A state of emergency—including those caused by natural disasters such as the recent wildfires around Los Angeles—can have serious implications for access to treatment for substance use disorders (SUDs). During and after powerful storms and wildfires, patients in affected areas may be cut off from transportation routes, phones, and internet, making it more difficult for them to reach health care facilities and providers. Research has found that communities vulnerable to natural disasters tend to have insufficient access to quality care for opioid use disorder (OUD). To help prevent a disproportionate number of overdose deaths, these communities would benefit from better matching available services to the potential needs of residents. It’s important that states plan ahead to avoid gaps in addiction treatment. By acting both before and while a disaster strikes, state agencies and lawmakers can take several steps to help ensure that effective, continuous SUD care remains available.
A health system that prioritizes patient-centered SUD care will be best equipped to meet people’s needs during emergencies. Care coordination—organizing patient care activities and sharing information among all providers involved in a treatment plan—is a cornerstone of patient-centered treatment and has been shown to both improve patient engagement and reduce costs. Care coordination can take different approaches. For example, the nurse care manager (NCM) model requires an NCM to initiate screening and to work and communicate with the patient throughout treatment while coordinating with the prescribing physician. The Medicaid health homes model allows the patient to begin care at a highly regulated and specialized opioid treatment program with the opportunity to continue longer-term treatment at an office-based setting that qualifies as a “health home.” However, both tend to include individualized care plans based on the patient’s needs, a lead provider as the point of contact who helps ensure that the care plan is implemented, and ongoing data-sharing and education for providers and patient.
Second, the health system should be as accessible as possible, even during a natural disaster. Telehealth is an important tool that allows people to receive treatment even when they can’t get to a health facility. During the COVID-19 pandemic, telehealth flexibilities were instrumental in treating individuals with OUD while they practiced social distancing. Instead of being evaluated and receiving medication in person, people were able to get services through phone or video appointments, which was found to help more patients initiate and remain in treatment.
States have several options for expanding telehealth for SUDs during emergencies. State Medicaid agencies and lawmakers can require public and private insurers to reimburse SUD treatment providers for all services delivered via telehealth; set public and private reimbursement rates for telehealth-based SUD services that are on par with in-person treatment; and allow patients with Medicaid to access SUD treatment services by phone. They can also ensure providers know that the telehealth flexibilities are extended until Dec. 31, 2025, and may become permanent.
Of the 29 million people in the U.S. who met the criteria for alcohol use disorder (AUD) in 2023, less than 10% received any form of treatment, and only 2% received medications. The medications—naltrexone, acamprosate, and disulfiram—can help patients reduce alcohol consumption. Yet patients may be unaware that medications exist for AUD; health care providers lack knowledge and experience to prescribe the medications; and there may be medication insurance and pharmacy stocking barriers.
Research shows that substance use, including alcohol consumption, increases during disasters and times of crisis, making it even more important that patients have access to treatment.
To accomplish this, it’s important that practitioners screen for AUD and prescribe medication; health insurance companies cover the drugs; and pharmacies stock the medications so they are readily available.
Methadone, a safe and effective medication for treating OUD, is tightly restricted. State rules vary about which patients are eligible to receive this medication and where they can take it, and some state rules are even stricter than federal guidelines. For example, some state regulations on methadone require that a patient undergo urine screening and counseling before receiving the medication, limit take-home doses, and prohibit patients from obtaining methadone at alternative locations when they are not near their usual clinic (a practice known as guest dosing). These conditions pose unnecessary obstacles to treatment, particularly during a natural disaster.
Federal methadone regulations became more flexible following the COVID-19 pandemic, and states should consider making the same changes. Additional tools are available to ensure access during disasters, such as suspending drug screening and counseling requirements and facilitating guest dosing (when a patient of one treatment program can receive medication at another) and take-home doses, as advised by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). Per SAMHSA’s guidance: “In some emergency situations (e.g., an impending snowstorm or hurricane that will likely make travel difficult for a few days), providing patients with extra take-home doses may make the most sense,” and “to ensure continued dosing in all circumstances, [a patient may need to access] another program that will provide guest dosing.”
The COVID-19 pandemic afforded a natural experiment around methadone dispensing flexibility, and many states allowed take-home doses for the first time. Several studies found that these eased regulations were associated with high patient satisfaction and no adverse medical outcomes, suggesting the policy’s safety and effectiveness.
Lifesaving strategies such as the use of naloxone are critical components of the SUD treatment system. Naloxone is an opioid overdose reversal medication that can be administered by bystanders, family members, law enforcement, medical professionals, and others who witness an overdose. Increasing naloxone’s availability is associated with reductions in overdose-related mortality, making it critical that naloxone be accessible to people who use drugs and their loved ones.
States should have strong naloxone policies in place that would also help during any natural disasters. Such policies include requiring first responders to carry naloxone and have the training to administer the medication; ensuring that community-based organizations, prisons and jails, and health care facilities offer free or low-cost naloxone and distribute free naloxone to individuals in need; and supporting pharmacy stocking of over-the-counter naloxone. If naloxone is available and administered by more laypeople, communities can help prevent fatal overdoses and intervene before the arrival of emergency medical services.
Natural disasters can devastate individuals, communities, and health systems. By anticipating the needs of SUD patients in times of emergency—and having a strong treatment infrastructure in place year-round—states will have valuable tools at their disposal to mitigate the effects of these events.
Alexandra Duncan directs The Pew Charitable Trusts’ substance use prevention and treatment initiative.