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COVID-19 and the opioid crisis: When a pandemic and an epidemic collide

Stacy Weiner , Senior Staff Writer
July 27, 2020

More than 20 million people in the United States have a substance use disorder. Now, COVID-19 has left many locked down, laid off, and flooded with uncertainty. So far, experts see signs of relapses, rising overdoses, and other worries. What can be done?

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Dave Quisenberry is determined to stay away from opioids, which have robbed him of so much. When COVID-19 put his building services job on hold for many weeks, though, the 48-year-old West Virginian kept looking over his shoulder to make sure loneliness wasn’t catching up with him.

“Being alone five days in a row can get to you, can make you anxious and depressed,” he says. “Back when I was using, I would just take care of that [with drugs].” Now, Quisenberry — who became addicted following shoulder surgery — says the possibility of relapse is always in the back of his mind. When he needs to steady himself, he makes sure to think about his family. “I don’t ever want to lose their trust again.”

Quisenberry is also glad that he’s been called back to work. “I know a lot of people in my support groups who have lost their jobs, which is completely miserable,” he says. “It’s a really bad deal right now for a lot of people who are trying to avoid drugs.”

Across the United States, as the COVID-19 pandemic has collided with the substance use epidemic, experts worry about the vast numbers of people who may be suffering from the impact.

Anxiety, grief, isolation, financial worries, changes at home and work, and an ongoing sense of uncertainty can all threaten people with a substance use disorder (SUD) as well as those at risk of developing one.

Researchers say it’s too soon to have definitive data on the pandemic’s effects, but early numbers are concerning. So far, alcohol sales have risen by more than 25%. A recent analysis of 500,000 urine drug tests by Millennium Health, a national laboratory service, also showed worrisome trends: an increase of 32% for nonprescribed fentanyl, 20% for methamphetamine, and 10% for cocaine from mid-March through May. And suspected drug overdoses climbed 18% in the same period, according to a national tracking system run out of the University of Baltimore.

On the ground, providers who treat SUDs note a complex mix of experiences among those needing care.

Sometimes, patients were loath to seek SUD treatment in the early days of the pandemic for fear of contracting COVID-19. Others who sought help had trouble finding it as facilities limited services or even closed. Some patients did well, as lockdowns kept them away from drug-using peers, but many others struggled with isolation.

“At first, some of our patients were resilient and resourceful in staying drug-free,” says Daniel Buccino, clinical manager of the Johns Hopkins Broadway Center for Addiction. “As time went on, it started getting harder for them, and I’ve been seeing drug use going up.”

What’s more, drug use during COVID-19 can be particularly deadly. As the pandemic hobbled illicit drug supply chains, people with SUDs sometimes turned to new dealers or unfamiliar drugs — with unforeseen and dangerous consequences. In addition, more people have been overdosing alone, with no one nearby to help. “We’re seeing more overdose cases going straight to the morgue rather than to the emergency department,” says Buccino.

“At first, some of our patients were resilient and resourceful in staying drug-free. As time went on, it started getting harder for them.”

Daniel Buccino
Clinical manager of the Johns Hopkins Broadway Center for Addiction

Meanwhile, providers across the country are determined to help patients avoid both illicit drugs and the novel coronavirus. This has required piecing together innovative treatment approaches, from creating online support groups to providing easier access to medications like methadone.

“For a while, providing care during COVID felt like flying a plane that’s held together with string and chewing gum,” says Aaron Greenblatt, MD, medical director of the University of Maryland Drug Treatment Center. “Now, we’ve actually managed a major reimagining of how we deliver addiction services,” he says. “I just hope some of the positive developments we’re seeing in treatment will continue once the pandemic is over.”

Fanning the flames of addiction

Before the pandemic, drug use had already burned a path across the country. In 2018, the number of people with an SUD related to illegal drugs or alcohol topped 20 million. Of those, 2 million had an opioid use disorder.

Now, factors that usually fuel substance use are heightened by the pandemic, experts say. For one, research shows that drug use often increases during economic downturns.

Stress is also a common trigger for those at risk of relapse.

“Someone trying to recover from a substance use disorder has a physiological hypersensitivity to stress due to the effects of the substance on their central nervous system,” explains John Kelly, PhD, director of the Recovery Research Institute at Massachusetts General Hospital. “They’re just more easily stressed than other people.

“In addition, chronically exposing the brain to drugs like opioids decreases a person’s ability to experience normal levels of rewards,” he says. “Reduced enjoyment combined with stress and isolation can really take people back over the edge into active problem use.”

Drug use gets riskier

During the pandemic, Gerry Moeller, MD, has seen a 1,000% increase in overdose cases in his emergency department. “We’re now up to over 60 a month,” says Moeller, the division chair for addictions in the department of psychiatry at Virginia Commonwealth University.

One of the key factors fueling overdoses is pandemic-related changes in drug supply chains. “You may have longer gaps between uses, or you may not be aware of a new drug’s potency,” says Charles Reznikoff, MD, an associate professor of medicine at the University of Minnesota Medical School who runs two addiction clinics. “When you’re dealing with a drug that can kill you, change is risky.”

Reznikoff also notes that people increasingly have been overdosing alone, with no one around to call 911 or administer the opioid-overdose antidote naloxone. Drug overdose deaths increased more than 11% in the first four months of 2020 compared to last year, according to government data.

“We’re seeing more overdose cases going straight to the morgue rather than to the emergency department.”

