How to prevent new stigmatization and even take advantage of the new opportunities: seven pillars
New clinical approaches implemented during the pandemic have helped to mitigate its impact on SUD treatment. But will they remain after the COVID-19 pandemic? We strongly advocate taking advantage of innovations initiated during the pandemic and continuing to develop them in a post-COVID-19 world. This situation is an opportunity to modernize SUD treatment, which is still largely based on that developed a century ago and only updated 40 years ago during the heroin pandemic. We believe that the renewed treatment systems should be based on the seven pillars described below. An overarching priority is to assure the renewal relies heavily if not exclusively on delivering treatments that have been proven to be effective, avoiding the temptation to use services that might seem to be readily available or that are promoted but that have no value.
Acceleration in the implementation of pillars 1 (telemedicine) and 2 (home hospitalizations) is necessary to cope with short-term and direct consequences of the pandemic, while pillars 3 to 7 are long-term and general measures to improve SUD treatment for the future.
Pillar 1: Telemedicine and digital solutions
Telemedicine in addiction shows favorable results for reduction of alcohol use and depressive symptoms; increased quality of life, patient satisfaction, and accessibility; and can be delivered at reduced cost . Evidence for the efficacy of digital interventions is of good quality for alcohol and cannabis use disorders [34, 35]. During the COVID-19 pandemic, our anecdotal experience is that patients find such treatment more accessible and easier to adhere to. Some potential risks need systematic evaluation, such as larger prescriptions of opioid agonists, and less biological testing (e.g., urine drug testing) and clinical supervision. Additional technological solutions may also help to minimize these risks. In some countries, such as the USA, a proportion of the organizations were already in a better position to cope with the pandemic using telemedicine. A 2018 study found that 45% of 363 SUD organizations in the USA offered computerized screening and/or assessments, almost 30% provided telephone support or treatment, and 20% already offered video therapy . Successful experiences with telemedicine in Italy, Spain, France, and the USA were reported during the current crisis, although these observations have not been backed up with specific clinical data [10, 37, 38].
However, use of technology in the SUD field is not just limited to online appointments. Smartphone and web-based interventions, text messaging for continuing contact and care, machine learning, and wearable devices, including digital phenotyping and ecological momentary assessment, biofeedback, and virtual reality, expand the range of available treatment opportunities and provide tools to help professionals and patients to make shared decisions [39, 40].
There is a need for a public health response to increase availability of treatment for SUDs, including training for healthcare professionals in online interventions and counseling. The concept of tele-expertise has also emerged as a new strategy that could be valuable in mitigating the impact of the pandemic on the SUD treatment system. In the tele-expertise framework, an addiction specialist could distantly supervise the work of other health professionals in the field .
Pillar 2: Home hospitalizations
Intensive outpatient treatments range in format from daily outpatient care in a hospital or center (e.g., day hospital) to home hospitalization. There are successful experiences in mental illness worldwide and emerging programs in SUD treatment [42,43,44,45].
Active healthcare treatment in the patient’s home (home hospitalization) is an alternative to inpatient treatment that has shown a reduction in readmissions, improvement of patient’s satisfaction, and reduction of hospital length of stay, with little or no differences in mortality for many medical conditions . The evidence in the treatment of mental health disorders is more limited. Hospitalization at home has been implemented as an alternative for inpatient mental health treatment with encouraging results in both adults and children and adolescents [47, 48], and has shown feasibility during the COVID-19 crisis . We strongly recommend that research and clinical practice of mental health home hospitalization include patients affected by SUDs. Furthermore, the link between telemedicine and home hospitalization may include nursing as daily contact and psychiatric and psychological support provided remotely.
In addition to home hospitalization, staying at home can also be viewed as “outpatient” treatment (e.g., where the patient is at home and has contact with a clinician electronically) and may for many people be preferable to inpatient treatment. Few if any studies find benefit for inpatient versus outpatient treatment for SUD, and thus, it is more appropriately reserved for patients who have no sober place to stay, lack social support or are vulnerable, need medical or psychiatric hospitalization, or have very severe SUD. During the pandemic, access to inpatient SUD care has been limited and greater use of outpatient treatment post-COVID-19 represents an advance in quality of care that should be maintained.
Since people living in deprived conditions are especially vulnerable to SUDs [49, 50], the implementation of pillars 1 and 2 should be carried out while in maintaining a focus on methods and processes which do not increase existing inequalities in treatment access.
Pillar 3: Consultation-liaison psychiatric and addiction services
Admission due to health problems in an acute hospital is an excellent opportunity to detect and manage SUDs, especially for patients with alcohol, opioid, and cocaine use disorders and multiple somatic and mental comorbidities . Additionally, admission creates an opportunity for people with SUDs to access treatment at an earlier stage and close the treatment gap.
