-to-face fill requirements. Pharmacy benefits, including state Medicaid formularies, also may be expanded to include newer, long-acting injectable formulations of buprenorphine.Efforts also are desperately needed to reduce face-to-face clinical encounters to treat opioid use disorder during the pandemic. Medicaid and Medicare waivers, made possible by national emergency declarations, can support these changes. For example, the recent declarations expand options for the remote prescription of controlled substances without an initial in-person evaluation (5). Likewise, Medicare rules have been relaxed to increase reimbursement of telehealth services, and SAMHSA has clarified that although the regulations around sharing of protected health information between addiction and general medical providers have not been suspended, providers can use their discretion to determine whether a bona fide medical emergency exists (such as a hospital needing more clinical information about an unconscious patient). In this case, the normal requirement to obtain informed consent may be waived (6). States also can request Medicaid reimbursement for telehealth services, including those used for opioid addiction treatment, and modes of communication that enable most patients to participate, such as telephone sessions. States also might relax licensure or other legal barriers to controlled substance prescribing via telemedicine during this national emergency (7). Additional waiver requests could support block grants for telemedicine infrastructure, including virtual counseling capabilities, remote delivery of medications, and additional wraparound support services to persons isolated, quarantined, or at risk due to COVID-19.Some treatment programs are introducing or expanding other approaches to reduce the demand for in-person care. For example, for patients with continued drug use, cognitive impairment, or severe mental illness, some programs may engage with a patient surrogate—identified by the patient and vetted by program staff—to pick up, secure, and supervise home dispensing of medication. Such technologies as automated, secure pill dispensers also may be used, unlocking daily medication doses and alerting programs about missed doses or device tampering. Other programs have initiated video-based “directly observed therapy” by using approaches first developed for treating tuberculosis that provide a video record of medication ingestion at home for confirmatory viewing by program staff (8).During the pandemic, the specialty substance use disorder treatment system must be integrated with other service providers who can help ensure the safety of patients with opioid use disorder. Now more than ever, patients need comprehensive case management with linkages to housing and social services programs. Because many of these patients are unstably employed, disruptions to their work also may lead to adverse outcomes, such as loss of housing, food insecurity, and ultimately a downward spiral that increases relapse risk and damage to recovery. Such prospects underscore the urgent need for emergency pathways, including through Medicaid waivers, to housing and social services.Disruptions in medication access are not the only threat facing persons with opioid use disorder. Despite efforts to augment take-home medications and other treatment, those with opioid use disorder—whether in opioid treatment programs or other treatment settings—will continue to require some in-person contact with health care providers for treatment assessments and to manage changes in care. Yet these contacts place both patients and providers at risk for COVID-19 infection and its sequelae. Treatment settings must rapidly implement safety plans to limit infection risk for patients and staff. Recommendations regarding patient screening, use of personal protective equipment, and maintaining workforce wellness have already been issued by some professional societies and should be broadly implemented to protect patients and providers (9).The COVID-19 pandemic strikes at a moment when our national response to the opioid crisis was beginning to coalesce, with more persons gaining access to treatment and more patients receiving effective medications (10). COVID-19 threatens to dramatically overshadow and reverse this progress. Some disruptions in the care of patients with opioid use