by Ryan Hampton
If we look up from what’s right in front of us — a global pandemic — we’ll remember that we’ve been battling a public health crisis for more than a decade. The opioid epidemic alone has stolen more than 450,000 lives from us since 1999, but the total number of deaths related to substance use is around 1.75 million for that same period. Before this virus swept through the U.S., we were starting to see real change in the opioid crisis — both in the health systems and the decline of drug overdose deaths. Overdose death rates decreased by 4.1% from 2017 to 2018 in the U.S. This is not to deemphasize the pandemic’s impact on our country or the critical response needed, but to remind America that the opioid epidemic did not go away when COVID-19 reared its head. We can’t forget about people living with addiction.
Now we’re simultaneously facing two crises, putting patients with opioid use disorder (OUD) at a significantly higher risk for overdose, death and relapse. When there is so much uncertainty for those with addiction about how to continue receiving care during this time, it’s essential that addiction treatment programs continue to receive federal and state support so that we don’t lose our foothold on combating the opioid crisis.
We can’t forget about people living with addiction.
Nationally we’re seeing increased unemployment and poverty, mandatory changes to daily routines, and increased anxiety and stress which are only magnified for people managing addiction. These added stressors can disrupt a person’s recovery journey by overwhelming their coping mechanisms. Addiction is a disease of isolation, so the necessary physical distancing protocols that yank people out of their routines and their communities and trap them alone with anxiety (and even boredom) is dangerous to recovery.
Not only that, but the pandemic is shifting how people can receive treatment. Many support groups and counseling sessions are being provided virtually. But how about people who use medication-assisted treatment? A significant portion of people in treatment pay out of pocket for their care. With a rising number of Americans losing their jobs due to the pandemic, including people in recovery, their ability to afford life-saving care is in danger.
The addiction treatment organizations are struggling too. They are spending more money to put protocols in place in response to COVID-19 while dealing with employee absences and patients forgoing treatment. Yes, federal and state regulators have loosened requirements for care at outpatient opioid treatment programs (OTPs), which is important. But if the OTPs don’t have the funding needed to continue operating in this new environment, these regulation modifications are irrelevant. Without ongoing treatment, those in addiction recovery are at risk of relapse and overdose.
Before COVID-19 hit, our nation was at a turning point in the fight against the opioid epidemic. The coronavirus pandemic not only threatens thousands of lives, it threatens to completely derail the progress we’ve made in digging this country out of one of the worst human-made epidemics in history. If people living with addiction can’t get the care they need, they too will die.
In a time when a pandemic is causing so much uncertainty, people living with OUD need stability. Addiction advocacy groups and others in the industry have issued a formal request to the federal government asking for $38.5 billion in emergency supplemental funding for direct payments to behavioral health organizations, which will help ensure they remain open and operating during the COVID-19 crisis. While this sounds like a lot, let me put this request into perspective: the Centers for Disease Control and Prevention estimates that the total “economic burden” of opioid misuse alone in the U.S. is $78.5 billion a year. We only need a small fraction of that cost to save lives.
If people living with addiction can’t get the care they need, they too will die.
The bottom line is this: we need to make sure organizations that help people in recovery — opioid treatment programs, community behavioral health centers, peer support organizations, and others — get the resources they need to continue providing addiction and mental health care.
Ryan Hampton is the organizing director at the Recovery Advocacy Project, author of “American Fix: Inside the Opioid Addiction Crisis — and How to End It” and national addiction recovery activist.
COVID-19: Potential Implications for Individuals with Substance Use Disorders
by Dr. Nora Volkow, National Institute on Drug Abuse (NIH)
As people across the U.S. and the rest of the world contend with coronavirus disease 2019 (COVID-19), the research community should be alert to the possibility that it could hit some populations with substance use disorders (SUDs) particularly hard. Because it attacks the lungs, the coronavirus that causes COVID-19 could be an especially serious threat to those who smoke tobacco or marijuana or who vape. People with opioid use disorder (OUD) and methamphetamine use disorder may also be vulnerable due to those drugs’ effects on respiratory and pulmonary health. Additionally, individuals with a substance use disorder are more likely to experience homelessness or incarceration than those in the general population, and these circumstances pose unique challenges regarding transmission of the virus that causes COVID-19. All these possibilities should be a focus of active surveillance as we work to understand this emerging health threat.
