Peter Grinspoon, MD
I am a primary care doctor who has recovered from — and who treats — opiate addiction. I work in an inner-city primary care clinic in Chelsea, Massachusetts, which currently has the highest rate of COVID-19 in the state, due, in part, to poverty. These two experiences offer me a clear view of how these two epidemics — COVID-19 and opioid addiction — can impact and worsen each other. Two great epidemics of our generation are intersecting in ways that are additively deadly, and which highlight the urgent ways we must respond to some of the underlying fault lines in our society that are worsening both crises.
Social determinants of health create greater vulnerability
People who suffer from the disease of addiction are particularly vulnerable to both catching the coronavirus and having a more severe disease when they do catch it. There are many reasons for this, but they boil down to something called social determinants of health, which according to the CDC are “conditions in the places where people live, learn, work, and play [which] affect a wide range of health risks and outcomes.” In short, people suffering from addiction are vastly more vulnerable to coronavirus, as they are more likely to be homeless, poor, smokers with lung or cardiovascular disease, under- or uninsured, or have experienced serious health and socioeconomic issues from drug addiction. There are also millions of vulnerable incarcerated people, many of whom are stuck in jail due to their addictions and related nonviolent drug offenses.
Treatments and support systems may be disrupted
For someone struggling with addiction, virtually all of the services and treatments available to them have been disrupted by the COVID-19 epidemic. People are told to stay home, which directly contradicts the need to go to clinics to obtain methadone or other medications for treating addiction. Our government, in response, has relaxed regulations so that, in theory, clinics can give 14-day or even 28-day supplies to “stable” patients, so that they don’t have to wait in line and can adhere to social distancing for safety. Unfortunately, there are countless stories of patients not being granted this privilege, including at least one of my own patients.
Similarly, the government has relaxed some restrictions on buprenorphine prescribing, and has allowed some telephone prescribing, but this presupposes that there are doctors available that are healthy and certified to prescribe this medication, and that the pharmacies and doctors’ offices are functioning. Access to clean needles is affected as well. Additionally, may rehab facilities have limited new admissions, cancelled programs, or even shuttered their doors for fear of spreading coronavirus in a communal living setting.
Social isolation increases the risk for addiction
A common truism in recovery culture is that “addiction is a disease of isolation,” so it stands to reason that social distancing — in every possible way — is counter to most efforts to engage in a recovery community. It is important to remember that experts distinguish between physical distancing and social distancing, and actually emphasize that we keep physical distance, but make extra efforts to maintain social bonds during this time of enormous stress and dislocation.
The social isolation that is so critical to preventing the spread of coronavirus prevents people from attending peer-support groups, which are such a vital source of emotional and spiritual support to people struggling to stay in recovery.
Isolation may increase the risk of overdose deaths
Heightened anxiety is a near-universal trigger for drug use, and it is difficult to think of a more stressful event — for all of us — than this pandemic. Users who adopted harm reduction techniques and had been using drugs with a friend are now using them alone, and there is no one nearby who could administer naloxone or call 911 in the event of an overdose. As a consequence, police have been finding people dead in their apartments. When people do call 911, the health care system is overloaded, and first responders may arrive more slowly. We know that starting addiction treatment in the ED can help prevent relapse, but right now emergency room doctors are absolutely overwhelmed with COVID-19 cases, and might not have the time or resources available to start addiction medications following an overdose.
Sadly, the ugly face of stigma and discrimination is coming out as well, as there are reports surfacing of police departments across the country that are refusing to offer naloxone to patients who have overdosed, on the pretext that it is too dangerous because the “addict” might wake up coughing and sneezing coronavirus droplets.
Multiple health crises mean comprehensive solutions
What we need to do now is reach out more than ever to those who are struggling with addiction, and provide them with the resources, such as online meetings, so that they are not alone and forgotten during this dual crisis of coronavirus and addiction. We need to make sure that they are getting the medications they need to recover, that they have access to clean needles if they are still using, adequate medical care, food, and housing — basic human needs.
If any good has come out of the misery of the combined COVID-19 and opioid epidemics, perhaps it is that a clear, bright light has been shined on the deadly social fissures — poverty, income inequality, lack of health insurance and access to healthcare, homelessness — that are the true social determinants of health we will need to address as part of an effective response to future pandemics.