disorder are inevitable during the weeks and months to come. However, extraordinary planning and support can limit excessive disruption and its dire consequences. These efforts will require new partnerships, unprecedented use of technology, and the dismantling of antiquated regulations. The greatest strength of the treatment system has always been compassion and care for the most vulnerable—qualities needed now more than ever.References1. Ferguson NM, Laydon D, Nedjati-Gilani G, et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand. Imperial College COVID-19 Response Team. Accessed at www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf on 30 March 2020. Google Scholar2. Substance Abuse and Mental Health Services Administration. Federal Guidelines for Opioid Treatment Programs. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP. Substance Abuse and Mental Health Services Administration. 2015. Google Scholar3. Substance Abuse and Mental Health Services Administration. Opioid Treatment Program (OTP) Guidance. Accessed at www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf on 16 March 2020. Google Scholar4. Haffajee RL, Cherney S, Smart R. Legal requirements and recommendations to prescribe naloxone. Drug Alcohol Depend. 2020;209:107896. [PMID: 32058248] doi:10.1016/j.drugalcdep.2020.107896 CrossrefMedlineGoogle Scholar5. U.S. Department of Justice, Drug Enforcement Administration. COVID_19 Information Page: Telemedicine. Accessed at www.deadiversion.usdoj.gov/coronavirus.html on 18 March 2020. Google Scholar6. Substance Abuse and Mental Health Services Administration. COVID-19 Public Health Emergency Response and 42 CFR Part 2 Guidance. Accessed at www.samhsa.gov/sites/default/files/covid-19-42-cfr-part-2-guidance-03192020.pdf on 30 March 2020. Google Scholar7. Yang YT, Weintraub E, Haffajee RL. Telemedicine's role in addressing the opioid epidemic. Mayo Clin Proc. 2018;93:1177-1180. [PMID: 30097301] doi:10.1016/j.mayocp.2018.07.001 CrossrefMedlineGoogle Scholar8. emocha Health. emocha Deploys Video Technology to Fight Opioid Crisis. Accessed at https://emocha.com/emocha-deploys-video-technology-to-fight-opioid-crisis on 16 March 2020. Google Scholar9. American Association for the Treatment of Opioid Dependence. AATOD Guidance to OTPs in Response to the Coronavirus (COVID-19). Accessed at www.aatod.org on 20 March 2020. Google Scholar10. Olfson M, Zhang VS, Schoenbaum M, et al. Trends in buprenorphine treatment in the United States, 2009-2018. JAMA. 2020;323:276-277. [PMID: 31961408] doi:10.1001/jama.2019.18913 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Eric Dawson, PharmD, Maria Guevara, PharmD, CPE, Leah LaRue, PharmD, PMP, Angela Huskey, PharmD, CPEMillennium Health, San Diego, California22 April 2020 An Epidemic in the Midst of a Pandemic: Opioid Use Disorder and COVID-19 Alexander and colleagues, and the Annals, are to be applauded for calling attention to and offering thoughtful solutions for a time when “millions of Americans with opioid use disorder [face] a particularly grave risk.” Their work, combined with that of Drs. Volkow, Becker, and Feillin, provide everyone responsible for the care of those suffering from this epidemic within a pandemic an array of risk mitigation strategies that can save lives (1, 2). Thankfully, some are already being employed due to quick action by the U.S. Department of Health and Human Services. As researchers for an accredited specialty laboratory, we have conducted studies aimed at better arming those fighting the substance abuse crisis with timely information to improve the efficient use of available resources and ultimately, reduce drug overdose deaths (3, 4). We’ve been closely following trends in our urine drug testing (UDT) data. This dataset consists of patient specimens submitted for testing by clinicians as part of patient care, primarily from the medical specialties of substance use disorder (SUD) treatment, pain management, primary care, and behavioral health. The analysis includes specimens with tests ordered for definitive drug testing by LC-MS/MS to detect the presence of select drugs. Since the COVID-19 pandemic was declared a national emergency about 30 days ago on March 13, 2020, our data indicates that the UDT positivity rate for methamphetamine has risen from 7.7% to 9.1%, an 18.2% increase over the previous 90-day period. The fentanyl