Daniel Buccino
Clinical manager of the Johns Hopkins Broadway Center for Addiction

Experts point to another significant concern: the inability of some patients to access care as addiction centers grappled with such issues as financial woes and social distancing requirements.

At West Virginia University Medicine, for example, the need to stop using double-occupancy rooms dramatically cut inpatient capacity for a while. “We just have 30 beds, and we had to cut that in half,” says James Berry, DO, director of addiction services there.

Treatment amid turmoil

The pandemic has spurred some innovations in addiction treatment, though, and each comes with pluses and minuses.

Teletherapy

In regions hit hard by COVID-19 outbreaks, providers quickly moved to provide nearly all care remotely. The shift would not have been possible, they say, without the loosening of federal telemedicine rules and payment changes from Medicare and Medicaid.

For many patients, the shift online has been a huge help. “Some patients used to have to travel four hours as often as once a week,” says Berry.

Calling in is easier than showing up in person in other ways, as well. “Because of the stigma, patients often worry about being seen entering a treatment facility,” says Carla Marienfeld, MD, medical director of the University of California San Diego Addiction Recovery and Treatment Program. “It can be quite intimidating.”

“People with substance use disorders can be very cautious about new people. … You just don’t get that trust as well from seeing someone in a 3-inch box.”

John Kelly, PhD
Director of the Recovery Research Institute at Massachusetts General Hospital

But remote care has its downsides, too. For one, not all patients have ready access to technology. Berry describes patients who sit in a McDonald’s parking lot to access Wi-Fi for their remote sessions.

New patients in particular may lose out from remote care, says Kelly. “People with substance use disorders can be very cautious about new people because they’re often discriminated against and feel frightened and ashamed,” he explains. “It can be a lot easier to build trust when people are together in person. You just don’t get that trust as well from seeing someone in a 3-inch box.”

Gathering groups from afar

People who have grappled with the lure of drugs say it’s a particular hell that only someone else who has gone through it can truly understand. Group sessions with a therapist or a mutual support organization like Narcotics Anonymous, therefore, are frequently crucial to recovery.

Now, many of these groups can only meet over the internet, and patients often miss the in-person connections.

“It’s not just the meeting itself,” says Quisenberry. “Before and after the meeting, people would hang out and talk about what has happened to them and what got them through it. You can always learn something that way.”

There are also positives to going online, though, including easier access. “People are able to try out groups that might be further from home but that feel like a really good fit for them,” Marienfeld says.

Meanwhile, providers in some locations have begun re-initiating in-person group sessions. Still, those won’t be quite the same, they note, as participants try to connect behind masks and while sitting 6 feet apart.

New ways to manage medications

Combining therapy with medications like methadone, buprenorphine, and naltrexone is a well-supported approach to treating opioid and alcohol addiction. Since the medications used are often controlled substances, though, distributing them requires following strict rules. But the demands of social distancing have led state and federal agencies to ease some of those rules for now.

“I used to get two weeks’ worth [of methadone],” says Frank, a Connecticut musician who prefers to use only his first name. “Now I get a whole month’s worth. I like being trusted instead of being treated like a little kid since I’m older than a lot of my counselors,” he says, noting that he hasn’t used drugs for nearly 15 years.

But providing more medication can be complex at times. “For some patients, it really helps their sobriety. If they don’t have to come into the office frequently, they can move where they want, like closer to family,” says Greenblatt. “But other patients come back and say their medication was stolen, or they lost track of the days and took all of it already. For those patients, we can instead go back to daily dosing."

Further complicating matters is that it’s harder now to conduct the in-person drug screening that’s often central to treatment with medications. “We usually use urine tests, breathalyzers, and other measures to help us understand what a person is taking,” explains Marienfeld. “It’s been an adjustment, and we’re working to be careful in our clinical decisions, but ultimately the enormous benefits of these medications outweigh the potential risks of having fewer drug screens.”

Moving forward

Given all the rapid changes, SUD experts are trying to assess what they’ve seen so far — and prepare for the future.

Research teams are working to gather more in-depth information on the pandemic’s impact. For example, researchers from the University of Florida’s schools of medicine and public health are spearheading a nationwide program, part of which will focus on interviewing such sources as first responders and funeral directors about drug use trends and related deaths. Elsewhere, researchers are looking at such issues as the effects of recent treatment changes and pandemic-related shifts in drug markets.

“The opioid crisis hasn’t just gone away. It’s not solved. It’s been shoved into the background by the 24/7 COVID-19 news cycle."

John Kelly, PhD
Director of the Recovery Research Institute at Massachusetts General Hospital

Meanwhile, providers are working to tackle treatment concerns that have popped up during the pandemic. At Hopkins, Buccino hopes to start lending tablet computers to patients who don’t have another way to access online meetings. And to safely dispense larger quantities of medications, his program has begun lending patients electronic pill dispensers. “They automatically open at a set time each day,” he explains. “They’re also connected to the internet, so we can monitor if someone is tampering with them.”

Other leaders, including those at the AAMC, are working to urge regulators to make some of the current flexibilities, such as those on telehealth, permanent even once the pandemic ends. They are also hoping for additional steps, such as suspending certain waiver requirements for clinicians so they can provide greater access to buprenorphine.

“The opioid crisis hasn’t just gone away. It’s not solved. It’s been shoved into the background by the 24/7 COVID-19 news cycle,” says Kelly. “We need to focus on making it much easier for people to get the help they need and get it as quickly as possible.”

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