Why the Covid-19 pandemic made drug overdoses worse

America’s Covid-19 epidemic is likely making its drug overdose epidemic even worse.

While there’s no good national data for the year yet, local and state jurisdictions have reported increases in overdose deaths. According to the American Medical Association, as of July 20, more than 35 states have reported increases in drug-related deaths and other concerns with drug use and mental illness. Some municipalities reported overdose deaths increasing by 20, 40, or 60 percent — or more.

Even before the pandemic, there were signs that the drug overdose crisis was worsening. Preliminary data from the Centers for Disease Control and Prevention found drug overdose deaths hit 72,000 in 2019, up almost 5 percent from nearly 69,000 in 2018. A preliminary study from researchers at Stanford, UCLA, and the Los Angeles LGBT Center found that fentanyl, a synthetic opioid more potent and dangerous than heroin, has started to spread to illegal drug markets in the West — a trend that will likely cause more overdoses.

“Our data shows [overdoses] were increasing before the pandemic,” Chelsea Shover, a Stanford epidemiologist who led the study, told me. “I think the pandemic can only make it worse.”

The demands of social distancing have worsened social isolation, possibly leading more people to use drugs to cope. Social services and addiction treatment programs — many of which already lacked in funding and rigor — have fallen to the side, as the economic collapse has crushed public and private revenues, and social distancing has forced some places to close.

Meanwhile, the actions that different levels of government have taken to shore up the gaps caused by the pandemic simply haven’t been enough. As experts told me, telemedicine — while certainly helpful for many, and better than nothing — simply can’t make up for being able to pick up new syringes or naloxone, the opioid overdose antidote, at the local needle exchange program.

The result: As America sees more than 166,000 Covid-19 deaths (and rising), it’s also suffering tens of thousands of drug overdose deaths due to a decades-old crisis now likely worsened by the coronavirus pandemic.

“I’ve been really depressed by this,” Kim Sue, medical director of the Harm Reduction Coalition, told me. “I try to be very upbeat. I try to encourage people. … But I’ve been feeling really beaten down by this.”

Before the pandemic, drug overdose deaths were rising

Drug overdose deaths in the US actually fell for the first time in decades in 2018 — by about 4 percent. Based on preliminary federal data, that drop was erased in 2019, with estimated drug overdose deaths that year topping not just 2018 but also 2017, which was previously the worst year for overdoses on record. The data is preliminary and subject to change, but it at the very least suggests a reversal from 2018.

There was also reason to believe 2020 would be worse — even before the pandemic.

First, there’s the spread of fentanyl. The synthetic opioid has already contributed to a rise in overdoses in the Northeast and Midwest, as it’s replaced the less potent — and therefore less dangerous — heroin in illicit drug markets. It’s the third wave of the opioid epidemic, following the first wave of opioid painkillers and the second of heroin, in these regions.

But a 2019 report from the RAND Corporation, a policy think tank, warned that fentanyl could spread to the West, which had so far been spared from fentanyl due to intricacies in its illegal drug market, and cause a spike in overdoses there. Indeed, that now seems to be happening: The preliminary study from the Stanford, UCLA, and Los Angeles LGBT Center researchers looked at overdose data in different local and state jurisdictions in the West and found significant increases in overdoses across the region.

That matches what, anecdotally, some experts in the West Coast have seen locally. “In Los Angeles and in the West Coast, 100 percent, we’re seeing more and more fentanyl,” Ricky Bluthenthal, associate dean for social justice and professor of preventive medicine at USC, told me. “We have … a more dangerous drug as a consequence.”

Beyond fentanyl, there were also signs that stimulant overdoses — particularly involving cocaine or meth — were on the rise before the pandemic, with increases in the preliminary federal data of 8 percent for cocaine and 26 percent for psychostimulants, including meth, in 2019. It’s unclear why that’s the case (though it’s not abnormal for stimulant epidemics to follow opioid epidemics), but it’s yet another way drug overdoses were on the way up going into 2020.

Along with both these trends, previous years of data suggest overdoses were increasing in different kinds of communities. During the early stages of the opioid crisis, white people were disproportionately likely to be victims of drug overdoses. In recent years, particularly as fentanyl and stimulant deaths have climbed, overdoses have climbed in Black and brown communities.

Given all these factors, experts were already worried about drug overdoses in 2020. Then the pandemic hit.

The Covid-19 pandemic exacerbated existing problems

With the pandemic, any sign of optimism in the opioid epidemic has been crushed. “I don’t see anything good happening,” Keith Humphreys, a drug policy expert at Stanford, told me. “And I see a number of things that are bad happening.”

A major contributor to drug addiction, experts say, is social isolation. Whether it’s due to a lack of meaningful social connections, insufficient access to social services or supports, or a general sense of loneliness and despair, each of these factors can contribute to drug misuse. The worse people feel about their lives, and the less support they get as they suffer, the more likely they are to turn to drugs to fill the void.