positivity rate increased from 7.3% to 9.9%, a 35.6% increase over the same period; both increases demonstrated statistical significance. Of the UDTs submitted by clinicians treating those with SUDs, double-digit increases in positivity are seen for cocaine, methamphetamine, heroin, fentanyl, and non-prescribed opioids, which had been declining. These data, although early and likely to evolve, are consistent with recent media reports of spikes in drug overdoses, suggesting that fears regarding relapse risk may be becoming reality. There are several factors potentially impacting shifts in drug use that bear watching closely. Emerging reports of changes in illicit drug prices and production by illicit manufacturers may shift drug utilization to that which is cheapest and easiest to obtain (5). Drug testing practices may also be shifting in response to COVID-19. We will continue to closely monitor developments and urge the adoption of Alexander et al.’s solutions to minimize the otherwise “dire consequences” that our data suggest may be at the doorstep. 1. Volkow N. Collision of the COVID-19 and Addiction Epidemics. Ann Intern Med. doi:10.7326/M20-12122. Becker WC, Fiellin DA. When Epidemics Collide: Coronavirus Disease 2019 (COVID-19) and the Opioid Crisis. Ann Intern Med. doi:10.7326/M20-12103. LaRue L, Twillman RK, Dawson E, et al. Rate of fentanyl positivity among urine drug test results positive for cocaine or methamphetamine. JAMA Netw Open. 2019;2(4):e192851. doi:10.1001/jamanetworkopen.2019.28514. Twillman RK, Dawson E, LaRue L et al. Evaluation of Trends of Near Real-Time Urine Drug Test Results for Cocaine, Methamphetamine, Heroin and Fentanyl. JAMA Netw Open. 2020;3(1):e1918514. doi:10.1001/jamanetworkopen.2019.185145. Hamilton K. Sinaloa Cartel Drug Traffickers Explain Why Coronavirus Is Very Bad for Their Business. Vice News. March 23, 2020. https://www.vice.com/en_us/article/bvgazz/sinaloa-cartel-drug-traffickers-explain-why-coronavirus-is-very-bad-for-their-business. Accessed April 16, 2020. Disclosures: Drs Dawson, Guevara, LaRue, and Huskey are employees of Millennium Health, San Diego, California. Author, Article, and Disclosure InformationAuthors: G. Caleb Alexander, MD, MS; Kenneth B. Stoller, MD; Rebecca L. Haffajee, JD, PhD, MPH; Brendan Saloner, PhDAffiliations: Johns Hopkins Bloomberg School of Public Health and Johns Hopkins Medicine, Baltimore, Maryland (G.C.A.)Johns Hopkins University School of Medicine, Baltimore, Maryland (K.B.S.)RAND Corporation, Boston, Massachusetts, and University of Michigan, Ann Arbor, Michigan (R.L.H.)Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (B.S.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-1141.Corresponding Author: G. Caleb Alexander, MD, MS, Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 North Wolfe Street W6035, Baltimore, MD 21205; e-mail, galexan9@jhmi.edu.Current Author Addresses: Dr. Alexander: Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 North Wolfe Street W6035, Baltimore, MD 21205.Dr. Stoller: 911 North Broadway, Baltimore, MD 21205.Dr. Haffajee: RAND Corporation, Department of Economics, Sociology, and Statistics, 20 Park Plaza, Suite 920, Boston, MA 02116.Dr. Saloner: Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Hampton House 344, Baltimore, MD 21205.Author Contributions: Conception and design: G.C. Alexander, K.B. Stoller, R.L. Haffajee, B. Saloner.Analysis and interpretation of the data: B. Saloner.Drafting of the article: G.C. Alexander, R.L. Haffajee, B. Saloner.Critical revision for important intellectual content: K.B. Stoller; R.L. Haffajee, B. Saloner.Final approval of the article: G.C. Alexander, K.B. Stoller, R.L. Haffajee, B. Saloner.Collection and assembly of data: B. Saloner.Administrative, technical, or logistic support: G.C. Alexander.This article was published at Annals.org on 2 April 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoWhen Epidemics Collide: Coronavirus Disease 2019 (COVID-19) and the Opioid Crisis William C. Becker and David A. Fiellin Collision of the COVID-19 and Addiction Epidemics Nora D. Volkow Metrics Cited byDevelopment of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care—a modified e-Delphi studyOpioid use disorder: current trends and potential treatmentsPeople who use drugs show no increase in pre-existing T-cell cross-reactivity toward SARS-CoV-2 but develop