Multidisciplinary treatment facilitates the treatment of underlying conditions in many areas such as emergency departments, liver units, or head and neck surgery units . It is also a helpful strategy to reduce stigmatization of people with SUDs and to promote an integrated treatment approach, with clinicians from different backgrounds (e.g., nursing, social workers, hepatologists, addiction specialists) working in an integrated way.
Pillar 4: Harm-reduction facilities
Abstinence is the most desirable objective for SUDs from a health perspective, but in some circumstances, this is not realistic (e.g., in severe and complex cases). Harm-reduction is a perfectly reasonable intermediate goal that many people can successfully achieve . Harm-reduction aims and has been shown to reduce mortality and morbidity through a reduction in risk behaviors or a reduction of drug use, and is implemented in many countries because of its effectiveness . “Housing first” is a practice for homeless people with co-occurring serious mental illness and SUD, which focuses on providing a stable home without requiring prior abstinence. This approach reduces homelessness and health service utilization and is efficient . And, helpfully, albeit unwittingly, it has been used during the COVID-19 crisis to ensure the quarantine of this population.
Pillar 5: Person-centered care
Person-centered care is clearly preferred by patients, and advocated by many clinicians, but has not been widely implemented due to a combination of arcane regulatory structures and clinical inertia. During the acute phase of the pandemic, this has been put in place on an emergency basis. Patient preferences for fewer in-person visits and testing, easier access to enter into and receive treatment, and fewer prescribing restrictions are likely to have improved the quality of care and access to it. These should be retained post-COVID-19 as key elements of any new treatment system. Motivational interviewing (MI) and shared decision-making (SDM) are two effective approaches to SUD that have shown increasing evidence in the last 30 years [56, 57]. They have in common: (1) an ethical approach to SUD management, focusing on the self-determination principle (autonomy); (2) flexibility in objectives and treatment decisions; and (3) both remove the stigma of SUD. In other words, MI and SDM facilitate person-centered care.
Pillar 6: Promote paid work to improve quality of life in people with SUDs
Having meaningful paid work contributes significantly to both better outcomes and a reduction in healthcare costs for SUD patients, specifically (but not exclusively) for those with complex mental health comorbidities [58, 59]. In the aftermath of the COVID-19 pandemic, there have been many calls for future economic structures which lead to more sustainable economies, with a broader, socially inclusive scope . We need to work together with these societal actors to include SUD patients in these new work contexts. The implementation of strategies such as “paid work or housing first” can be challenging in times of recession, when the forecast (from the International Labour Office) indicates that 6.7% of working hours will likely be lost during the second trimester of 2020 .
Pillar 7: Integrated addiction care
Reducing pressure and costs on acute and mental healthcare will be a priority after the pandemic due to increased demands on health systems. Cutting addiction services is a false economy as the impact is displaced onto already overstretched hospitals . The solution is an integrated addiction care model that spans from early detection and brief interventions in primary care (both health and social) to highly specialized hospital services. Within this integrated approach, gambling and gaming problems deserve special attention.
The way to end the stigma experienced by these groups is to fully respect the civil rights of people with SUDs, including equality of access to health services. From the addiction treatment perspective, we have to guarantee access to evidence-based treatments in a modernized healthcare system, with these seven pillars offering a guide on how to do this and concurrently reduce stigma.
Public health and prevention
Even though this communication focuses on SUDs and their treatment, in a time of crisis, it is also very important to implement preventive activities and take a public health perspective. Public health responses must be based on a realistic analysis of needs. The three “best buys” of the WHO (reduce availability, increase prices, and a ban on advertising)  and other evidence-based public health preventive strategies should be reinforced for legal drugs, including the alcohol, tobacco, and gambling markets (online and offline). In addition, new strategies must be implemented to systematically deal with (a) fake news concerning legal and illegal drugs and (b) controversial scientific information and messages (e.g., nicotine and protection from COVID-19)—especially when society is in a state of collective panic, people look for “the truth,” and science needs more time and greater integrity to provide clear answers.
The short-term impact of the pandemic has already been described, and relevant institutions (EMCDDA, AMSA, SAMSHA, and NIDA) have published guidelines on the management of this situation [8, 63,64,65]. This article focuses on the opportunities that could exist in the wake of the pandemic to make long-overdue improvements to the long-term healthcare of people who suffer from SUDs. We are fully aware that our world is facing a period of uncertainty and that this comes in a time that healthcare workers and systems are chronically overstretched. Nevertheless, we strongly feel the priorities outlined in the seven pillars should serve as a guide in the redesign of drug policies worldwide, irrespective of the different impacts and experiences of the COVID-19 outbreaks. Specifically, we think that the implementation of pillars 1 (telemedicine) and 2 (home hospitalizations) should be done quickly, as a short-term response to the pandemic, while pillars 3 to 7 represent much needed long-term and general measures to improve SUD treatment.