The COVID-19 pandemic and our national response has commanded our full attention in recent months. All of us have been asked to make drastic changes and substantial sacrifices to protect public health. We have seen the virus cause more than 150,000 deaths nationally with Florida surpassing 10,000 deaths in recent weeks. We have also seen untold economic damage in the state and across the country. More than 650,000 have died globally. This has understandably crowded our national discourse and dominated other topics.
But the opioid epidemic that has ravaged communities throughout the United States for a decade has not gone away. In 2018, we saw promising signs that the opioid epidemic may have peaked, with overdose deaths declining for the first time in many years. However, in 2019 overdose deaths increased again. Healthcare providers have made strides to reduce reliance on opioid medications and better educate patients about safely using these medicines, but the drug overdose epidemic has become more and more an epidemic of illicit heroin and fentanyl as well as stimulants like cocaine and methamphetamine.
Even more troubling, addiction and the coronavirus may interact in ways that make both problems worse. As the Director of the U.S. National Institute on Drug Abuse, Dr. Nora Volkow has described it, we are witnessing the collision of the COVID-19 and addiction epidemics.
Early in the pandemic, during our initial response, addiction experts sounded the alarm about the potential fallout, identifying characteristics of people who use drugs that might make them particularly vulnerable to adverse outcomes from coronavirus infection.
Social distancing is a critically important tool to reduce the spread of COVID-19. But addiction experts are worried that being apart from a community of support may make it more difficult for people to find and stay in recovery. It is often said that “addiction is a disease of isolation, and recovery is about connection.” Regular, mutual support is essential for many to maintain their recovery, especially at a time like this that is so full of uncertainty and stress.
Twelve-step programs like Alcoholics Anonymous and Narcotics Anonymous or other self-help groups like SMART recovery traditionally meet in person. Social distancing makes that extremely difficult. In response, some meetings have moved online using videoconferencing platforms. Face-to-face interaction is an important part of recovery support groups, but virtual meetings can temporarily provide enough support for many individuals.
Another concern has been that the response to the pandemic has interrupted patients’ access to addiction treatment. Most addiction counseling is delivered in person, but face-to-face counseling and group therapy sessions have been largely discontinued. Access to addiction medications like methadone, buprenorphine, and naltrexone has been a major concern because they are often prescribed and dispensed in person, sometimes on a daily basis.
Telehealth addiction counseling was already expanding to serve rural communities and other patients who lack access to in-person treatment before COVID-19, and this trend has accelerated for patients across the country. And federal regulators stepped in to make it easier for providers to prescribe take-home doses of methadone (the regulations usually require most patients to receive methadone in-person for each dose) and get patients started on buprenorphine.
Experts worry that health comorbidities common among patients with substance use disorder make these patients more susceptible to coronavirus infection and adverse outcomes. Chronic illnesses such as heart, kidney and liver disease are all risk factors for the novel coronavirus and are more prevalent among patients with addiction. Lung damage in individuals who vape, smoke tobacco or marijuana, or use opioids or methamphetamine make them more vulnerable to a disease that attacks the lungs. Even patients properly taking prescribed opioids could be at heightened risk of adverse health outcomes from coronavirus infection due to opioids’ suppression of respiration.
What We Have Learned
There are still many unknowns - top experts are quick to point out that we do not have enough data to make definitive claims about the overall impact of the collision of COVID-19 and the addiction epidemic. However, we have already seen dramatic increases in the numbers of overdoses and deaths since the beginning of the COVID-19 pandemic. “A White House drug policy office analysis shows an 11.4 percent year-over-year increase in fatalities for the first four months of 2020.”
We also know that syringe services and naloxone distribution have become increasingly difficult. These services can’t be done virtually, and many of the organizations that provide them have had to reduce hours because of sick staff or stop operating because of the requirements of local emergency orders. Clients of shuttered programs report reusing and sharing needles. Public health authorities worry that these risky behaviors could spark outbreaks of HIV or Hepatitis C. Even for those who are still able to obtain naloxone, social distancing makes it more likely they will be using alone and less likely that somebody will be there to deliver the life-saving medication if they overdose.
Additionally, people with substance use disorders are more likely to be incarcerated or experience homelessness. Homeless shelters, prisons, and jails have emerged as high-risk locations where the coronavirus can spread quickly.This increases the risk that patients with addiction will be exposed.
What Has Surprised Us
Regulatory flexibility and telehealth counseling have ameliorated the anticipated problems with access to treatment, but fewer patients are getting started on treatment in emergency departments. Because so many patients with opioid use disorder don’t typically seek health care until it’s urgent, emergency departments have become critical point entry points for treatment and addiction medications. But with emergency departments in many parts of the country overwhelmed, that access point has been shut down. In other places, patients may be too scared to go to the hospital, concerned they may become infected with COVID-19.
Border closures and social distancing have reportedly disrupted illegal drug supply chains, so supplies in some parts of the country have declined substantially. While this sounds promising there are potential consequences, including the fact that people may overdose when they begin using again after a period of abstinence, which lowers their tolerance for drugs. Drug traffickers may increase the potency of drugs they sell since supply is more limited, and people may seek out new sources of supply and experience adverse consequences from using substances they are unfamiliar with. All of this rightfully worries public safety and health practitioners.
While it’s still too early to determine the full impact of COVID-19 on the addiction crisis, some trends are emerging. Overdoses are increasing at an alarming rate. However, the requirements of social distancing are encouraging regulators, community partners, and practitioners to adapt and innovate to find ways to better use technology to address the mental health needs of our communities and for the delivery of treatment services and recovery support. Governor Ron DeSantis and First Lady Casey DeSantis are prioritizing this effort and assembling government leaders, health care providers and the private sector in an effort to showcase the kind of help that is needed.The crisis is revealing the deepening integration of addiction treatment with the rest of the healthcare system. We are learning that simultaneous disruptions in supply chains for illegal drugs and harm reduction supplies present a complex picture and a variety of potential outcomes for rates of drug use, overdose, and infectious disease spread.
This is a time of great stress, but also of great change and potential. Stress and uncertainty, social isolation and disconnection make recovery more challenging and addiction more likely. But there is also an optimistic side to this story because of our renewed focus on the importance of connection and cooperation. In a conversation with NIDA’s Dr. Volkow, Director of the U.S. National Institutes of Health Dr. Francis Collins observed that “if you look back in history, often these times of national crisis have been times when people did have the chance to survey what really matters around them, and perhaps to regain a sense of meaning and significance.” I hope Dr. Collins is right.