Over the last decade, the United States has experienced what has been termed an opioid epidemic. Currently, an estimated 130 Americans die each day from opioid overdose (CDC, 2020). Now, the COVID-19 pandemic threatens to disrupt the medical community’s treatment of opioid use disorders (OUD). Below is a summary of observed and potential effects of the COVID-19 pandemic on people with OUD.

As SARS-CoV-2, the virus that causes COVID-19, spreads across the country, opioid overdoses appear to be surging. U.S. government officials reported a spike in overdose deaths, with deaths increasing over 11 percent year-over-year for the first four months of 2020 (Weiner, 2020). What about the pandemic could be encouraging this trend?

One physiological explanation for this observation is that respiratory disease increases the mortality rate associated with opioid overdose (Leece, 2015). Opioid overdoses occur when the drug acts on brainstem respiratory centers to slow breathing to dangerous levels. Chronic lung disease impairs breathing, increasing the likelihood that an overdose becomes fatal. Moreover, people with OUD are more likely than the general population to smoke tobacco which increases the risk of developing chronic obstructive pulmonary disease (Rajabi, 2019). Diminished lung capacity caused by SARS-CoV-2 infection of the lungs could put someone struggling with OUD at an even greater risk of respiratory failure during an overdose (NIDA, 2020). Thus, the combined physiological effects of opioid use and SARS-CoV-2 infection may partially explain the rise in overdose deaths associated with the pandemic.

Social effects of the pandemic could also be at play. One possibility is that some of these deaths may be attributed to patients in recovery experiencing a relapse. People with OUD show disproportionately high rates of trauma and mental health problems, both of which can be exacerbated by social isolation (Williams, 2020). Support groups and peer recovery programs are often critical for addiction treatment, but transitioning these programs to an online format may not be as effective as in-person contact. Anecdotally, initial reports show that telehealth support groups have received mixed appraisal, with a few patients remaining engaged and others losing motivation to attend (Cenziper, 2020). The loss of in-person addiction treatment may leave some patients feeling a lack of accountability in addition to experiencing isolation-related stress. These individuals may be more likely to relapse. People with a long period of sobriety prior to relapse may also face a lowered tolerance to opioids, meaning amounts of the drug they could previously withstand now result in an overdose.

Overcrowded emergency rooms could be another factor in rising overdose deaths. Overcrowding may discourage opioid users from seeking emergency care due to fear of becoming infected with SARS-CoV-2 (McCann, 2020). Moreover, fear of spreading the virus to others may increase solitary opioid use, leaving users more vulnerable to death from overdose (Jenkins, 2020). Finally, shelter-in-place orders may be discouraging heavy opioid users from seeking life-saving measures such as fentanyl test kits and naloxone. Without access to these tools, people with OUD face increased risk of death every time they use opioids.

It is also important to note that the pandemic has had a disproportionately negative effect on people with OUD when compared with the general public. First, rural and low-income populations are particularly affected by the opioid epidemic. These areas are also generally less prepared for the COVID-19 pandemic (CDC, 2020). Although rural areas may have more space per capita which could help slow virus transmission, healthcare barriers are high due to low socio-economic status, lack of access to education, and underfunded healthcare systems (Kaufman, 2020). Therefore, people living in these areas have fewer resources to mitigate the effects of the pandemic. In urban settings, people with OUD may be unemployed and consequently unable to afford adequate housing; this could result in difficulty adhering to stay-at-home orders and increased risk of exposure to the virus. Finally, people with OUD may lack reliable internet access—a disadvantage that impedes one’s ability to obtain reliable information about public health recommendations and local restrictions. Turning to informal sources for medical information could result in harmful consequences.

In response to rising opioid overdose deaths, the federal government has taken steps to increase the availability of medications like methadone and buprenorphine, which help manage opioid withdrawal and craving and are usually administered daily. The U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) released updated guidelines stating that any state may request that OUD patients in an opioid maintenance treatment program be allowed a 28-day take-home supply of methadone (SAMHSA, 2020). Previously, patients only had access to this medication through in-person daily dosing. Additionally, buprenorphine has been made available for prescription through telehealth services rather than in-person visits to a doctor (DEA, 2020). Increasing the availability of these medications was a critical decision by the federal government because social distancing protocols would have made it impossible for some people with OUD to receive medication-assisted treatment.

In conclusion, the U.S. faces two intersecting public health crises: the opioid epidemic and the COVID-19 pandemic. Data so far suggest that the COVID-19 pandemic has exacerbated the already devastating opioid epidemic, leading to a spike in overdose deaths. Several factors could be driving this trend, increasing the complexity of devising solutions to this crisis. This is a critical time to conduct addiction research so that the scientific community can better understand how to protect the health of people suffering from OUD during this pandemic.  

Authors: Cory Kittleman and Emma Erickson

Edited by Drs. Robert O. Messing and Emma Erickson, and Niki Garcia-Holmes

Photo by Michael Longmire on Unsplash

References

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