Worst Case Scenario: The Opioid Epidemic meets the COVID Pandemic

Fears that COVID-19 pandemic would have a serious negative impact on persons with substance abuse disorder (SUD) appear to have been realized.  A new study reports emergency room visits for nonfatal opioid overdoses more than doubled between March 2020 and June 2020 compared to the same period in 2019. (1)  Another recent study of 75,000 urine drug screens in persons with or at risk for SUD conducted after March 12th, 2020 and compared with a similar sample from the same time period in 2019 found specimens testing positive for fentanyl almost doubled from 3.80% to 7.32%.  Similar increases were observed for heroin and methamphetamine. (2)

The pandemic has stressed and disrupted health care delivery while augmenting psychosocial and financial stressors of isolation, job and insurance loss.   Distancing and shutdowns have limited the face to face treatment and group therapy which benefits persons with SUD.   ERs overwhelmed with COVID patients may deprioritize care for stigmatized opioid overdose patients with only about half receiving a prescription for naloxone at discharge. (1) 

Unfortunately, the COVID - SUD intersection is a two-way street.   Persons with a SUD diagnosis are almost 9 times more likely to be diagnosed with COVID-19, the greatest risk for persons with opioid use disorder (OUD).   Persons with SUD and COVID are also more likely to die than those without SUD. (3)   Comorbidities in SUD patients, particularly compromised lung function from cigarette smoking or chronic vaping, is likely one factor responsible for the increased mortality.  In some persons, COVID results in chronic lung damage which might even increase the risk for fatal overdose in those who use opioids therapeutically. (4)

There are several strategies which companies can pursue to support employees with struggling with SUD and other mental or behavioral health challenges in the face of the pandemic:

• The pandemic has prompted a mass migration to remote work.  Increased social isolation increases risk of substance abuse relapse and even unobserved overdose.   Leaders should check-in daily directly with employees and consider regular virtual team meetings or “events” to promote social interaction.

• Companies should double-down on reducing stigma associated with SUD, particularly now in the remote workplace.   Leaders’ sharing and validating pandemic related psychosocial stressors with personal examples help to create a comfortable environment for employees who may need to seek help.

• The pandemic has brought disruption and change to health care delivery.  Employers should provide advice to employees who need to navigate in a new and adapting health care world.   Tools such as Operation Lighthouse and Shatterproof can provide confidential quality guidance.  Companies with employee assistance programs (EAPs) should re-evaluate the services offered post-pandemic.

Another response to the threats posed by the COVID pandemic for patients with SUD is the urgent expansion of telehealth services. (5)  Barriers to telehealth access are being rapidly reduced.  The Drug Enforcement Administration has recently permitted prescription of schedule II-V medications, including buprenorphine treatment for OUD, without patients being seen in person.  Prescription of buprenorphine via telehealth is included in the new guidelines for opioid treatment programs issued by The Substance Abuse and Mental Health Services Administration (SAMSA).  Finally, the Center for Medicare and Medicaid Health Services (CMS) has authorized Medicare to cover telehealth services.  Monitoring patients treated for SUD remotely remains a challenge, but an array of apps and transdermal devices are under study.  Group therapy is integral to many SUD treatment programs and amenable to telehealth, but privacy and security must be addressed.

The timing of the COVID pandemic couldn’t have been worse for persons struggling with SUD.  Innovating new health care delivery strategies to regain momentum against the epidemic are required.  Creating supportive remote work environments which combat isolation, encourage dialogue about psychosocial stressors and effectively destigmatize substance abuse disorders is a critical first step.

1. Ochalek TA, et al.  JAMA 2020: 324:1673-4.

2. Wainwright JJ, et al.  JAMA 2020: 324:1674-77.

3. Rubin R.  JAMA  2020: 324: 1598.

4. Volkow ND.  Annals Int Med 2020: 173: 61-62.

5. Lewei L. JAMA Psychiatry 2020.

Dan Mazanec, MD, FACP