Coping with Opioid Addiction and HIV in the time of a pandemic

Addiction care

As public health officials struggle to control the spread of the coronavirus, recovery centers for people with opioid addiction are adapting to a new reality.

Since the start of the pandemic, houses in St. Louis run by Assisted Recovery Centers of America have been at full capacity. Housing manager Jordan Hampton said they’ve also seen a rise in the number of calls, which is unusual for springtime.

Dr. Fred Rottnek, a family and addiction medicine professor at Saint Louis University School of Medicine who often works with the ARCA houses, said some area inpatient facilities had to stop accepting patients due to the spread of Covid-19.

One was CenterPointe Hospital, a rehabilitation facility in St. Charles County where more than 15 staff members and patients tested positive for the virus in early April.

In India, which entered a lockdown in late March, people struggling with opioid abuse face similar obstacles.

“The current lockdown situation is a double whammy for people affected by addiction,” said Dr. Atul Ambekar, professor of addiction psychiatry at All India Institute of Medical Science, New Delhi.

“The illicit drugs that they have been using are not (easily) available, and even if they want to access treatment or health care services, the availability is restricted because of lockdown,” he said.

"The most effective and evidence based treatment of Opioid dependence involves provision of opioid agonist medications like buprenorphine or methadone.  While availability of this treatment at the required level of scale and coverage was already low in India, the lockdown situation makes it even more challenging for patients to receive their treatment," Dr. Ambekar said.

Restrictions at national borders impede the flow of drugs worldwide, driving some people to seek help as they suffer withdrawals -- and others to abuse alcohol.

“A lot of people now are presenting for alcohol use..and that has to do with supplies of street drugs being kind of problematic right now,” Rottneck said on the situation in USA.

Brandon Costerison, policy coordinator for the St. Louis-based National Council on Alcoholism and Drug Abuse, said he worries people not yet ready to seek treatment might overdose.

“Their risk factors for overdoses are going to dramatically increase over the coming weeks and months because the drug supply is going to be unstable, and very volatile,” he said, “and so we’re going to see a lot of changes coming that can mess with people’s tolerances and can lead to very dangerous consequences.”

To meet the new needs, Rottneck worked with Missouri officials to ease regulations on morphine so it can be prescribed via video chat. Indian officials have also relaxed access to opioid treatment medications such as buprenorphine and methadone. Rather than being administered daily by a medical professional, these medications are being made available at clinics to be used at home.

Recovery meetings are also being held on Zoom through ARCA and other organizations.

“When you get to that meeting, it's like, man, it doesn't matter what shows up,” Hampton said. “It doesn't matter if it's a world pandemic, we are still going to make this step into uniting together.”

HIV prevention

The pandemic has made it tougher for doctors, activists and patients fighting another virus: HIV. But it hasn’t stopped that fight.

Dr. Rupa Patel, director of infectious disease at Washington University in St. Louis, is among the many physicians committed to battling HIV even as the world focuses on the coronavirus. She works with Humsafer Trust, one of the largest LGBTQ organizations in India, on research and outreach to increase access locally and abroad for PrEP, or pre-exposure prophylaxis to prevent HIV.

PrEP is a once-a-day pill, taken for seven days, and has been shown to be 99% effective in stopping the spread of HIV. The medicine blocks the virus from entering someone’s body if they have been taking it for at least seven days before being exposed through sex.

The majority of PrEp users -- between 152,000 and 157,000 -- are in the United States, with 1,000-1,500 users in India. In both countries, the Covid-19 pandemic and the resulting lockdowns have made the drug difficult to access. 

Before the world went into quarantine, Patel and Shruta Rawat, research manager at Humsafar Trust, did outreach in India, telling people about PrEP and how it helps prevent the spread of HIV. Patel spent time in India, going to where vulnerable people hung out, such as night clubs and parks.

Under the lockdown, Patel grew concerned about how Indians would get the services they need. Rawat has seen people face barriers to care at their clinic in Mumbai. It’s almost impossible to get the word out about PrEP the same way that they used to because all in-person outreach has been put on hold. It’s unclear when they’ll be able to start again.

Stigma can make things worse, since people are wary of disclosing their HIV status. Even in normal times, Rawat said it can be scandalous for gay men in India to say they are living with the virus.

Stigma is also strong in Missouri, where Patel has patients who drive 200 miles for treatment so people in their counties don’t know they have been exposed to HIV.

Before the coronavirus struck, people in the United States and India faced other barriers to PrEP. For example, patients without access to a car or money or the ability to take the day off and go to places such as labs prevented people from accessing treatment.

The coronavirus pandemic only exacerbated such issues in both countries.

“You need to have supply and a location, factors of cultural humility and a place they can feel safe and they don’t feel judged,” Patel said.

Just as access to PrEP has gotten more difficult, those already living with HIV are also facing new dangers. Dr. Parneeth Pillala, an HIV primary care physician at the Bengaluru-based PCMH Restore Health Clinic in India, said people with HIV that’s not under control have weakened immune systems that put them at greater risk from Covid-19.

"Because of the lockdown it is difficult to get the medications, but we are successful enough to talk to the local agent and ensure that they are getting the medications. But, yes there has been a lot of disturbance in delivery  because there is no outsource of the medication," Dr. Pillala said.

(Reporting from USA by Kaitlyn Hoevelmann, Kelly Kullman, Clare Roth, Kate Robbins, Christina Mascarenas, Bailey Yang, and from India by Deblina Biswas and Natasha Sethia.)

(The students worked on the projects through an international journalism program at the University of Missouri under the instruction of journalists Laura Ungar in the United States and Sujoy Dhar in India.)

Image Credits: Opioid Addiction- Photo by Michael Longmire/Unsplash.  / PrEP: Kendel/Unsplash