a normal polyfunctional T-cell response after standard mRNA vaccinationTelehealth Initiation of Buprenorphine for Opioid Use Disorder: Patient Characteristics and OutcomesImpact of the COVID-19 pandemic on treatment for mental health needs: a perspective on service use patterns and expenditures from commercial medical claims dataPatient experiences of methadone treatment changes during the first wave of COVID-19: a national community-driven surveyBuilding an inpatient addiction medicine consult service in Sudbury, Canada: preliminary data and lessons learned in the era of COVID-19Reported adverse events related to use of hepatitis C virus direct-acting antivirals with opioids: 2017–2021Interrupted time series analysis of drug overdose fatalities in service-related industries versus non-service-related industries during the COVID-19 pandemic, 2018–2021Characterizing the mechanisms of social connectionFrequency of opioids prescribing in the postoperative period and ways to reduce their needThe impact of the COVID-19 pandemic on medications for opioid use disorder services in the U.S. and Canada: a scoping reviewHow are state telehealth policies associated with services offered by substance use disorder treatment facilities? Evidence from 2019 to 2022Social vulnerability predictors of drug poisoning mortality: A machine learning analysis in the United StatesMobilizing nurses to address the opioid misuse epidemicMethadone Dose and Timing of Administration as Predictors of Sleep Apnea Syndrome During Methadone Maintenance Treatment: A Retrospective Cross-sectional StudyThe impact of the implementation of medication for opioid use disorder and COVID-19 in a statewide correctional system on treatment engagement, postrelease continuation of care, and overdoseResidence in urban or rural counties in relation to opioid overdose mortality among Kentucky hospitalizations before and during the COVID-19 pandemicThe Influence of COVID-19 on Utilization of Epidural Procedures in Managing Chronic Spinal Pain in the Medicare PopulationImpact of COVID-19 on poisoning-related mortality in Iran: An interrupted time series studyRecruiting hand therapists improves disposal of unused opioid medicationClinician Perspectives on Delivering Medication Treatment for Opioid Use Disorder during the COVID-19 Pandemic: A Qualitative EvaluationOverall and Telehealth Addiction Treatment Utilization by Age, Race, Ethnicity, and Socioeconomic Status in California After COVID-19 Policy ChangesInvestigating Social Media to Evaluate Emergency Medicine Physicians’ Emotional Well-being During COVID-19Morphine Withdrawal-Induced Hyperalgesia in Models of Acute and Extended Withdrawal Is Attenuated by l-TetrahydropalmatineInfant factors that impact the ecology of human milk secretion and composition—a report from “Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)” Working Group 3Public Opinion about America’s Opioid Crisis: Severity, Sources, and Solutions in ContextPalliative care for people who use drugs during communicable disease epidemics and pandemics: A scoping review on access, policies, and programs and guidelinesA patient-centered nurse-supported primary care-based collaborative care program to treat opioid use disorder and depression: Design and protocol for the MI-CARE randomized controlled trialThe use of telemedicine for perioperative pain management during the COVID-19 pandemicTemporal and spatial trends in suicide-related visits before and during the COVID-19 pandemic in the US, 2018–2021Physicians’ experiences with buprenorphine: A qualitative study of motivations for becoming X waivered and barriers to and facilitators of prescribing the medication for opioid use disorderLeveraging Randomized Controlled Trial Design: HIV and Wellness Interventions with Marginalized PopulationsCost-effectiveness of office-based buprenorphine treatment for opioid use disorderDiscontinuation of Buprenorphine Treatment for Opioid Use Disorder During the Coronavirus Disease-2019 PandemicBuprenorphine Treatment Episodes During the First Year of COVID: a Retrospective Examination of Treatment Initiation and RetentionTrends and Characteristics of Buprenorphine-Involved Overdose Deaths Prior to and During the COVID-19 PandemicThe Case for Neuroinnovation: Health Burdens Associated with Psychiatric, Addiction-Related, and Co-occurring DisordersAssociation of