A Growing Crisis
In 2019, approximately 50,000 individuals in the United States died from opioid-related overdoses (National Institute on Drug Abuse [NIDA], 2021). The following year, amidst the heat of the devastating COVID-19 pandemic, the Centers for Disease Control and Prevention (CDC) recorded 81,000 drug overdose deaths for the 12 month period ending in May of 2020—the highest number ever recorded for a 12-month period (CDC, 2020). This “acceleration” of overdose deaths was observed to be primarily due to synthetic opioids, like fentanyl, leading to a 38.4% increase in deaths from June 2019 to May of 2020 (CDC, 2020).
The Start of an Epidemic
The foundation of the present opioid epidemic was built in the late 1980s, when pain was increasingly accepted as a problem that needed to be treated (DeWeerdt, 2019). In 1995, the American Pain Society, an organization for physicians based in Chicago, coined the phrase “the fifth vital sign,” describing and emphasizing the need to manage and monitor pain (DeWeerdt, 2019). Opioids, the main source of pain relief, started being prescribed for short-term use, often for post-surgery patients or individuals with advanced or terminal illnesses. This course of pain treatment functioned under the guise that opioids were only addictive when used for recreational purposes, not through medically prescribed pain treatment (DeWeerdt, 2019).
A spike in opioid prescriptions, especially for chronic pain, followed in the next decade, when pharmaceutical companies like Purdue Pharma, the manufacturer of OxyContin, started heavily promoting their products to the medical community. From lobbying lawmakers to funding professional and patient organizations, these companies continued to stress the safety and low risk of addiction for users of prescription opioids (DeWeerdt, 2019). This reassurance led to doctors prescribing and even overprescribing opioids without hesitation (DeWeerdt, 2019). Before the medical community realized the addictive potential of these prescription opioids, prescriptions and misuse were already prevalent among the population.
As regulations on prescription opioids started to be set in place, in 2010, a second wave of opioid-related deaths followed—this time with a different culprit: heroin (CDC, 2021). Previous users of prescription opioids found themselves switching to this new drug, discovering it to be easier to obtain than the now-regulated prescriptions. From 2010 to 2016, heroin-related deaths increased fivefold (DeWeerdt, 2019). The third wave, beginning in 2013, brought unspeakable statistics. Involving synthetic opioids, particularly illicitly manufactured fentanyl, this new wave catalyzed an 88% increase of fentanyl-related deaths from 2013 to 2016. While pharmaceutical fentanyl, approved for treating pain in cases like cancers, is 50 to 100 times more potent than morphine, the misuse of fentanyl stems from illegally produced fentanyl which is circulated on illegal drug markets and known for its heroin-like effects (DeWeerdt, 2019). As the current market for illegally produced and distributed fentanyl continues to change, it can be found in combination with heroin, cocaine or counterfeit pills (CDC, 2021). These implicit traces of fentanyl, many times unknown to the user, can have synergistic effects when mixed with other opiates, resulting in lethal consequences.
Caught in a Global Pandemic
Record numbers of overdose deaths were seen as the pandemic ravaged the country. Minimal access to treatment, a rise in mental health problems and greater availability of dangerous street drugs solidified this disastrous outcome (Rabin, 2021). The vast majority of these deaths can be attributed to the misuse of synthetic opioids, mainly fentanyl and its addition to other illegally manufactured drugs for enhanced potency (Rabin, 2021).
As the pandemic’s lockdowns created a loss of social support networks, an unfortunately perfect stage was set for those struggling with addiction or on the journey to recovery to relapse. Simultaneously, as the nation grappled with limited resources to fight enemy #1, COVID-19, any COVID-19 cases demanded all the “time and expertise” of medical personnel (Khatri & Perrone, 2020). Any condition not deemed life-threatening or not involving an infected individual was immediately demoted and considered a lesser priority, inevitably turning away those requiring critical treatment for substance use disorders (Khatri & Perrone, 2020). As telemedicine gained traction, improving access for various demographics, the most vulnerable were left behind (Khatri & Perrone, 2020). Unstable housing and low socioeconomic status, common for many individuals with opioid use disorder, made necessities like a cellphone and stable network connection unattainable.
