As COVID worsens, don’t forget about the opioid crisis

For the past seven months, an epidemic in our country has spiraled out of control, claiming thousands of lives that could have been saved. It has been met by an inadequate, meandering national response that has often lacked urgency. It has disrupted families, and at times has overburdened our health care system grappling with limited resources.

This assessment undoubtedly describes the COVID-19 pandemic that is now resurging in many communities across the country, but it also describes an ongoing opioid crisis that has worsened this year. Throughout 2020, drug overdoses have spiked in states across the country, including in Rhode Island, where we are both practicing physicians. In September, a study in JAMA noted that rates of positive urine drug screens for opiates, particularly fentanyl, have nearly doubled since March.

Those statistics are, unfortunately, not surprising. Lockdowns, which may again be necessary,  and a rise in unemployment have increased social isolation, with profound consequences to mental health, rates of depression, and increased rates of suicide. Also, missing stimulus funds have forced many primary care clinics that prescribe buprenorphine, a medication used to treat opioid use, to close their doors.

COVID itself and the opioid crisis often afflict the same vulnerable patients – socially and economically marginalized and with multiple medical comorbidities like heart disease that leaves them more susceptible to serious cases of coronavirus. On the ground, in clinics and hospitals, we’ve seen how COVID has changed patient behaviors. After drug relapses and subsequent infections of the heart called endocarditis, we’ve seen patients leave the hospital against medical advice after being presented with an option to take necessary intravenous antibiotics at a skilled nursing facility for fear of catching COVID there. In other cases, we’ve seen patients skip appointments and go without prescriptions, too afraid of visiting their local pharmacy.

In the first wave of COVID, the federal government did, in fact, take some creative steps to address the dual epidemic. For example, the Substance Abuse and Mental Health Services Administration allowed states to extend the period of time in which established methadone patients can take home doses to up to 28 days – normalizing medication-assisted treatment for many. Requirements for prescribing buprenorphine were also loosened, with waivered physicians now allowed to conduct initial visits with patients over the phone or through a video chat.

Although we are in the midst of yet another wave of COVID, we must also continue to confront the opioid crisis. A national response is clearly needed – one that addresses challenges to infrastructure supports harm reduction, loosens regulations judiciously to ensure access to key resources, and eases the public’s fears. The 2020 election results have created the possibility of a divided government, but there are reasons to be hopeful. Responding to the opioid epidemic has been of bipartisan interest for the past few years, and ideas from both sides of the aisle could form a truly national response to address it. As Surgeon General Jerome Adams has called for in the past, the federal government should help ensure widespread availability of naloxone through public advertising and targeted campaigns to physicians and pharmacists. The Department of Health and Human Services should allocate more funding toward needle exchange programs.  State health departments, like in Rhode Island, should continue to explore novel approaches like safe injection sites. If Congress considers another round of stimulus, it should include funding to keep primary care and methadone clinics open. Perhaps even more broadly, a national response to the opioid epidemic at this juncture could challenge longstanding but unusual norms in how our country’s medico-legal apparatus approaches opioid use disorder – pushing us to consider ideas like deregulating buprenorphine as countries like France have successfully done for decades.

Over the next few months, as COVID possibly spirals out of control, it may be easy to forget about the opioid crisis – one that has targeted many of the same individuals affected by this pandemic and one that has only grown more dire in the past year. But it deserves an urgent, national response too.

Vishal Khetpal is an internal medicine resident. Nishant Shah is a cardiologist. 

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