For the past few months, US public health specialists, policymakers, the general public have had one thing in mind: Covid-19. All health resources have been focused on the pandemic, from government funding to pharmaceutical development to broader medical research.
But only months ago, there was another epidemic at the center of the national debate. Opioid addiction disorder, which caused nearly 70,000 deaths in 2018 alone, the most recent year with reliable data, and nearly 800,000 fatalities in the previous decades.
As the opioid epidemic was forced to cede priority to the more immediate crisis of Covid-19, many of the resources devoted to treatment and research of opioid abuse were curtailed or put on pause. Combined with the interruption of outpatient services in hospitals and clinics, and socioeconomic changes that can lead to relapse, has experts worried the progress made so far on tackling the opioid crisis may be jeopardized.
“There is a risk that the opioid crisis […] gets de-prioritized in the midst of the appropriate focus on Covid-19, and that the challenges that we’re facing in the gains that we’re making unfortunately get forgotten,” says David Fiellin, a professor of public health and director of Yale’s program on addiction medicine.
The challenges, and setbacks, are fundamentally threefold, affecting the magnitude of the crisis itself, the treatment of people suffering from opioid abuse disorder, and ongoing research.
A crisis that worsens the other
When it comes to risk factors for opioid addiction, Covid-19 is a perfect storm.
The risks of relapsing or taking more drugs—opioids as well as benzodiazepines like Valium—is increased by the stresses related to the pandemic, and it is especially difficult for people who are in the early stages of treatment. “One thing that is important for treating many medical conditions is patients establishing a routine,” Fiellin says. For patients with opioid addiction disorder, the disruption of that routine can be even harder to deal with: The meetings of support groups such as Narcotics Anonymous have been interrupted, routine check-in with clinicians are put on hold or held remotely, and even changes in work hours and childcare can remove some of the structures that help maintain abstinence.
“We’ve certainly seen in our community patients having their work curtailed or being required to work from home has led to instances where they are increasing their use of either benzodiazepines or heroin,” Fiellin says. These changes aren’t uniform across states either. “It’s mirroring the pandemic in that there are large regional variations in the impact of Covid-19 on the opioid crisis,” he says.
Doctors and health workers across the country have seen an increase in fatal overdoses, though it’s hard to quantify by how much, says Nora Volkow, the director of the National Institute on Drug Abuse (NIDA). Not only does the official data lag behind incidents, but its collection relies on autopsies to confirm overdose as the cause of death. With coroners and pathologists overwhelmed by Covid-19, performing such checks has been impossible in many cases, which will likely result inaccurate data for 2020.
Still, says Volkow, data collected from apps such as ODMAP—which allow first responders to enter cases of overdose and are mandatory in some states—clearly point toward an increase in cases.
But the emergency isn’t just in the short-term. The long-term economic impact of the Covid-19 crisis is likely to exacerbate socio-economic trouble in rural and poorer communities, which are at higher risks of opioid abuse. “Isolation, social distancing, uncertainties, loss of jobs, and decreasing support systems: All of these actually are known risk factors for increasing drug use and for people that are in recovery for relapse,” Volkow says.
At the end of the pandemic, she says, these areas risk being worse off than they were a decade ago, and supporting their financial recovery is essential to avoid further exacerbating the opioid crisis. “We need to provide them with resilience, otherwise we’re going to have a new generation facing the pain or worst challenges that led their parents to take drugs.”
Covid-19 poses challenges to treatment, too, with counseling and outpatient visit paused. For many people already under treatments with methadone or other opioid addiction medications, some accommodations have been made to make their medications available for longer courses. Rather than needing a daily dose from a methadone clinic, for instance, they are getting refills for two weeks or a month at a time. Further, a change of policy from the Drug Enforcement Administration prompted by the Covid-19 pandemic allowed doctors to prescribe controlled substances, such as medications for opioid abuse disorder, via telemedicine. This has brought treatment opportunities in otherwise underserved areas, paradoxically expanding access to treatment.
But in many other cases, the situation has made treating new patients harder. Often, says Volkow, the emergency room would be the first point of contact, not just to treat overdoses, but to enroll overdose survivors into addiction treatment programs. But currently physicians are too busy dealing with Covid-19 patients to have time to start patients on other programs, and with hospitals directing resources toward coronavirus treatment, opioid abuse patients might end up discharged without a comprehensive follow-up plan.
There are, too, patients who find themselves suddenly without insurance. Those include people who lost coverage through work, and might need time to enroll in Medicaid, and could lose continuity of treatment, which increases the risk of overdose.
Volkow says something similar is happening to the jail population. “We know that a significant number of people that end up in justice settings have a problem with [substance abuse] disorders, including opioid abuse disorder,” she says. In some cases, nonviolent offenders were released at the beginning of the pandemic to reduce the density of prisons but there hadn’t been enough time to set up the supports necessary to continue treatment outside the jail, or even proper housing arrangements. Effectively, their release happened in conditions that increased their risk of relapse.
A pause on research momentum
The most effective treatment for addiction is medication-based, says Fiellin, but it’s only available to about 20% of the individuals who need it. Investments into expansion of treatment, particularly in rural communities as well as among Black patients and other minorities, have achieved significant progress especially in the past five to 10 years, but it all risks being undone if funding is curtailed—as seems likely given the current crisis.
Academic and medical institution both are bracing for the impact of a combined financial and medical crisis, and diverting investments and resources while imposing hiring freezes and budget cuts.
Volkow echoes these concerns. Much research has come to a halt because of the pandemic, and especially clinical research, because hospitals don’t have sufficient capacity to take care of patients with Covid-19 and also continue their work on opioid addiction research. In some cases, too, doctors no longer have access to the patients they were studying. That’s the case in prisons, where many studies were conducted but have been closed to external visitors since the beginning of the pandemic.
This might even discourage younger researchers from pursuing research into opioids, which was until recently an area where research was supported and encouraged. Additionally, many projects funded by NIDA have been paused, says Volkow, compromising the ability to gather information about how coronavirus crisis is promoting the spread opioid addiction disorder. And without that information, it is difficult to devise intervention strategies. “It’s very, very frustrating because we have an opioid crisis and we’re seeing that the number of people that are overdosing are going up,” she says.