This spring, an emergency department in Virginia saw more than twice as many non-fatal opioid overdoses as last spring, while fentanyl showed up in more urine samples nationwide this spring than over the winter, according to two recent studies in JAMA.
In an accompanying commentary in JAMA, two School of Public Health researchers discuss these studies and what they demonstrate about the resurgence of the opioid epidemic within America’s unequal COVID epidemic.
“The US COVID-19 epidemic has been accompanied by an increase in substance use with important consequences (nonfatal overdose), with a signal of greater effect among people who are Black,” write Danielle Haley, assistant professor of community health sciences, and Richard Saitz, professor and chair of community health sciences. “It is likely that left unaddressed, the synergistic effects of COVID-19 and the opioid epidemic will further widen racial and socioeconomic disparities in the health of the US population.”
However, they write, “COVID-19 has ushered in the introduction of policies that, if made permanent, have the potential to not only mitigate the effect of the COVID-19 pandemic on overdoses, but also address long-standing structural barriers to accessing proven treatments,” they write.
Haley, who joined the faculty in July, discussed these dual affects of the COVID crisis on the opioid crisis, what motivates her public health work, and why she chose SPH.
Why is the US COVID epidemic causing more substance use?
As we are all aware on a personal level, this is an incredibly stressful time. Many people are faced with multiple, co-occuring economic and social stressors eroding mental health, such as temporary or permanent job loss, social isolation, illness or death of loved ones, and juggling increased care responsibilities for children or other family members. Drugs and alcohol may be ways to cope with this stress.
At the same time, we have seen a disruption in social safety nets (such as closure of soup kitchens and suspension of traditionally in-person support programs such as Alcoholics Anonymous or Narcotics Anonymous) and health care systems (including closure of physician offices providing buprenorphine, a proven treatment for opioid use disorder) that may support people in treatment and recovery.
And, although we have a powerful tool (naloxone) available to rapidly reverse overdose, it requires the administration of a bystander. It is unclear whether the US COVID-19 epidemic and associated stay at home orders are fueling use in isolation or in the presence of others.
The COVID crisis is disproportionately affecting Black communities in the US, and one of these studies finds COVID may also be having a greater impact on opioid use in Black communities. Why would this be?
There are notable disparities in the distribution of COVID-19 cases and deaths by race/ethnicity, socioeconomic status, and by neighborhood sociodemographic characteristics, with areas with more poverty and residents belonging to a racial or ethnic minority experiencing a disproportionate burden of COVID-19 cases and mortality.
These same factors are also associated with greater COVID-19 economic effect, such as job loss, and are known to shape disparities in substance use, access to healthcare, and health more broadly.
In effect, these communities are facing the brunt of the epidemic—not only in terms of illness and loss, but also with respect to downstream economic and social impacts. These disparities are long-standing, but being laid bare in mainstream media by COVID-19.
Your commentary also notes that the study of non-fatal overdoses points to another issue that pre-dates COVID.
In addition to widening health disparities, the study by Ochalek et al suggests an additional problem: the failure to deliver effective treatment for opioid use disorder, even among patients with a symptomatic life-threatening episode requiring emergency treatment, and even in tertiary care institutions that offer substantial addiction specialty treatment services.
Despite a wealth of data supporting evidence-based approaches to treating opioid use disorder, the systems we have in place were inadequate prior to COVID-19. In the absence of targeted responses, COVID-19 is likely to exacerbate these gaps.
At the same time, you write that some policies specific to the time of COVID may actually improve access to opioid use disorder treatment. How so?
Although COVID-19 has introduced a number of stressors likely to drive substance use and challenges to receiving substance use treatment, all differentially affecting low-income or other vulnerable populations (e.g., clinic closures, public transportation disruptions, financial stressors), it has also been accompanied by changes favoring access to care. These changes include: 1) reducing financial barriers to treatment and naloxone through the emergency expansion of Medicaid, 2) easing of restrictions on the dispensing of methadone (e.g., take-home doses for 14-28 days instead of daily directly observed dosing), and 3) expanding the role of telemedicine in the care of patients with opioid use disorder (e.g., buprenorphine initiation and follow-up by video or phone visit).
These changes, if made permanent, have the potential to not only mitigate the effect of the COVID-19 pandemic on overdoses, but also address long-standing structural barriers to accessing proven treatments for opioid use disorder.
We cannot stop with policies alone. Successfully linking and retaining individuals in care and treatment for substance use will require comprehensive approaches to expanding access, such as eliminating caps on the number of patients who can be treated by a prescriber, expanding community outreach, social services, and telemedicine, and by more emergency department physicians obtaining waivers to initiate medication treatment for patients with opioid use disorder who are discharged from the emergency department.
How do these issues—the unequal impact of COVID, challenges in accessing opioid use disorder treatment—fit into your broader work?
My work focuses on how features of the social and built environment, including policies, shape health and health disparities.
When we think about health and well-being, it is easy to focus on an individual and whether they have “healthy” behaviors. However, we are all part of larger ecosystems that influence where we live, work, and play, and the people with whom we interact with in each of these arenas.
My work seeks to understand the ways in which these ecosystems shape our health (and whether these impacts vary differently by individual characteristics, like your income or the color of your skin) so that we can develop system-approaches to improving health and well-being.
What motivates you in this work?
Early in my career, I worked closely with people who were living with HIV who were recently released from prison. Prior to release, many people were optimistic about what their life back in the community would look like. They envisioned jobs, stable housing, developing strong social networks, easily connecting back to health care and social supports.
In reality, many faced constant challenges meeting these goals, and these cumulative hardships often prompted people to start using drugs and alcohol again. I realized that people were doing the best they could with the few options available to them and that systems were not created equal nor serving people equally. It’s hard to focus on longer term preventative health behaviors when meeting immediate daily needs is a struggle.
I want my work to contribute to dismantling systems that oppress while building systems that allow people to truly prioritize health and well-being.
In academia, there’s always the risk of getting overly focused on grants and publications, at the cost of staying grounded in the “why” of what we do. BUSPH’s commitment to social justice and focus on building the evidence-base (Think), teaching and mentoring the next generation of public health leaders (Teach) and in turn developing evidence-based responses to complex real-world challenges (Do) is a critical anchor to ensuring our work is meaningfully improving the health and well-being of the people and communities we seek to serve.