“It’s like getting a hug from God. A warm feeling.”
That’s how “Robbie,” my 27-year-old patient, responded when I asked what he enjoyed about heroin. A tall, lean young man wearing a wrinkled white t-shirt, Robbie had soft hazel eyes and an embracing demeanor. Later, when asked how life would be different if heroin were no longer part of it, he said “Drugs drained everything from my life. It does nothing for me. But I just can’t stop.”
Before the Covid-19 pandemic, 130 people were dying each day in the United States from drug overdose. Fueled mostly by opioids such as prescription painkillers then later heroin and fentanyl, deaths related to drug overdose were making nearly daily headlines. Life expectancy had also been declining pre-pandemic, driven mostly by drugs, alcohol and suicide.
Drug-Related Deaths Mounting Nationwide in the Wake of COVID-19
Today, with 1.6 million cases and 96,000 deaths and rising in the U.S. alone, the novel coronavirus understandably has dominated every news storyline. But make no mistake, drugs and drug users have not magically disappeared. In fact, a recent study by Well Being Trust and the American Association of Family Physicians estimates an additional 75,000 lives lost due to substance use and suicide, compounded by isolation and uncertainty. A few concerning examples across the U.S.: a 20% increase in overdose calls in Jacksonville, Florida; a spike in drug-related deaths in Cayuga County, New York; and 13 overdose deaths in five days in Hamilton County, Ohio.
“A lot of factors place individuals at increased risk for overdose during the COVID-19 pandemic,” explained Timothy Wiegand, MD, FACMT, associate professor of emergency medicine, University of Rochester Medical Center. “Stress, isolation and depression can drive individuals to substances, relapse or combine substances like adding alcohol or sedatives to opioids.”
Addiction and Mental Illness are Chronic Illnesses of the Brain
According to the American Society of Addiction Medicine (ASAM), addiction is a treatable, chronic, relapsing and remitting disease of the brain that causes compulsive drug seeking and use despite harm to the person using or to those around him or her. It is NOT a sign of moral weakness or failure. My patient, Robbie, initially used drugs to relieve stress. But when his use increased and impaired his daily living (“I lost control of everything”), he couldn’t stop even though he wanted to. He developed a substance use disorder (SUD, a.k.a. addiction). Robbie also experienced anxiety and job insecurity.
“I recently cared for a hospitalized patient with advanced heart disease who was at high-risk for overdose, had no phone, and lived alone in a tent,” shared Honora Englander, MD, FACP, associate professor of medicine at Oregon Health and Science University. “This pandemic adds layers upon layers of vulnerabilities, and onto our health systems and communities.”
People Are Suffering
Environmental stressors including trauma are known risk factors for SUD and relapse. And right now, there’s no shortage of things to be stressed about. According to the Bureau of Labor Statistics, the national unemployment rate skyrocketed from 3.5% in February to 14.7% in April, the worst since the Great Depression. Without a paycheck, people can’t pay rent, utilities, buy food, clothing and other essential needs. Record-breaking job loss has been matched by record-breaking anxiety. What’s more traumatizing than a crushing blow to every aspect of life? Now consider a person already teetering on the brink of medical and psychological instability? It’s like balancing a crystal vase on a high-wire.
“Alcohol sales and consumption substantially increased in most areas during the pandemic,” noted Dr. Wiegand. “I anticipate we will find increased alcohol associated with fatal opioid overdoses, as well as an increase in detoxification admissions, DWIs and other alcohol-related complications.”
To make matters worse, public health-driven stay-at-home orders have disrupted the most essential of human needs – connection. People can’t see their loved ones, attend group therapy or receive face-to-face support services. Because this pandemic is unlikely to relinquish anytime soon, we will continue to exist in an atmosphere of chronic stress – in addition to our baseline worries (marriage, mortgage, medical bills, etc.) The despair is palpable. Without proper provisions in place, people will self-medicate their pain and suffering. They always have, they always will.
Some Positive Signs
Regulatory changes related to dispensing methadone and prescribing buprenorphine have significantly reduced barriers for people with opioid use disorders, according to Sarah Bagley, MD, MSc, assistant professor of medicine and pediatrics at Boston Medical Center (BMC).
“What I’ve witnessed locally is incredible dedication, persistence and creativity from harm reduction and outreach workers who provide overdose education, naloxone and syringe access despite incredibly difficult circumstances,” described Dr. Bagley, medical director of the CATALYST Clinic, which helps teens and young adults who are experiencing addiction.
BMC’s Office Based Addiction Treatment (OBAT) Program transitioned to telemedicine: they created a hotline, provided patients with phones (pre-programmed with clinicians’ numbers) and proactively contacted individuals who may require OBAT’s services (e.g. people released from jails and prisons, and/or using syringe exchange programs).
We Need to do More
The clash of two colossal, emergent crises will need sizeable and sustainable attention. To start:
1. Increased Investment in SUD Care – This includes widespread education to decrease stigma; a massive increase in the addiction workforce; and data-driven treatment and recovery services for SUD and mental illness. Per Dr. Englander: “As policymakers make decisions about what services to cut in these dire economic times, I hope they increase investments in evidence-based addiction care.”
2. Harm Reduction Strategies – We need to double-down on access to clean syringes, naloxone, condoms, HIV and hepatitis prevention; behavioral health counseling; food, clothing, health and legal services.
3. Chronic pain management – During the opioid crisis, the pendulum swung too far the other way, leading to increased suffering for chronic pain patients including veterans; during this pandemic, we need to use evidence and empathy to ensure safe and effective treatment of pain
4. Telemedicine – Insurers including state Medicaid programs need to reimburse clinicians for telehealth and telephonic services the same way they did for in-person visits
5. Special Populations – Both epidemics highlighted the disproportionate impact on specific populations (Black, Hispanic and Native Americans; pregnant women; incarcerated and homeless individuals; adolescents, etc.) We need targeted, culturally-sensitive outreach to each of these communities.
A common motto in the addiction field is, ‘The opposite of addiction isn’t sobriety, it’s connection.’ During this unprecedented time of isolation, uncertainty, anxiety and despair, we MUST find creative and effective ways of forging connections with one another, particularly with our most vulnerable fellow brothers and sisters – many of whom already felt segregated and distrustful of authority. COVID-19 has augmented the urgency of delivering much-needed services to the people who need it most. This is feasible: we’ve already seen this country implement supposedly unthinkable adaptations to life as we knew it to flatten the curve…in the span of a few weeks. As my father loves to say, ‘When there’s a will, there’s a way.’ We must have the collective will to resolve these dueling epidemics so that Robbie’s next hug can come from a human rather than heroin.