Beyond lack of access to quality care, the stress and anxiety of the tumultuous social and political climate could function as a trigger for reuse and misuse of drugs. Social distancing, while preventing the spread of COVID-19, dangerously provides for an isolated environment for incidents of overdose without any chance of a timely rescue (Khatri & Perrone, 2020). Disruptions in the supply chain for illegal drugs brought on by the pandemic leave users relying on new sources for their drugs, potentially increasing the risk of an overdose due to unknown additions of powerful substances like fentanyl (Thompson, 2021). These factors, unique to the environment brought about by the pandemic, leave individuals previously struggling with addiction and opioid use in even more dire situations, demanding urgent action.
This ongoing crisis, coupled with the compounding effects of the novel coronavirus, necessitated critical adjustments on the policy and organizational level. Medicaid and Medicare now cover all three medications approved to treat opioid use disorder: methadone, buprenorphine and naltrexone (Thompson, 2021). The stimulus bill of last spring allocated $1.5 billion for the prevention and treatment of substance use disorders, and $30 million for the funding of local services for people struggling with addiction. These funds can also be used to buy rapid test strips to detect the presence of fentanyl in illicit drugs. Furthermore, treatment centers are shifting to take-home doses of medications, allowing for more efficient handling of patients (Thompson, 2021). These changes have been vital to accommodating individuals with opioid use disorder while the nation’s attention and efforts focused on the pandemic unfolding across the globe.
However, there are criticisms that the federal response has been inadequate. The magnitude of this public health emergency necessitates greater funding, universal access to treatment, and centers in every county for same-day treatment. There also needs to be greater flexibility with the prescription of buprenorphine, as it still requires federal permission before doctors can prescribe, limiting the number of providers and patients that can be reached (Rabin, 2021). Furthermore, there are numerous concerns of what will happen to the government-granted flexibility once the pandemic winds down (Thompson, 2021). Telemedicine, an undoubtable step in the right direction, and take-home doses have opened doors that were previously closed for many vulnerable populations and a sudden reversion of this much needed adjustment could once again place many in desperate situations.
In the words of Dr. Andrew Kolodny, medical director of the Opioid Policy Research Collaborative at Brandeis University’s Heller School for Social Policy and Management, “It has to be easier to get treatment than to buy a bag of dope” (Rabin, 2021). Barriers to care must be removed, and communities with differing levels of access must be considered, if we expect to see any significant change in overdose-related deaths and move forward in our journey of creating a more equitable and accessible healthcare system.
References
Centers for Disease Control and Prevention [CDC]. (2021, March 17). Understanding the Epidemic.
Centers for Disease Control and Prevention. https://www.cdc.gov/opioids/basics/epidemic.html
Centers for Disease Control and Prevention [CDC]. (2020, December 18). Overdose Deaths
Accelerating During COVID-19. Centers for Disease Control and Prevention. https://www.cdc.gov/opioids/basics/epidemic.html
DeWeerdt, S. (2019, September 11). Tracing the US opioid crisis to its roots. Nature.
Khatri, U. G., & Perrone, J. (2020). Opioid Use Disorder and COVID-19: Crashing of the Crises.
Journal of Addiction Medicine, 14(4), e6–e7. https://doi.org/10.1097/ADM.0000000000000684
National Institute on Drug Abuse. (2021, March 11). Opioid Overdose Crisis. National Institute on
Rabin, R. C. (2021, November 17). Overdose Deaths Reached Record High as the Pandemic Spread.
The New York Times. https://www.nytimes.com/2021/11/17/health/drug-overdoses-fentanyl-deaths.html
Thompson, D. (2021, October 1). How the COVID Pandemic Made the Opioid Epidemic Worse, Even
as Telehealth Helped. U.S. News & World Report. https://www.usnews.com/news/health-news/articles/2021-10-01/how-the-covid-pandemic-made-the-opioid-epidemic-worse-even-as-telehealth-helped