Dr. Laura Kehoe
Title: Medical director, Massachusetts General Hospital Substance Use Disorder Bridge Clinic; assistant professor of medicine, Harvard Medical School
The U.S. Centers for Disease Control and Prevention recently reported 93,980 drug overdose deaths in 2020, a record high. That’s about 5,000 people short of the population of Erie, Pennsylvania. The number of overdose deaths, up from 70,890 in 2019, marks the largest annual surge in at least five decades. Federal officials attributed nearly three-quarters of the fatal overdoses to opioids. Many of the deaths were associated with fentanyl, a powerful synthetic drug. Overdose fatalities from use of methamphetamines and cocaine also increased.
As told to Ruben Castaneda, as part of U.S. News & World Report’s “One Pandemic Question” series. Responses have been edited for length and clarity.
Q: How has the COVID-19 pandemic affected the opioid crisis?
The COVID-19 pandemic has exacerbated the many challenges people with any substance use disorder face, not just opioids. Most distressing is that overdose deaths have skyrocketed.
Pre-dating the pandemic, the “opioid” crisis had ballooned into an all-substance crisis. Multiple substance use is now the norm. The vast majority of my patients use multiple substances — it could be a primary opioid use disorder with intermittent cocaine or methamphetamine and alcohol use — or multiple substance use disorders coexisting at once. Fentanyl, which is 100 times more potent than heroin, has poisoned the drug supply, putting anyone who uses drugs at risk of overdose every time they use.
Social distancing for people who use drugs increased social isolation and despair, both of which fuel addiction. For people with opioid use disorder, going days to weeks without opioids decreases their tolerance, which puts them at higher risk of overdose when they do regain access to opioids. To compensate and self-treat the painful withdrawal without opioids, people may use any other available substances like alcohol and sedatives, which further increase their risk of overdose. We saw much of this.
Vulnerable and marginalized patients experiencing homelessness were particularly hit hard and are those I worry most about. Early on, shelters and social service agencies shut down or limited their hours and numbers of people they could serve. Also, public bathrooms to wash hands closed, and it’s almost impossible to maintain social distancing and good hygiene if you’re surviving on the street with other people in the same situation.
Infections related to injection use increased because people could not access harm-reduction supplies, like needles or pipes. Before the pandemic we didn’t have adequate harm-reduction measures, and we still don’t. The pandemic further highlighted the dire need to incorporate and offer harm reduction, as well as welcoming safe spaces throughout the continuum of care for people who use drugs, not just in clinics like mine or needle exchanges.
If I have patients who are injecting and are unable to access safer supplies, their drug use doesn’t just stop. They’re going to use and share needles with other people, which puts them more at risk not only of contracting and spreading COVID, but also other blood-borne infections like hepatitis and HIV.
Patients who were taking buprenorphine, life-saving medication for opioid use disorder, had trouble getting their medication. Buprenorphine is a partial opioid agonist medication, which means it activates the same receptors in the brain as other opioids, but only partially. It prevents and treats painful withdrawal, relieves cravings and prevents overdose death. As it restores altered neuropathways that drive ongoing compulsive opioid use, it helps people with opioid misuse disorder regain normal function.
Many patients had a hard time reaching their prescribers when clinics shut down, so we accepted them at our clinic. We’d get calls from the New England area, not just Massachusetts but places like New Hampshire and Maine. People would say, ‘I can’t reach my provider, what should I do?’
My clinic is a safety net, low barrier, walk-in, “come as you are” clinic. Our model took a hit during the COVID peak as we had to follow social distancing and strict hospital infection-control measures. We could no longer use our usual walk-in model — we had to socially distance the waiting room and make sure patients were seen efficiently and exited the hospital quickly. They couldn’t hang out with us all day; they couldn’t stay at the clinic while they came down from a high. They connected with the recovery coach or therapist by phone from clinic. It was very different from the model we’d been using. We had to transition to a somewhat more traditional model.
We were vigilant about staying open daily for in-person and virtual care, especially for those who didn’t have access to a phone or computer, but needed to cut our hours because we also needed to care for people in COVID clinics. Other staff worked remotely during the peak.
Early on, patients with substance misuse disorder could only be seen in the hospital if they had an appointment. We’d have to communicate to hospital staff: ‘These are very high-risk patients, many won’t have appointments in the system, please let them in.’
When the pandemic hit, I was worried that pharmacies would run out of buprenorphine, which would put people at risk of withdrawal and returning to opioids. We stocked up on monthly extended-release buprenorphine. If patients couldn’t access their daily oral medication, we were able to provide it in a monthly injection if they wanted that. Many patients found it extremely stabilizing, particularly patients who were worried about losing their prescriptions or having them stolen.
We’ve had some silver linings during the pandemic. We’ve seen barriers lowered to improve access to the life-saving medications buprenorphine and methadone by allowing virtual care vs. in-person consultations. The federal government eased regulations to allow methadone clinics to give up to 28 days of methadone at one time to patients. Before the pandemic, patients who used methadone had to go to a clinic every day to get their dose with very limited additional take-home doses if they met certain strict requirements.
My hope is that the rapid and empathic mobilization our country showed in response to the COVID pandemic will translate to the opioid crisis. People showed that they can jump into action, assume care roles outside of their comfort zone, adopt new protocols and widely disseminate life-saving treatment for people suffering from COVID, a lethal illness. Imagine if we took some of that energy and applied it to the most lethal drug crisis our country has ever experienced?
The good news is we already know what works to defeat the opioid overdose crisis. We now need an expanded workforce to help us increase access to life-saving medications that we know work, stick with people when they most need us, and keep them safe and engaged in a manner that balances their competing life priorities.
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How the COVID-19 Pandemic Sparked a Surge in Opioid Overdose Deaths originally appeared on usnews.com