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Management of the painkiller addiction crisis looked optimistic headed into 2020. The pandemic brought a heavy toll to efforts that took years to establish.
In 2018, the United States saw a small decline in deaths caused by all opioids after a nearly 20-year rise, giving some a sense of optimism in what has been a long, ugly battle. Tragically, those hopes were dashed the following year, when new cases increased by more than 3000.
This equates to 136 people dying every day from an opioid overdose, a number that is simply bewildering in its perplexity.
In the few years leading up to COVID-19, the opioid epidemic was receiving an unheralded amount of attention, and rightfully so. Both the Obama and Trump administrations sought to address the public health crisis with policies like the Comprehensive Addiction and Recovery Act and the SUPPORT for Patients and Communities Act.
During the fiscal years of 2017 and 2018, the federal government spent nearly $11 billion on programs aimed at prevention, treatment and recovery, as well as on research, criminal justice, and public health surveillance.
Substance abuse treatment facilities were increasing all across the country, with 2376 opening their doors between 2017-2019 alone.
All of this pointed to the fact that despite the growing number of overdose deaths, as far as fighting opioid addiction went, the nation was headed in the right direction.
However, when the ongoing COVID-19 pandemic took center stage last year, the opioid issue was forced to take a backseat—to the detriment of many.
The COVID-19 pandemic immediately intensified some of the most prominent issues that cause many people to relapse or start abusing opioids in the first place; economic fears, stress, isolation and loneliness.
Even strategies designed to curb the virus, like community-wide lockdowns, social distancing, and building capacity regulations, drove addicition patient stressors and negatively impacted care centers and clinics where those with an opioid use disorder (OUD) were being treated.
“In March and April 2020, some addiction treatment programs were closing to new patients, anyone with a sniffle was getting quarantined or turned away, and outpatient programs were closing and/or minimizing its group therapy sessions, and all of it was based on the individual program's preference and comfort level with maintaining appropriate social distancing measures and safety,” Jim Baird, the medical director of My Friend’s House, an outpatient facility in New Jersey, said.
“There wasn't COVID-19 testing readily available, we were learning how to do adequate COVID-19 screenings, we all raced to stock up on PPE and thermometers, with the anxieties over the debate of ‘Do we stay open or not?’ and ‘Do we take new patients or not?’”
Compounding the issue further, those with an OUD have been found to be at an increased risk for contracting COVID-19 itself. They have a significantly higher prevalence of comorbidities like chronic kidney, liver and lung disease, cardiovascular disease, type 2 diabetes, obesity, and cancer, all of which are risk factors for acquiring the virus.
Due to stay-at-home-orders, less people with an OUD were starting new courses of treatment and fewer were seeking out care. In the same 3-month period, the percentage receiving at least 1 fill of OUD medication and at least 1 OUD visit was lower in 2020 than in 2019. This may be partly due to the fact that many providers did not feel comfortable beginning new patients on medicine during the pandemic.
In an effort to combat this, policies guiding the use of telehealth visits in addiction treatment were relaxed. For instance, prescribing buprenorphine and other controlled treatment medications to patients virtually was not allowed under the Ryan Haight Act, but this was changed to allow providers to do so. The Substance Abuse and Mental Health Services Administration also altered their guidance to make communication between clinicians and patients easier through video and telephone calls.
“One of the best things for me, and I think the addiction treatment community at large, was the relaxing of telehealth,” Tildabeth Doscher, MD, a specialist in addiction medicine and clinical assistant professor at the Jacobs School of Medicine and Biomedical Sciences said. “I love that we have been able to expand the telehealth model and I’ve seen it very, very effective.”
Despite the attempt to alleviate the complications forced on opioid treatment during the pandemic, overdoses and overdose related deaths are increasing at an alarming rate.
The Overdose Detection Mapping Application Program (ODMAP), which provides near real-time suspected overdose surveillance data that was developed by the High Intensity Drug Trafficking Area program (HIDTA), showed that following March 19 of 2020, over half of the counties that participate in the program experienced a spike in overdose submissions. Additionally, the number of alerts, as well as the duration of the spikes, have increased nationally.
The ODMAP team released a study on May 13 of last year that applied the Autoregressive Integrated Moving Average (ARIMA) model to their submission dataset and found a direct correlation between reported overdoses and the mandating of social distancing and stay-at-home orders.
“The opioid epidemic is a complex problem that has manifest itself over decades,” Doug Thornton, the director of the Prescription Drug Misuse Education and Research (PREMIER) Center at the University of Houston College of Pharmacy said. “Specifically, co-morbid mental health conditions, isolation, and unemployment have all been exacerbated by the COVID-19 pandemic and contribute to the worsening opioid crisis.”
Hospital emergency rooms, which have been experiencing lower-than-average visits, have seen a frightening surge in overdose cases. In Virginia, the VCU Medical Center emergency department saw a 123% increase in nonfatal opioid overdose visits between March and June of 2020 in comparison to the same months in 2019.
A report from the Johns Hopkins Bloomberg School of Public Health, titled Saving Lives from Overdose During a Pandemic, collected data from North Carolina and Arizona which showed a 15% and a 35% rise in opioid-related overdoses between March of 2019 and 2020, respectively.
Sara Whaley, a research associate in the Bloomberg School's Department of Health Policy and Management and the lead author of the report, stressed that without an appropriate amount of attention to the overdose crisis, COVID-19 will have a grave impact on the vulnerable populations who use drugs.
“It is important that as we focus our attention on the immediate threat of the COVID-19 pandemic that we don’t forget the existing public health crisis: the opioid epidemic,” she said.
It is clear that the US is currently experiencing not 1, but 2 concurrent national public health emergencies. Priorities cannot be made to neglect 1 for the other.
The opioid epidemic, which was already becoming worse, has undeniably been aggravated by COVID-19 and there are no signs of it improving anytime soon.
It is paramount that proper resources are allocated to the treatment of those with an OUD in this unprecedented moment in time. While the pandemic is unquestionably the chieftan concern, it is equally important that those with substance abuse issues are in need of tailored response during all this.
And at the very least, the burden faced by the addiction population from COVID-19 was, in some ways, a rallying point to the field. Baird has witnessed, amid more substance abuse deaths, a surge of new patients seeking first-time care—more than he’s ever seen before.
“More people with opioid addiction definitely died as a result of COVID-19 pandemic restrictions, but opioid addiction advocacy and treatment, from my perspective, has continued to be pushed forward by those heavily involved,” Baird said.
“I have seen more people reaching out for help than I've ever seen before. I have seen addiction treatment programs collaborate and work around all of these restrictions and new rules and regulations in order to keep their doors open to those who seek treatment. I think focus and media attention has been stolen by COVID-19, but the 'boots on the ground' have been running faster and working harder since March 2020, and I think they will continue to do so.”
Although clinicians are bearing the brunt of the weight, the public also shares in some of the responsibility.
Thornton emphasized the need for all of us to realize and understand that substance misuse is not something that stems from a lack of morals or a failure of character but is a mental health disorder that has been overly stigmatized.
Being more compassionate towards one another, touching base with people who are struggling, is something anyone can do to lend a hand to those who need it now more than ever