COVID-19’s Detrimental Effects on the Opioid Epidemic
By: Amy Rzezniczek
The COVID-19 pandemic has impacted the lives of millions of people across the globe. The words “lockdown, quarantine and social distancing” were most likely not a part of your vocabulary in 2019, but now these words seem to appear in every conversation and dictate the ways in which we live our daily lives. While promoting safety amongst communities to prevent transmission of the virus is critical, it appears as though matters regarding mental health and addiction have been placed on the back burner. For example, the opioid epidemic – a crisis that was paid much attention to in previous years – has been seemingly pushed aside in order to have all focus placed on ending the COVID-19 pandemic.
Since the beginning of the pandemic in Canada, there has been a staggering increase in both non-fatal and fatal opioid overdoses. There was a 25% increase in opioid-related fatalities in the early months of 2020, followed by a doubling in drug-related overdoses between June and December of 2020.1 In the months following initial community mitigation measures, Canada lost 3,351 individuals to opioid-related overdoses, which was a 74% increase from the number of opioid-related deaths six months prior. 96% of these overdoses were deemed accidental.2
Opioids are chemicals that bind to receptors in the brain and are associated with the reward and pain pathways. This class of drugs are typically prescribed by healthcare professionals to relieve pain (oxycodone, buprenorphine, morphine, codeine, methadone and fentanyl) or can be obtained illegally (heroin and fentanyl).3 They can provide a sense of pleasure and euphoria, but improper and/or long-term use can lead to Opioid Use Disorder (OUD).3 Further, OUD is characterized by problematic patterns of opioid use which causes severe impairment in various aspects of life and distress.4
News reports have falsely attributed the rise of overdoses to the COVID-19 relief fund distributed by the government and allege that the extra money has increased the consumption of alcohol and drugs throughout North America.5 In reality, thousands of North Americans continue to struggle with OUD and the pandemic has most definitely had a worsening effect on the condition of the opioid crisis. Research suggests that intersecting risks of both the pandemic and the opioid epidemic heighten the likelihood for individuals with OUD to increase drug use and amplify the risk of overdosing.6 This blog post aims to address each of the intersecting factors in order to shed light on the reasoning behind this drastic increase in overdoses over the past 15 months.
Pandemic Social Isolation and Opioid Overdose
A feeling that can be associated with the burden of the pandemic is the sense of loneliness due to social isolation. As part of the attempt to mitigate the spread of COVID-19, Canada has implemented lockdown orders and social distancing measures. These procedures limit the amount of family and friends one can come into physical contact with, and have moved daily tasks such as work and school online. While these measures are incredibly important, they are contributing to the rise in opioid related overdoses in the following ways:
- Individuals who have OUDs have extremely high rates of experiencing psychological trauma and other mental health issues.7 Lockdowns and social distancing policies may increase the likelihood of death due to overdose as social isolation can negatively impact mental health. Also, when individuals have more than one mental illness, they have a higher risk for opioid overdose.8
- It is also known that loneliness and social isolation are some of the leading factors that lead to relapse and using drugs can be used as a coping mechanism for individuals who struggle with OUD.9 Thus, the consequences of these protective measures (including economic hardship and isolation) paired with the anxiety around contracting the virus can worsen symptoms of OUD.10
- The lack of individuals walking freely around towns and cities due to the “stay-at-home” order can also impact the degree to which individuals experiencing an overdose can receive help. Social distancing prevents bystanders from delivering life-saving naloxone treatment – a medication that can temporarily reverse the effects of an opioid overdose – therefore heightening the risk of overdosing alone.8
- Due to the fact that individuals are required to stay at home, the risk of overdosing alone increases significantly.8
Safety Measures Acting as a Barrier to Accessing Treatment
As a result of the “stay-at-home” orders, access to medications used to treat OUD, opioid overdoses and mental health conditions have been limited as a result of office closures and remote treatment options.7 In response to the physical distancing and lockdown restrictions, methadone and buprenorphine treatment (common medication based treatments for OUD) have both been restructured in order to allow for at home administration which are directed by a medical professional over the phone.11 In addition, the rules governing the distribution of these OUD treatment medications have become less rigid to allow for easier access to these medications as well as to make these medications available to be taken outside of a clinic.11 While these modifications seem promising, many individuals with OUD do not have access to cellular phones or computers, which may impact the number of patients able to use these telemedicine services.