With the pandemic, social distancing has become an evidencebased step to fight Covid-19. While that’s needed to get the disease under control and get life (and the economy) back to normal, it has the unfortunate side effect of pushing people further into social isolation. And that likely led to more people using drugs, causing more addiction, overdoses, and deaths.

Then there’s America’s faulty addiction treatment system. It was already riddled with problems before the pandemic, from evidence-free practices to downright fraudulent activity. It’s also inaccessible — due to the high cost and lack of insurance coverage — which is a big reason, according to the surgeon general, that only one in 10 people with a drug addiction get treatment.

The pandemic made that inaccessibility worse. Some treatment centers closed down, either as a social distancing measure or as a collapsing economy tanked their finances. Many people felt unsafe leaving their homes, including to get health care and treatment. As people lost their jobs with the economic downturn, they lost insurance — making addiction treatment less accessible.

Some patients saw the consequences early on, sending me panicked emails about what they could possibly do without treatment. “I still have not received any response from [the treatment facility] about what happens if I get sick and have no other place to go,” a patient in Chicago wrote. “I’m homeless, jobless, and I am immunocompromised. I’m wondering if I should also refuse to leave if I become sick.”

Public health programs that help people with addiction, like needle exchanges and other harm reduction services, also had to shut down or cut back — creating further gaps in a system already riddled with holes. With a bad economy heralding further cuts to private, municipal, and state budgets, this problem will likely get even worse.

In some cases, Covid-19 has simply taken priority over drug addiction and overdoses. “Health departments have pulled their staff to work on Covid,” Sue of the Harm Reduction Coalition said, speaking to her experience in New York City. “Already underfunded public health infrastructure has been eroded.”

Among the addiction programs that have remained open, the work has generally gotten harder, too. Building a connection and trust with a therapist, social worker, or peers at an Alcoholics Anonymous meeting is simply much harder to do over Zoom or Skype than it is in person. Outreach has been massively inhibited by the pandemic, as many of the people who were already difficult to reach burrowed further into isolation along with everyone else.

A potential silver lining is the pandemic could have disrupted drug markets, shutting them down as people remained indoors and lost income to buy drugs. But there’s little evidence so far that’s happened.

Compounded by preexisting conditions that were already making drug overdoses worse, it adds up to the worst year for public health — in terms of Covid-19 deaths as well as likely overdose deaths — in recent US history.

“The only way I could imagine overdose deaths being lower this year is if it turns out that Covid kills those people who would have died of an overdose,” Humphreys said. “Everything seems to be pointing in the wrong direction.”

The US needs to get both its major epidemics under control

As long as the pandemic rages on, there are short-term solutions that could help alleviate drug overdoses. Addiction treatment could be made more accessible, building on federal action to, for example, let doctors prescribe medications for opioid addiction over the phone. Public health programs that help people with addiction could get emergency funding and, if it’s not already the case, be deemed “essential” to let them stay open. More treatment facilities and organizations could embrace alternatives to in-person meetings, as some peer-support communities have with Zoom and Skype.

To the extent the pandemic has made drug overdoses worse, though, Shover of Stanford offered a more straightforward piece of advice: “Get the pandemic under control.” To do that, the public and different levels of government — particularly with federal leadership — will need to embrace the strategies that have worked for South Korea, Germany, and others against Covid-19: physical distancing, masking, and testing, tracing, and isolating the sick.

To the extent the pandemic has exposed or exacerbated underlying structural issues, those preexisting problems will have to finally be addressed. In my conversations with experts about overdoses during the Covid-19 pandemic, the same problems that I’ve reported on for years — lack of access to treatment, lack of evidence-based treatment, and skepticism toward proven harm reduction services — came up again and again. The same solutions came up too: less excessive opioid prescribing, building addiction treatment into the health care system, more money to and better oversight of treatment, a greater use of harm reduction services, and a wider embrace of evidence-based policies and practices.

Some of the problems are shockingly basic. Because of shoddy surveillance systems, we can’t say with certainty if overdose deaths have increased nationwide this year. In fact, the full data for drug overdoses has in recent times come out more than a year after the year the data is relevant for, so we get 2018 data in 2020. Our best source of preliminary data, from the CDC, still comes with a months-long delay, with the latest data available as of August 2020 coming from January 2020. That the US can’t even track the problem as it’s most relevant helps show why it’s still such a big problem.

One way to think about all of this: If the US had successfully gotten control of its opioid crisis years ago, the current rise in overdoses almost certainly wouldn’t be as widespread. Since these systemic problems remain, though, the overdose crisis shows no real sign of abetting.

Whether that changes could come down to how seriously US policymakers and the public take a public health crisis. But, experts said, the Covid-19 outbreak hasn’t given them much faith that will happen.

“Politically, we don’t care about people dying. We don’t care about people dying of Covid. We don’t care about people dying of overdoses,” Sue said. “We should care about everyone having access to a healthy, happy life. Covid has shown us we don’t care.”

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