How COVID-19 Worsened the Opioid Epidemic

Though the COVID-19 Pandemic has dominated the discussion for almost a year now, the United States was already in the midst of a large-scale epidemic of their own. According to A Brief History of the Opioid Epidemic and Strategies for Pain Medicine, opioid abuse and misuse had reached such staggering levels that “[a]s of October 16, 2017, the US Government declared the opioid epidemic a public health emergency.” While “the opioid epidemic has resulted from myriad causes and will not be solved by any simple solution,” a widespread effort was being made at the federal, state, and local levels to decrease the negative impacts on patients and those around them.

A Home-Grown Crisis

Opioids were initially intended, as described by the National Institute of Environmental Health Sciences (NIH) “to be used when other treatments and medicines are not able to provide enough pain relief, or they can’t be used because of safety concerns” and include prescription oxycodone, hydrocodone, codeine, and morphine as well as illegal drugs like heroin and its derivatives, and synthetic opioids including fentanyl. These medications have very serious risks that can extend well beyond the prescribed patient and into family members, friends, etc. who may be intentionally or accidentally exposed to these drugs which can also result in the same serious consequences. This can have (profound) impacts—physical, financial, emotional, and potentially fatal—on those affected by the abuse and misuse of opioids.

Prior to the COVID-19 Pandemic, prescription opioid volume, after reaching a peak in 2011, was expected to be in decline for the ninth year in a row and the use of prescription opioids per capita was expected to return to the levels of use recorded in the early 2000s, according to an iQvia Institute Report. Driven by “changes in clinical usage, regulatory and reimbursement policies, and progressively more restrictive legislation enacted since 2012,” the number of opioid prescriptions to Medicare patients has increased since 2011, believed to be the result of an aging population, even as other groups saw a decline.

Between 2014 and 2015, and despite “substantial reductions in opioid prescriptions in the USA,” researchers of A Brief History also noted a 20% increase in opioid deaths. Pre-pandemic, the main focus had shifted to treating the underlying diseases causing chronic pain and “developing non-opioid therapies.”

Along Came COVID-19

Then, as it did with so many other factors of our daily lives, the COVID-19 pandemic profoundly affected many of those already impacted by the opioid epidemic. Many of the stressors that cause people to misuse and abuse substances such as anxiety, grief, seclusion, and financial worries have been exacerbated during the pandemic and mandatory quarantines. In Episode 11 of FDA Insight Associate Director of Opioid Policy, Megan Moncur discusses that “unhealthy responses to these stressors can lead people to turn to substance use.” In addition, “people are also experiencing decreased access to treatment.” Moncur explains: “Early in the pandemic…there was a lot of concern about seeking any kind of medical treatment….even going to an emergency room, because we were all afraid of contracting…COVID-19, that even when people with opioid use disorder did seek treatment, they were faced with closed treatment centers, cancellations of in-person recovery meetings, or difficulty in accessing their opioid use disorder medications.”

The NIH also notes that additional challenges to sobriety include home isolation and the resulting “excess of unstructured time, cancellation of in-person recovery meetings, anxiety or inability to visit a doctor’s office, which may cause people to (attempt to) self-medicate, loss of contact with peers and advocates, and worry about the future.” Parents or other guardians/caretakers of children have the “added worry about when schools will reopen and attending to family members[’] needs while trying to work from home.”

For those not able to work from home, another host of stressors can include: “loss or reduction in hours, loss of income, inability to pay bills, work-family imbalance, discrimination due to race or ethnicity, lack of access to COVID-19 testing, inadequate access to personal protective equipment and respirators, fear of getting infected or infecting family members, and constantly changing work and government safety and health guidelines.” Additionally, work-related ergonomics, including “lifting, pushing, pulling, bending and reaching of heavy loads, awkward postures, [and] repetitive motion” have changed as: “employers have seen redesigning work to physically distance workers (6-foot rule) and eliminate touching of shared equipment and workstations. This may result in workers performing tasks that were previously performed by two or more people by themselves, increasing the risk of sprains and strains and pain.” Even for at-home workers, “poorly designed at-home computer stations can also lead to discomfort that can result in opioid use.”

Furthermore, many “healthcare providers have prescribed longer opioid prescriptions to mitigate COVID-19 disruptions” which can inadvertently lead to misuse. Mental health professionals and advocates have long known that “[u]nhealthy responses to stress include self-medication and can lead to new addictions.” For many already in recovery all of this in addition to any stressors present can make it “much harder to maintain a sober lifestyle” and “may lead to returning to use.”

Unlike COVID-19, however, we do not have a real-time accounting of national deaths from opioid overdose, so the real tally will come to light over the months and years post-pandemic. We do know from Moncur that, as of September 1, 2020, “at least 30 states [had] reported increase in opioid fatalities since the start of the pandemic.” The iQvia report also notes that, “given the difficult economic environment exacerbated by the pandemic and limited amount of federally-funded aid, the poor recovery in this segment may have long-standing impacts that may further delay the progress made in addressing the opioid crisis.”

So, What Now?

Where do we go from here? While the COVID-19 Pandemic is certainly one of the utmost priorities worldwide, the opioid epidemic is, and will continue, to affect patients and families. There are plenty of ways that individuals and employers can make an impact, though.

The Substance Abuse and Mental Health Services Administration (SAMHSA) highlights “[f]our major elements of recovery that may be disrupted by the pandemic:

Health – overcoming or managing one’s disease(s) or symptoms and making informed, healthy choices that support physical and emotional well-being.

Home – having a stable and safe place to live.

Purpose – conducting meaningful daily activities and having the independence, income, and resources to participate in society.

Community – having relationships and social networks that provide support, friendship, love, and hope.”

Firstly, the NIH recommends that employers and companies make sure they have “established health benefits and adequately cover treatment for mental health and substance use” in addition to “assistance and peer support programs.” Employers can also take the added preventative step to identify “jobs and other work factors that pose a risk of injury, stress, and pain and take action to prevent injuries and stressors that may lead to prescription opioid use or self-medication.”

At the individual level, we can all help ourselves and our loved ones to get adequate sleep, be mindful of exercise and movement, healthy eating, and opportunities to relax. When we suspect others may be struggling, we can reach out and, if appropriate, encourage that they get professional help if we notice their stressors having a strong negative impact on their life or the lives of their loved ones.

Telehealth has also become a major factor in many patients’ regular interactions with healthcare providers. Moncur also notes that since the onset of the COVID-19 Pandemic, “[g]overnment agencies have made a temporary change in regulations allowing people in recovery to access telemedicine to obtain medically assisted treatment (MAT) and counseling and to obtain larger supplies of these lifesaving medications.” However, while the “option for telehealth has been critical for some people….while, for others, it may not even be an option; and still for others…they may feel that it doesn’t have the same impact as having face to face contact with health care providers.” Given the rise in telehealth, “researchers are definitely paying close attention to the outcomes of these new flexibilities, because if the outcomes are good, this may be a way to improve access to treatment in the future.

Looking forward, it will take a large-scale, concerted effort to solve the opioid crisis. However, that effort will only succeed if the industry can work together.

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