Access to residential treatment programs has become more difficult due to the pandemic as well. As a result of government orders, treatment programs in which individuals live for a period of 4-16 weeks are running at limited capacity. These programs have inadequate quantities of personal protective equipment (PPE), limited space for social distancing measures, a limited number of employees to execute the community mitigation methods, and are at high risk of transmission of the virus due to frequent turnover as well as patients sharing a living space.12
In a study by Pagano and colleagues (2021), it was shown that there has been an overall threat to program existence due to inadequate resources to apply virus transmission control measures and a decrease in services available. Both of these issues are results of a decline in revenue. Additionally, individuals with OUD have restricted access to receiving residential treatment as these programs now offer shorter stays and fewer services in addition to longer wait lists and delayed treatment initiation. Further, individuals can be faced with difficulties when transitioning out of treatment (i.e lack of or loss of work) as well as inabilities to interact with local recovery communities such as Narcotics Anonymous (NA).13
Harm reduction services including safe syringe exchange programs and supervised injection sites have been especially impacted by the COVID-19 pandemic. Harm reduction strategies focus on mitigating the negative effects of drug use as opposed to eradicating drug use completely.14 In safe syringe programs, individuals can safely dispose of their used syringes and receive new ones in order to reduce the transmission of HIV.15 Supervised injection sites allow individuals to inject drugs in a safe environment while being supervised by medical professionals in case of the occurrence of an overdose.16 Due to government orders requiring places to run at limited capacity, as well as social distancing measures and provincial lockdowns, these harm reduction programs have become increasingly difficult to access.
Although many of the treatment options available for OUD such as therapy and telemedicine guidance in drug therapy programs have been able to move online in light of the pandemic, it is impossible for most harm reduction services to be used remotely and many of these programs have been forced to close or limit capacity.17 Harm reduction strategies actively prevent overdoses, transmission of substance-use related illnesses and provide other services such as therapy. The restricted access to these services poses a threat to the lives of individuals struggling with an OUD, increasing the risk of overdoses and overdosing alone.
Subjugated Groups Are Particularly at Risk
Members of minority groups – specifically Black Americans – are experiencing higher rates of overdoses than non-subjugated groups.18 Preceding the COVID-19 pandemic, Black Americans battled structural obstacles that restricted their access to substance use disorder treatment. These barriers include lack of insurance, access to transportation and healthcare provider prejudice.19 These obstacles have been furthered by the pandemic and Black Americans face excessive health and financial hardships due to COVID-19 including lack of access to medication to treat OUD.18 The pandemic has worsened preceding stressors, social isolation, and economic disparity disproportionately for Black individuals, and this has most likely increased substance use among this population.20
In a study by Nguemeni Tiako (2020), it is revealed that the social circumstances that have resulted from the pandemic are contributing to the detrimental impact of the opioid epidemic with a rise in overdose deaths among Black individuals. Prior to the pandemic, Black patients were half as likely to be offered follow-up appointments for OUD care following a non-fatal overdose. In the current climate of the pandemic, it appears as though white individuals are receiving more mental health and substance use disorder treatments via telehealth than Black individuals.19 Systemic racism, institutional racism and discrimination impact health outcomes through access to healthcare, level of education, income and living conditions. These circumstances affect mental health and are exacerbated by the lack of mental health and substance use disorder treatments available in non-white communities.21 Banks et al., (2021) suggests that the pandemic has intensified racial inequities in opioid-related fatal overdoses impacting Black individuals and that funding and policy efforts “should prioritize local strategies that build community trust, such as grassroots organizations engaged in outreach, advocacy, and harm reduction services” (p. 686).
Where Can We Go From Here?
