The US opioid crisis in the era of COVID-19

The American Medical Association (AMA) released a press briefing last week on reports of an increase in opioid-related overdoses during the COVID-19 crisis. According to the document, over 20 states have reported an increase in opioid-related mortality since the official declaration of the pandemic.

While sufficient data is not yet available to officially determine what is behind the recent increase in opioid overdoses, many experts, including Nora Volkow, renowned neuroscientist and director of the National Institute of Drug Abuse, point to social isolation, anxiety, an overburdened health care system, and disruption of scheduled medication-assisted treatment (MAT) such as buprenorphine and methadone.

The concept of social distancing has made those living with or recovering from an opioid use disorder (OUD) more vulnerable to relapse and overdose, as once relied upon social support networks or therapy sessions fade or switch online. Isolation as well as financial stress caused by massive unemployment rates can spark an increase in feelings of anxiety, depression and worthlessness, all frequent triggers of drug use.

Social isolation can also be deadly. Using opioids alone significantly increases risk of fatality with no one nearby to notice symptoms of an overdose and administer Narcan (naloxone HCI) or call for help. It is not unusual for medical professionals to offer “harm reduction” strategies for those who are unable or unwilling to quit, one of which being: Never use alone.

Even if the overdose is witnessed—with resources stretched and health care personnel exhausted or quarantined at home—EMT workers are less likely to reverse an overdose on time and, if reversed, patients may refuse an emergency room (ER) visit for fear of coronavirus infection or arriving at a chaotic, understaffed ER. As a result, they may not receive lifesaving resources to prevent future overdoses such as referrals for rehabilitation, Narcan prescriptions, or follow-up visits to begin MAT.

Substance use and abuse also increases the risk of both infection and poor prognosis with COVID-19. In an interview with Kaiser Health News, Dr. Volkow discussed how drug use, in particular opioid use and vaping (THC or nicotine), is intensifying COVID-19 risks. The effect of opioids on the immune system, Volkow explains, has been extensively studied. Those using opioids chronically or therapeutically have been shown to have both slower and weaker immune responses.

Indirectly, those who misuse or abuse opioids tend to have a weakened immune system due to nutritional deficits, unreliable sleep patterns, and chronic infections from injection sites or untreated medical issues that exhaust and consequently weaken an immune system response.

Also well understood is the effect of opioid use on respiratory health. Even with short-term use at therapeutic doses, opioids lower the respiratory rate, in turn leading to a lower level of oxygen in the blood. COVID-19 also targets the respiratory system, damaging surface tissues of the lungs that are primarily responsible for oxygen and carbon dioxide exchange.

Dr. Volkow explains, “If you get COVID and you are taking opioids, the physiological consequences are going to be much worse. You’re not only going to have the effects of the virus itself, but you’ll have the depressive effects of opioids in the respiratory system [and] in the brain that lead to much less circulation in the lungs.”

Overdose deaths from prescription opioids, heroin and synthetic opioids such as fentanyl have increased sixfold since 1999. In 2018, 47,000 people across the US died from an opioid overdose. Uncounted are the tens of thousands more who use drugs but have not overdosed, who face a daily fight against their addiction.

Amidst the COVID-19 pandemic, the fight has grown more difficult with many new barriers arising to addiction treatment. Some inpatient rehabilitation services fail to maintain safe conditions, outpatient treatment centers struggle to switch to online platforms, harm reduction centers such as syringe exchanges close or significantly reduce their hours, and methadone clinics turn into frightening petri dishes with long lines and close quarters.

Both public and private inpatient and outpatient rehabilitation centers are still open, and national addiction and recovery organizations, such as the federal Substance Abuse and Mental Health Services Administration (SAMHSA), encourage those with an addiction to continue seeking treatment during COVID-19, ensuring visitors to their website that treatment centers “are taking preventive measures to ensure that their facilities remain coronavirus-free.”

However, drug and alcohol rehabilitation is an unregulated industry with many touting unproven or harmful treatments like equine therapy, work programs, confrontational interventions with family, or sound bath meditation at high, debt-burdening prices. Given the lack of regulation and the profit-oriented nature of the rehabilitation industry, it would be short of miraculous if these facilities were “coronavirus-free.”

Syringe exchanges, often located in areas highly trafficked by people struggling with drug addiction, provide clean needles as well as Narcan and recovery resources. A high proportion of these sites have closed, and others have reduced their hours or begun appointment-only exchanges. Twenty out of the 80 Ohio syringe exchange locations have closed. In New Jersey, some syringe exchanges have been forced to close as employees run out of PPE.

Some methadone clinics have also been forced to reduce hours of operation or are unable to see the same volume of patients as staff members fall ill or PPE runs short. Wait times are longer, and some clinics are too crowded to allow for proper six-foot distancing. Methadone—a full opioid agonist—has a significant potential for abuse and overdose and is parceled out, in-person, in daily doses. While more “stable” patients receive take-home doses, requiring fewer weekly clinic visits, the nature of methadone treatment increases the risk of COVID-19 exposure.

There have, however, been major changes to medication-assisted treatment as a result of the coronavirus pandemic. Laws that addiction medicine physicians and the greater recovery community have been fighting to change for years have changed quickly under emergency measures. For example, methadone clinics have allowed for home delivery of methadone or monthlong take-home doses. While not without risk, these regulations have increased access to the MATs, saving thousands from overdose each year. Physicians are also now allowed to prescribe buprenorphine—a partial opioid agonist—over telehealth as opposed to the once required face-to-face physical exam, posing certain risks as well.

The opioid and COVID-19 crises both expose the fundamental and irreconcilable conflict between the capitalist class and the working class. Pharmaceutical companies, with the complicity of the political establishment, raked in profits from Oxycontin and Percocet prescriptions as workers with painful overuse injuries found themselves hooked on painkillers and children, orphaned after a parent’s overdose, are raised in foster care. Wall Street saw an explosive rise in share values as mass graves on New York’s Hart island were filled with victims of the coronavirus, while families, if lucky, received paltry $1,200 stimulus checks. At the root of both crises is a society riven with growing inequality, corporate greed and a profound indifference to the lives of the international working class.