Impact of COVID-19 Pandemic on the Opioid Crisis

Ellen Su, Princeton University

Introduction

The impact of the opioid epidemic continues to impact the global society and patients at an unprecedented rate.  Patients, families, policymakers, and healthcare professionals continue to grapple with the twin crisis emerging from COVID-19 and the opioid crisis and the potential lasting impact that will surface. The opioid epidemic in the United States and often times many prescriptions for opioids following hospitalizations can lead to long-term opioid use, which raises concerns during this current pandemic and the rise in hospitalizations and urgent intensive care unit admission. Reducing exposure to opioids in these settings and the postoperative setting is critical to curbing the opioid epidemic in the United States.           

Since the coronavirus was discovered in Wuhan, China, in December of 2019, the world has not been the same, which is evident in the data.  COVID-19 has managed to extend its reach to all the corners of the earth and alter all avenues of normalcy in health and business. As the pandemic has taken hold of the world, other collateral health risks, unfortunately, are also surfacing. In the state of Wisconsin, opioid overdoses have more than doubled in the past few months. From March of 2020 to July 13, 2020, there have been 325 opioid overdoses as opposed to the 150 from the same period in 2019 [1]. Experts believe that this is a result of various factors, including the correlation that added stress, isolation, and financial pressures have on substance abuse [1]. The COVID-19 situation in Wisconsin is not light— since the start of the pandemic, there have been 49,427 confirmed cases of the virus and a resulting 893 deaths [3]. According to Paul Krupski, the director of Opioid Initiatives at the Department of Health Services, the pandemic set in just as the state was making strides in reducing deaths from an overdose [2]. The state's health line is also seeing an increase in requests for information on behavioral health, which creates concern for a further rise in drug use [3]. As the nation and the world continue to combat the coronavirus and its effects, it is crucial not to neglect other health concerns such as the opioid crisis to maximize health and safety during these uncertain times.  

The Long Haul

The opioid crisis has been an increasingly severe problem in the last few years. In an interview of Dr. Nora Volkow, the director of National Institute on Drug Abuse, by the National Health Institute, Dr. Volkow said that research, work done to only prescribe opioids to patients who genuinely need it for pain management, the distribution of Naloxone, the opioid overdose reversal drug, and better access to the medication has led to a decrease in overdoses from 2017 to 2018 [5]. However, the overdose occurrences soon grew again from 2018 to 2019, hitting 70,000 deaths due to the growing popularity of fentanyl, a synthetic opioid, and psychostimulant drugs such as cocaine and methamphetamine [5]. Although measures are being taken to combat this problem actively, only 26% of the 2 million Americans with Opioid Use Disorder (OUD) were able to receive treatment in 2018 [6]. 

Over 115 Americans die of opioid misuse daily, even as effective treatment options exist [9][5]. According to the New England Journal of Medicine, more than 11 million people misused prescription opioids in 2016 [9]. Misuse is characterized by taking medicine in a way other than prescribed, taking others' prescription medicine, or taking the medication to get high [10]. Opioids operate by binding to opioid receptors, blocking pain signals from the brain to the body, and releasing large amounts of dopamine into the user [10]. Originally meant as a pain management drug, an epidemic has grown due to its high addictiveness and ability to create the desired high feeling in the user. Misuse of the medication can slow breathing and lead to hypoxia, a state where the brain does not receive adequate oxygen. The user can experience psychological and neurological effects, fall into a coma, suffer permanent brain damage, or die [10]. Also, users that choose to inject their drugs risk contracting HIV or other infectious diseases from unsterilized needles [10]. 

The Root Issue

Ironically, the opioid epidemic's root lies within the medical sector, which is meant to save and improve the quality of human lives. In a study conducted over the last two decades, surgery and chronic opioid use have been strongly linked [4]. Constant opioid use in surgical patients is defined as filling ten or more prescriptions— or more than 120 days' supply— of opioids in the first year after surgery, excluding the early 90 postoperative days [4]. In this study, 11 standard surgical procedures were considered: total knee arthroplasty (TKA), total hip arthroplasty (THA), laparoscopic cholecystectomy, open cholecystectomy, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery (FESS), cataract surgery, transurethral resection of the prostate (TURP), and simple mastectomy [4]. These procedures were chosen for their regularity, and none are meant to relieve pain or put patients at risk for long term pain. The study concluded that all of the surgeries, excluding laparoscopic appendectomy, FESS, and TURP, led to an increased risk of chronic opioid usage [4]. Additionally, males above the age of 50 appeared to be particularly susceptible to opioid use disorder after surgery, especially if they have had a history of alcohol or drug abuse or have used benzodiazepines or antidepressants preoperatively [4]. Now that the correlation between surgery and opioid use disorder has surfaced, medical professionals must be informed of the risks of overprescribing opioids and understand that what is meant as pain relief may unmask an individual's susceptibility towards long term opioid use and harm a human life [4].  

In surgical patients, alternative pre and postoperative interventions such as evidence-based psycho-behavioral pain management skills may be further researched and developed to reduce overprescribing drugs in the future [4]. Further down the path, treatment for opioid abusers includes medications such as buprenorphine and methadone, which both binds to the same opioid receptors to reduce cravings and withdrawal symptoms in the user [10]. These symptoms, which appear when the user ceases intake of the drug, include muscle and bone pain, sleep problems, diarrhea and vomiting, cold flashes, and cravings [10]. Also, some cognitive behavioral therapy has been shown to help patients manage their triggers and stress and increase their life skills [10]. Medications for opioid use disorder are much more useful than those for alcoholism or nicotine use; unfortunately, many substance users feel criminalized and stigmatized. The vulnerability and fear instigated in them prevent them from seeking help and treatment when they need it [5].