Overall, opioid-related overdose rates have skyrocketed since the pandemic turned our world upside down, and researchers have been working hard to discover the reasoning behind this striking increase as well as how to stop the rates continuing to rise. Thus far, it has been proposed that the following aspects are contributing to the jump in opioid overdoses:
- Being stuck in the house during lockdowns and forced to maintain six feet apart from other human beings has increased feelings of loneliness and isolation – factors that worsen mental health and OUD symptoms.
- Access to medication-based therapies for OUD have been restructured to be delivered through an online/telephone setting; however, not all individuals may be able to access these services.
- Residential treatment centers have been attempting to provide services while abiding by COVID-19 preventative measures, but individuals with OUD are experiencing longer wait times, shorter stays and difficulties transitioning back into society after treatment due to the uncertainties resulting from the pandemic.
- Black individuals with opioid-use disorder are overdosing more frequently than non-minority groups due to lack of access to services and mental health issues as well as discrimination exacerbated by the pandemic.
It is imperative for the government to work with Drug Advisory Commissions in determining ways in which treatment and harm reduction services can be delivered in such a way that aligns with community mitigation measures. Similar to the ways in which the government is rolling out vaccines through opening more pop-up clinics, perhaps additional safe injection sites and syringe exchange programs can be temporarily opened up to lessen the risk of overdosing alone. Another possible solution is to open public spaces and provide free computer use for individuals to attend Narcotics Anonymous meetings while maintaining social distancing. Lastly, the government can provide funding to residential treatment programs to prevent these important institutions from permanently shutting down.
COVID-19 precautions remain important as we continue our battle against this virus, but the opioid crisis continues to pose an unrelenting public health threat that will only worsen if it continues to be left on the back burner.
References
1Blancher, P. (2021, Feb 10). Opioid overdose numbers rise during pandemic. The Canadian Press. http://ezproxy.lib.ryerson.ca/login?url=https://www-proquest-com.ezproxy.lib.ryerson.ca/wire-feeds/opioid-overdose-numbers-rise-during-pandemic/docview/2488773297/se-2?accountid=13631
2Special Advisory Committee on the Epidemic of Opioid Overdoses. Opioids and Stimulant-related Harms in Canada. Ottawa: Public Health Agency of Canada; March 2021. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants
3CAMH. (n.d). Opioid Addiction. CAMH. https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/opioid-addiction
4Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.
5Tasker, J.P. (2020, Oct 28). Opioid deaths skyrocket, mental health suffers due to pandemic restrictions, new federal report says. CBC. https://www.cbc.ca/news/public health-annual report-opioid-deaths-skyrocket-1.5780129
6Becker, S. J., Garner, B. R., & Hartzler, B. J. (2021). Is necessity also the mother of implementation? COVID-19 and the implementation of evidence-based treatments for opioid use disorders. Journal of Substance Abuse Treatment, 122. https://doi.org/10.1016/j.jsat.2020.108210
7Henry, B. F., Mandavia, A. D., Paschen-Wolff, M., Hunt, T., Humensky, J. L., Wu, E., Pincus, H. A., Nunes, E. V., Levin, F. R., & El-Bassel, N. (2020). COVID-19, mental health, and opioid use disorder: Old and new public health crises intertwine. Psychological Trauma: Theory, Research, Practice, and Policy, 12, S111-S112.