polysubstance use disorder with treatment quality among Medicaid beneficiaries with opioid use disorderImpact of the COVID-19 pandemic on liver disease-related mortality rates in the United StatesGeographic variations in opioid overdose patterns in Pennsylvania during the COVID-19 pandemicOnline Peer Support for Substance Use DisordersImpact of the COVID-19 Pandemic on the Public Perceptions of the Roles and Functions of Community Pharmacies in South Korea: Updated Cross-Sectional Self-Reported Web-Based SurveyImplementation and Evaluation of Primary Care Team Participation in Opioid Use Disorder Learning SessionsProviding Low-barrier Addiction Treatment Via a Telemedicine Consultation Service During the COVID-19 Pandemic in Los Angeles, County: An Assessment 1 Year LaterEvaluating the Effect of COVID-19 on Outpatient Opioid Utilization Among Health First Colorado Members and a National Non-Medicaid Cohort: An Interrupted Time Series AnalysisStructures of drug-specific monoclonal antibodies bound to opioids and nicotine reveal a common mode of binding“It’s Also Pushed People to a New Level of Desperation:” COVID-19 Impacts on Experiences of Persons Who Use Illicit OpioidsSubstance use workforce training needs during intersecting epidemics: an analysis of events offered by a regional training center from 2017 to 2020Opioid treatment program safety measures during the COVID-19 pandemic: a statewide surveyExploring the impact of the COVID-19 pandemic on syringe services programs in rural KentuckyNaloxone administration by law enforcement officers in New York State (2015–2020)Concerns among people who use opioids during the COVID-19 pandemic: a natural language processing analysis of social media postsNavigating intersecting public health crises: a qualitative study of people with opioid use disorders' experiences during the COVID-19 pandemicImpacts of COVID-19 at the intersection of substance use disorder treatment and criminal justice systems: findings from three statesRisk of COVID-19 infection and the associated hospitalization, ICU admission and mortality in opioid use disorder: a systematic review and meta-analysisThe opioid epidemicAn Education Intervention to Raise Awareness Reduces Self-reported Opioid Overprescribing by Plastic Surgery ResidentsAssessing Clinical Impacts and Attitudes Related to COVID-19 among Residential Substance use Disorder PatientsProject ECHO and Primary Care Buprenorphine Treatment for Opioid use Disorder: Implementation and Clinical OutcomesPerceived Impact of COVID-19 on Prevention, Treatment, Harm Reduction, and Recovery Services for Opioid use Disorder: National Survey of Local Health DepartmentsA Qualitative Study of Patient Experiences with Telemedicine Opioid use Disorder Treatment during COVID-19Characteristics of fatal drug overdoses among college age decedents in Tennessee, 2019–2020Evaluation of substance use in Izmir during the COVID-19 pandemicCurrent and emerging pharmacotherapies for opioid dependence treatments in adults: a comprehensive updateEditorial: Prescribing psychotropics: Misuse, abuse, dependence, withdrawal and addiction, Volume IIReceipt of Telehealth Services, Receipt and Retention of Medications for Opioid Use Disorder, and Medically Treated Overdose Among Medicare Beneficiaries Before and During the COVID-19 PandemicFlexible Buprenorphine/Naloxone Treatment Models: Safe and Effective in Reducing Opioid Use Among Persons With Prescription Opioid Use DisorderThe Importance of Diversity, Equity and Inclusion From the Clinician’s PerspectiveOpioid Use Disorder and COVID-19: Treatment and Recovery Factors among Vulnerable Populations at the Intersection of Two U.S. EpidemicsPalliative care interventions for people who use substances during communicable disease outbreaks: a scoping reviewWomen-Reported Barriers and Facilitators of Continued Engagement with Medications for Opioid Use DisorderConsensus recommendations for opioid agonist treatment following the introduction of emergency clinical guidelines in Ireland during the COVID-19 pandemic: A national Delphi studyDigital Interventions to Save Lives From the Opioid Crisis Prior and During the SARS COVID-19 Pandemic: A Scoping Review of Australian and Canadian ExperiencesSimulated opioid choice linked to opioid use disorder severity among veterans with chronic pain: initial validation of a novel paradigmA potential