Challenges Ahead 

Meanwhile, COVID-19 has not only halted nearly the entire world in its tracks but also exacerbated the opioid epidemic. In the months of COVID-19, agencies reporting overdoses recorded an increase in phone calls by 20% as OUD patients sought practical help [5]. With the world in lockdown, people lack their usual support systems, have less access to treatment programs without an emergency, and have increased stress levels, possibly due to employment changes, which may lead to relapse [5]. The risk of suicide is also associated with COVID-19 as people struggle with isolation [5]. Furthermore, as the virus threatens all public spaces, substance abusers have a fear of using public transportation to seek help when they need it, especially since the substance use disorder compromises their respiratory, cardiovascular, and metabolic systems [5]. As people are unable to gather according to new regulations set in place to fight the spread of the virus, there is no one to call 911 when overdoses occur in isolation [7]. 

Additionally, since the pandemic began, amounts of opioids arriving from Mexican drug cartels seem to decline due to borders being closed to all but essential imports and traffic, which has increased the prices of these opioids [8].  This encourages some substance abusers to dangerously mixing their opioids with other drugs such as cocaine or psychiatric medicines more frequently to stretch out the duration of their highs [8]. To further complicate the problem, patients placed on ventilators require opioid sedation. With the coronavirus debilitating so many globally to the point of needing ventilator support, a shortage of certain opioids has emerged [6]. To support those in need, the government has increased the 2020 production quota of certain opioids— including fentanyl, morphine, hydromorphone, codeine, ephedrine, and pseudoephedrine— by 15% [6]. Although this will be beneficial to hospitalized patients, experts are also concerned about such patients developing chronic opioid use or the increased volume of drugs reaching the black market and enslaving so many more lives. 

Virtual Solutions 

Although many clinics and health centers are closed to substance abusers, telehealth and virtual consultations have evolved in an attempt to substitute in-person consults. In some cases, such as in prisons or jails, virtual technologies provide more equity since communities that previously lacked physicians are often still able to acquire an iPad and virtually bring help to their people [5]. Recently, to try and combat some effects of COVID-19, doctors have been allowed to prescribe buprenorphine, a form of medication-assisted treatment (MAT), for chronic opioid users virtually, and patients can take home 28 days' worth of treatment at a time rather than one dose per week [6]. Such changes are meant to encourage patients to still seek help while limiting their public exposure and risk to the coronavirus.

Conclusion

Currently, with pandemics and epidemics overlapping and weaving their way into so many lives, the weakness of the health systems in the world are ever so apparent. All eyes are trying to focus on the most vulnerable populations, which include those most susceptible to COVID-19 and also those who suffer from substance use disorders [5]. This twin crisis can only be improved by providing better global crisis training to all health workers and providing resources and access to treatment and health centers for drug users. More work needs to be done to educate all parties involved so that substance abusers understand where and how to seek help, and health workers are aware of how to administer that aid. This pandemic has curated a unique global environment of empathy towards the suffering of others. It has never been more urgent or fitting to destigmatize substance abuse and instead advocate for it. Because the opioid epidemic will remain standing when only faced with whispers. COVID-19 and its magnifying effects on the opioid crisis should be taken as an opportunity to shout about this issue and stare it in the face. It is a rarity when all the people on earth face one common enemy. Rather than watch as COVID-19 and its trickled down threats take even more lives, timely changes must be made in attitude, expectations, inactions, knowledge, and service.

References

[1] Wisconsin Opioid Overdoses More Than Double During COVID-19 Pandemic. (2020, July 22). Retrieved August 02, 2020, from https://minnesota.cbslocal.com/2020/07/22/wisconsin-opioid-overdoses-more-than-double-during-covid-19-pandemic/

[2] Richmond, T. (2020, July 22). Wisconsin opioid overdoses more than double during the coronavirus pandemic. Retrieved August 02, 2020, from https://www.chicagotribune.com/midwest/ct-wisconsin-opioid-overdoses-20200722-c3fkts4zarhkzmwcww3i25imou-story.html

[3] Coronavirus Wisconsin: COVID-19 cases increase by 957, with 1 new death; total cases top 48K. (2020, July 26). Retrieved August 02, 2020, from https://abc7chicago.com/coronavirus-wisconsin-covid-19-online-school-reopening/6335757/

[4] Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA Intern Med. 2016;176(9):1286–1293. doi:10.1001/jamainternmed.2016.3298

[5] Effects of COVID-19 on the Opioid Crisis: Francis Collins with Nora Volkow. (2020, July 06). Retrieved August 02, 2020, from https://www.drugabuse.gov/videos/effects-covid-19-opioid-crisis-francis-collins-nora-volkow

[6] Keenan, C. (2020, June 10). How Covid-19 is impacting the opioid crisis (and 5 ways providers can help). Retrieved August 02, 2020, from https://www.advisory.com/daily-briefing/2020/06/10/opioids-covid

[7] Williams, M., MD. (2020, July 16). Why are overdose deaths surging amid COVID-19? Retrieved August 02, 2020, from https://wexnermedical.osu.edu/blog/why-are-overdose-deaths-surging-amid-covid-19

[8] Buckley, M., & Keilman, J. (2020, July 21). Opioid overdoses skyrocket in the face of COVID-19 pandemic; stronger drugs, scarce treatment blamed. Retrieved August 02, 2020, from https://medicalxpress.com/news/2020-07-opioid-overdoses-skyrocket-covid-pandemic.html

[9] CMS Opioid Roadmap: Strategy to Fight the Opioid Crisis. (2020, June). Retrieved August 01, 2020, from https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Opioid-epidemic-roadmap.pdf

[10] NIDA. 2020, July 24. Prescription Opioids Drug Facts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/prescription-opioids on 2020, August 1