8Walker, D. D., Jaffe, A. E., Pierce, A. R., Walton, T. O., & Kaysen, D. L. (2020). Discussing substance use with clients during the COVID-19 pandemic: A motivational interviewing approach. Psychological Trauma: Theory, Research, Practice, and Policy, 12, S115-S117. http://dx.doi.org.ezproxy.lib.ryerson.ca/10.1037/tra0000764
9Myers, J., & Compton, P. (2018). Addressing the potential for perioperative relapse in those recovering from opioid use disorder. Pain Medicine, 19(10), 1908-1915. http://dx.doi.org.ezproxy.lib.ryerson.ca/10.1093/pm/pnx277
10Jones, C. M., Guy, G. P., & Board, A. (2021). Comparing actual and forecasted numbers of unique patients dispensed select medications for opioid use disorder, opioid overdose reversal, and mental health, during the COVID-19 pandemic, United States, January 2019 to May 2020. Drug and Alcohol Dependence, 219. https://doi.org/10.1016/j.drugalcdep.2020.108486
11Nunes, E. V., Levin, F, R., Reilly, M. P., & El-Bassel, N. (2021). Medication treatment for opioid use disorder in the age of COVID-19: Can new regulations modify the opioid cascade? Journal of Substance Abuse Treatment, 122,108196-108196
12Pagano, A., Hosakote, S., Kapiteni, K., Straus, E. R., Wong, J., & Guydish, J. R. (2021). Impacts of COVID-19 on residential treatment programs for substance use disorder. Journal of Substance Abuse Treatment, 123, 108255-108255. https://doi.org/10.1016/j.jsat.2020.108255
13Herrera, A. (2021). A delicate compromise: Striking a balance between public safety measures and the psychosocial needs of staff and clients in residential substance use disorder treatment amid COVID-19. Journal of Substance Abuse Treatment, 122, 108208-108208. https://doi.org/10.1016/j.jsat.2020.108208
14Schlosser, A., & Harris, S. (2020). Care during COVID-19: Drug use, harm reduction, and intimacy during a global pandemic. The International Journal of Drug Policy, 83, 102896-102896. https://doi.org/10.1016/j.drugpo.2020.102896
15Centers of Disease Control and Prevention. (n.d). Syringe Services Programs. CDC.gov. https://www.cdc.gov/ssp/index.html
16City of Toronto. (2019). Supervised Consumption Sites. City of Toronto. https://www.toronto.ca/community-people/health-wellness-care/health-programs-advice/supervised-injection-services/
17Roxburgh, A., Jauncey, M., Day, C., Bartlett, M., Cogger, S., Dietze, P., Nielsen, S., Latimer, J., & Clark, N. (2021). Adapting harm reduction services during COVID-19: lessons from the supervised injecting facilities in Australia. Harm Reduction Journal, 18. https://doi.org/10.1186/s12954-021-00471-x
18Banks, D. E., Carpenter, R. W., Wood, C. A., & Winograd, R. P. (2021) Commentary on Furr‐Holden et al.: As opioid overdose deaths accelerate among Black Americans, COVID‐19 widens inequities—a critical need to invest in community‐based approaches. Addiction, 116, 686– 687. https://doi-org.ezproxy.lib.ryerson.ca/10.1111/add.15362.
19Nguemeni Tiako, M. J. (2021). Addressing racial & socioeconomic disparities in access to medications for opioid use disorder amid COVID-19. Journal of Substance Abuse Treatment, 122. https://doi.org/10.1016/j.jsat.2020.108214
20Khatri, U. G., Pizzicato, L. N. Viner, K., Bobyock, E., Sun, M., Meisel, Z. F., & South, E. C. (2021). Racial/Ethnic Disparities in unintentional fatal and nonfatal emergency medical services–attended opioid overdoses during the COVID-19 pandemic in Philadelphia. JAMA Network Open, 4(1), e2034878. https://doi.org/10.1001/jamanetworkopen.2020.34878.
21Czeisler, M. É., Howard, M. E., & Rajaratnam, S. M. W. (2021). Mental Health During the COVID-19 Pandemic: Challenges, Populations at Risk, Implications, and Opportunities. American Journal of Health Promotion, 35(2), 301–311. https://doi.org/10.1177/0890117120983982b
Photograph References
Immigration Canada. (2020). COVID-19 Isolation [photograph]. Immigration.ca. https://www.immigration.ca/covid-19-anyone-entering-canada-must-have-plan-for-14-day-isolation
Psychiatry Advisor. (2021). Expert Perspective: The Opioid Crisis and COVID-19 [photograph]. Psychiatry Advisor.https://www.psychiatryadvisor.com/home/topics/addiction/opioid-related-disorder/expert-perspective-the-opioid-crisis-and-covid-19/
The Wall Street Journal. (2020). Individual receiving opioid-use disorder medication treatment [photograph]. The Wall Street Journal. https://www.wsj.com/articles/coronaviruspandemic-complicates-opioidtreatment-11586262903