Is the Coronavirus Pandemic Worsening the Opioid Epidemic? Largely, Yes.

States are reporting more opioid-related deaths and, with less access to care and more mental stress, pain patients and communities are suffering.

A disturbing and costly trend is emerging across America – an increase in opioid-related deaths that runs parallel to social distancing measures, meant to curtail the spread of the coronavirus. The American Medical Association (AMA) reports that more than 30 states have had increases in opioid-related deaths, in correlation with the COVID pandemic.

The opioid epidemic (often referred to as the opioid crisis) traces back to aggressive marketing campaigns in the 1990s, the over-prescription of opioids for chronic pain, and ultimately, to physical dependence, addiction, and illicit use of street-procured opioids.

Opioid-related deaths are running parallel to social distancing measures, meant to curtail the spread of COVID-19. (Image: iStock)

Common opioids available by prescription include oxycodone, hydrocodone, codeine, and morphine. The brain does not differentiate between them and the illegal opioid heroin. Roughly 2 million people in the US live with opioid addiction, now termed Opioid Use Disorder (OUD), and approximately 80% of those individuals have been prescribed opioids at one time.1

OUD is defined as:

  • loss of control
  • continuation of opioid use despite significant adverse consequences
  • preoccupation with obtaining, using, and recovering from the effects of the drug.2

Anyone with a history of OUD is at high risk of developing it when prescribed opioids.

Editor’s note: Opioid addiction is not to be confused with physical dependence, a physiological change that occurs in almost  anyone who uses opioids at more than a minimal dose for more than a few days and which results in withdrawal symptoms when the medication is stopped, which is why prescribed opioids need to be tapered rather than stopped abruptly.3 More on the addiction-dependence distinction.

Individuals who become physically dependent on or addicted to a drug often need to keep taking that drug to prevent withdrawal symptoms. In the case of OUD, the AMA classifies opioid addiction as a chronic disease, which requires specific medical care and community support.4 Factors that can increase addiction include:

  • poverty
  • unemployment
  • stressful circumstances
  • regular contact with high-risk people or high-risk environments.

Unfortunately, social distancing, quarantine, isolation, and the economic repercussions driven by the COVID pandemic have exacerbated all of these risk factors – and it shows.

 

Enter COVID

“The coronavirus has definitely made the opioid crisis worse,” says Kevin Graves, counselor, and former program coordinator for the department of sociomedical sciences at Columbia University’s Mailman School of Public Health. “It’s a combination of things. Isolation is a major risk factor for addictions, as is the stress from unemployment and economic hardship. Specifically for opioid addiction, access to medications is important.”

The medications that Graves refers to are methadone and buprenorphine – used as part of medication-assisted treatment (MAT) for OUD. Unlike methadone, which (when prescribed for addiction rather than for pain) typically must be administered in a substance use disorder clinic, buprenorphine (a partial opioid agonist) can be prescribed or dispensed in physician offices.

Graves explains that access to opioid medications and treatment differs across state and county lines – but with in-office visits limited the past few months, even these guidelines have bumped up against new barriers.

In Chicago’s Cook County, for example, overdose deaths have doubled since this time last year, according to a Prop Publica report. With the scaling back of many addiction treatment services, communities are struggling to assist an already vulnerable population.5

In New York’s Erie County, medical examiners are seeing the amount of presumed opioid-related deaths double in the past months. With time, the opioids have progressed from prescription pills to heroin, and now, fentanyl, a synthetic opioid that is almost 100 times more potent than morphine.6 Health authorities report that opioid use has not increased, but rather, many people are using opioids without physician monitoring and without access to medications that treat overdose, such as naloxone.7

In Indiana’s Clark County, officials are reporting the highest dose of opioid overdoses since February 2017, mainly due to an increase in the use of heroin and fentanyl.

In Kentucky’s Lexington County, officials are reporting a 42% increase in fatal opioid-related overdoses from this time last year.8

Misinformation and stigma around addiction and mental health are largely driving the opioid epidemic. (Image: iStock)

 

Mental Health Weighs Heavily

There’s a lot of misinformation and stigma around addiction and mental health, two of the driving forces behind the opioid epidemic. Benjamin F. Miller, PsyD, chief strategy officer of Well Being Trust, a foundation that focuses on prevention, treatment, and recovery for mental health and substance misuse issues, says, “There have been three major missteps in our opioid response that I think has been exacerbated by COVID:

  1. We treated the opioid epidemic as if it were only about opioids and not about the broader problem of mental health and substance misuse.
  2. We used a one-size-fits-all approach to address opioids without taking into account the unique needs of specific communities such as communities of color.
  3. We failed to make the connections between social, economic, and health factors in our response.