paradigm shift in opioid crisis management: The role of pharmacogenomicsChanges in Buprenorphine and Methadone Supplies in the US During the COVID-19 PandemicMixed methods prospective findings of the initial effects of the U.S. COVID-19 pandemic on individuals in recovery from substance use disorderHuman Factors and Ergonomics (HFE) applications in responses to the COVID-19 pandemic: Lessons learned and considerations for methodsMedicaid expansion and opioid supply policies to address the opioid overdose crisisA Community-Based Participatory Intervention in the United States Using Data to Shift the Community Narrative From Deficits to StrengthsA Pilot Program of Interprofessional Care for the Patient with a History of Injectable Drug Use Requiring Intravenous MedicationAddiction and COVID: Issues, Challenges, and New Telehealth ApproachesImpact of Coronavirus Disease-2019 on Hospital Care for Neonatal Opioid Withdrawal SyndromeOpioid usage and COVID-19 prognosis: A systematic review and meta-analysisThe estimated impact of state‐level support for expanded delivery of substance use disorder treatment during the COVID‐19 pandemicCOVID-19 Impact on Australian Patients with Substance Use Disorders: Emergency Department Admissions in Western Sydney before Vaccine Roll OutPotential long-term effects of SARS-CoV-2 infection on the pulmonary vasculature: a global perspectiveHow Physician Workforce Shortages Are Hampering the Response to the Opioid CrisisPre-clinical safety and toxicology profile of a candidate vaccine to treat oxycodone use disorderOverdose deaths and the COVID ‐19 pandemic in British Columbia, CanadaChanges in Sewage Sludge Chemical Signatures During a COVID‐19 Community Lockdown, Part 1: Traffic, Drugs, Mental Health, and DisinfectantsTelehealth Adoption by Mental Health and Substance Use Disorder Treatment Facilities in the COVID-19 PandemicGastrointestinal symptoms and healthcare utilization have increased among patients with functional gastrointestinal and motility disorders during the COVID‐19 pandemicEffect of reductions in opioid prescribing on opioid use disorder and fatal overdose in the United States: a dynamic Markov modelEvaluation of Stigma Related to Perceived Risk for Coronavirus-19 Transmission Relative to the Other Stigmatized Conditions Opioid Use and DepressionAcceleration of opioid-related EMS runs in the spring of 2020: The National Emergency Medical Services Information System data for 2018–2020Mal/adaptations: A qualitative evidence synthesis of opioid agonist therapy during major disruptionsTransformation of Outpatient PsychiatrySimilar COVID-19 incidence to the general population in people with opioid use disorder receiving integrated outpatient clinical careThe COVID-19 pandemic and the health of people who use illicit opioids in New York City, the first 12 monthsBarriers to Care Experienced by Patients Who Inject Drugs During the COVID-19 Pandemic: A Qualitative AnalysisShifting Medication Treatment Practices in the COVID-19 PandemicResponding to the opioid crisis in North America and beyond: recommendations of the Stanford–Lancet CommissionEmergency Department Visits for Nonfatal Opioid Overdose During the COVID-19 Pandemic Across Six US Health Care SystemsCoexisting Substance Use Disorder and Chronic Pain During COVID-19Moving Upstream: A Social Emergency Medicine Approach to Opioid Use DisorderThe COVID-19 pandemic and opioid use disorder: Expanding treatment with buprenorphine, and combining safety precautions with telehealthOpioids in COVID-19: Two Sides of a CoinSubstance Use Disorder Treatment in the Age of COVID-19: Challenges, Responses, and Lessons for the FutureSubstance Use Disorder Treatment in the Age of COVID-19: Challenges, Responses, and Lessons for the FutureHIV Risk Among Urban and Suburban People Who Inject Drugs: Elevated Risk Among Fentanyl and Cocaine Injectors in MarylandDigital Analgesic Comprising a Second-Generation Digital Health System: Increasing Effectiveness by Optimizing the Dosing and Minimizing Side EffectsFeasibility of a Novel COVID-19 Telehealth Care Management Program Among Individuals Receiving Treatment for Opioid Use Disorder: Analysis of a Pilot ProgramScreening for Unhealthy Alcohol and Drug Use in General Medicine SettingsThe EASL–Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortalityComparing mortality from covid-19 to mortality d