SARS-CoV-2, the virus that causes COVID-19 is believed to have jumped species from other mammals (likely bats) to first infect humans in Wuhan, capital of China’s Hubei province, in late 2019. It attacks the respiratory tract and appears to have a higher fatality rate than seasonal influenza. The exact fatality rate is still unknown, since it depends on the number of undiagnosed and asymptomatic cases, and further analyses are needed to determine those figures. Thus far, deaths and serious illness from COVID-19 seem concentrated among those who are older and who have underlying health issues, such as diabetes, cancer, and respiratory conditions. It is therefore reasonable to be concerned that compromised lung function or lung disease related to smoking history, such as chronic obstructive pulmonary disease (COPD), could put people at risk for serious complications of COVID-19.
Co-occurring conditions including COPD, cardiovascular disease, and other respiratory diseases have been found to worsen prognosis in patients with other coronaviruses that affect the respiratory system, such as those that cause SARS and MERS. According to a case series published in JAMA based on data from the Chinese Center for Disease Control and Prevention (China CDC), the case fatality rate (CFR) for COVID-19 was 6.3 percent for those with chronic respiratory disease, compared to a CFR of 2.3 percent overall. In China, 52.9 percent of men smoke, in contrast to just 2.4 percent of women; further analysis of the emerging COVID-19 data from China could help determine if this disparity is contributing to the higher mortality observed in men compared to women, as reported by China CDC. While data thus far are preliminary, they do highlight the need for further research to clarify the role of underlying illness and other factors in susceptibility to COVID-19 and its clinical course.
Vaping, like smoking, may also harm lung health. Whether it can lead to COPD is still unknown, but emerging evidence suggests that exposure to aerosols from e-cigarettes harms the cells of the lung and diminishes the ability to respond to infection. In one NIH-supported study, for instance, influenza virus-infected mice exposed to these aerosols had enhanced tissue damage and inflammation.
People who use opioids at high doses medically or who have OUD face separate challenges to their respiratory health. Since opioids act in the brainstem to slow breathing, their use not only puts the user at risk of life-threatening or fatal overdose, it may also cause a harmful decrease in oxygen in the blood (hypoxemia). Lack of oxygen can be especially damaging to the brain; while brain cells can withstand short periods of low oxygen, they can suffer damage when this state persists. Chronic respiratory disease is already known to increase overdose mortality risk among people taking opioids, and thus diminished lung capacity from COVID-19 could similarly endanger this population.
A history of methamphetamine use may also put people at risk. Methamphetamine constricts the blood vessels, which is one of the properties that contributes to pulmonary damage and pulmonary hypertension in people who use it. Clinicians should be prepared to monitor the possible adverse effects of methamphetamine use, the prevalence of which is increasing in our country, when treating those with COVID-19.
Other risks for people with substance use disorders include decreased access to health care, housing insecurity, and greater likelihood for incarceration. Limited access to health care places people with addiction at greater risk for many illnesses, but if hospitals and clinics are pushed to their capacity, it could be that people with addiction—who are already stigmatized and underserved by the healthcare system—will experience even greater barriers to treatment for COVID-19. Homelessness or incarceration can expose people to environments where they are in close contact with others who might also be at higher risk for infections. The prospect of self-quarantine and other public health measures may also disrupt access to syringe services, medications, and other support needed by people with OUD.
We know very little right now about COVID-19 and even less about its intersection with substance use disorders. But we can make educated guesses based on past experience that people with compromised health due to smoking or vaping and people with opioid, methamphetamine, cannabis, and other substance use disorders could find themselves at increased risk of COVID-19 and its more serious complications—for multiple physiological and social/environmental reasons. The research community should thus be alert to associations between COVID-19 case severity/mortality and substance use, smoking or vaping history, and smoking- or vaping-related lung disease. We must also ensure that patients with substance use disorders are not discriminated against if a rise in COVID-19 cases places added burden on our healthcare system.
As we strive to confront the major health challenges of opioid and other drug overdoses—and now the rising infections with COVID-19—NIDA encourages researchers to request supplements that will allow them to obtain data on the risks for COVID-19 in individuals experiencing substance use disorders.