All three of these factors are exacerbated in a time of crisis like COVID. They weren’t addressed well before, and thus why we might see those issues worsen now.”

 

Addiction Treatment is Lacking

To add to this, addiction continues to be a poorly understood disease. To put things into context, imagine you were prescribed opioids for chronic pain, such as arthritis. You take the medication and over time develop a physical dependence on it. The coronavirus hits America. You lose your job and your health insurance. Do you have access to care and proper monitoring of your opioid therapy to ensure proper use, or to help prevent or avoid addiction?

“It depends where you are. It depends what state you’re in,” Graves tells PPM. An exacerbating factor is the refusal of certain states to expand Medicare. In these 14 states, about 40% of the people who lose their jobs and their health insurance will end up with no coverage at all.

The highly addictive nature of opioids makes clinical monitoring and intervention crucial. A recent study, published in the journal Addiction, found that people receiving MAT for OUD had an 80% lower risk of dying from opioid overdose, compared with people in treatment without the use of medications.9

Unfortunately, the controversy surrounding medical intervention to treat addiction has historically limited its availability. According to some data, 42% of US counties have no buprenorphine prescribers.10

The highly addictive nature of opioids makes clinical monitoring and intervention crucial. There are resources being made available. (Image: iStock)

 

Government Response

In response to the recent spike in overdoses and the COVID public health emergency, the US Drug Enforcement Agency (DEA) issued guidance earlier this spring that gives physicians more leeway to treat patients suffering from OUD. Practitioners now have more flexibility to prescribe buprenorphine to new and existing patients without an in-person or telemedicine exam.

While many states are not fully implementing these measures, some states are seeing positive results from their utilization of telemedicine and increased access to care.

In Massachusetts, two-thirds of the more than 23,000 people prescribed methadone, are now allowed to take it at home. The state has  seen zero incidents of methadone overdose since implementing this measure.11 Boston Medical Center’s Office-Based Addiction Treatment Program (OBAT) moved to telemedicine in March 2020 when the virus struck the US in full force; since then, the number of patient visits to the program has doubled.

In Northern Michigan, telemedicine is making access to MAT more accessible than ever before.12

Graves hopes that some progress will result from the effects of the coronavirus pandemic on the opioid epidemic. He points out that insurance companies are now covering telehealth services, which can make care more accessible now and, ideally, in the long term.

           
What to Do If You or Someone You Know is Struggling with Opioids

If you or someone you know is contending with opioid addiction, what can you do during this crisis?

“It depends on the person,” Graves explains. “You don’t want to have someone stop opioids immediately, because it can send them into withdrawal. You can begin with a conversation. Addiction is often called a disease of loneliness, and this is an especially lonely time in the United States.”

Graves also recommends visiting the Substance Abuse and Mental Health Disorders Administration Resources for Families Coping with Mental and Substance Abuse Disorders. Additionally, the Harm Reduction Coalition  has issued a brief on safer drug use during the coronavirus pandemic. You can access that chart.

Most importantly, you should reach out to your provider, whether your primary care doctor or pain specialist or psychologist, who can guide you through the proper steps. Options may include an opioid tapering plan, in which you slowly back off your opioid doses under healthcare supervision, MAT which will help you through withdrawal, and psychotherapeutic support.

Overall, the US has been in the midst of an addiction crisis (despite some success in confronting the opioid epidemic) for years. The coronavirus pandemic has both worsened this crisis and shed light on the underlying conditions that fuel it. The latest CDC data reveals that one-third of Americans report feelings of depression or anxiety, comorbidities for both pain and addiction.13 Until we collectively address the issues of chronic pain, mental illness, economics, and inequality, we cannot properly treat America’s ongoing opioid crisis.

Updated on: 06/23/20
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COVID-19: How Pain Patients Can Take Control (Infographic)
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