Drug Helpline is placing 28 states on red alert for increased risk of deaths from overdose of opioids and other drugs. Reports from law enforcement, state officials, and health providers point to rising numbers of overdoses and substance abuse cases across the nation, including in California, Florida, New York, and Ohio.
The 28 states at highest risk are Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Kentucky, Maryland, Michigan, Nevada, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Utah, Vermont, Virginia, West Virginia, and Wisconsin.
The opioid epidemic was already taking 50,000 lives a year in the USA as of 2019.  The COVID-19 pandemic has exacerbated the problem, because of rising unemployment, reduced access to healthcare and treatment programs, and increasing levels of social isolation.
Prescription opioid pain relievers can control chronic pain effectively when used as directed. But due to the pandemic and efforts to stop the spread of the virus, people on opioid medications for chronic pain have had their treatment delayed and been forced to remain on opioid pain relievers for longer than is normally the case. This has contributed significantly to increased overdoses and substance abuse.
Various studies have looked at the effects of the pandemic, the disruption in social safety nets and healthcare, and additional economic and social stressors. One study found an increase in the detection of illicit substances in 150,000 random samples ordered for urine drug tests by healthcare professionals. In particular, fentanyl and methamphetamine detection was higher, and heroin and cocaine were also detected more. 
The Opioid Crisis Before COVID-19
In the 1990s, pharmaceutical companies aggressively marketed opioid pain relievers, assuring the medical community that these medications were not habit-forming. Over the ensuing decades, healthcare providers began prescribing these drugs at greater rates. Ultimately, this led to widespread misuse and abuse of prescription opioids. Research has shown that prescription opioid painkillers are in fact highly addictive. At present, the United States is in the midst of an opioid epidemic. The Department of Health and Human Services has declared the opioid crisis a public health emergency. Some statistics that underline the gravity of the opioid epidemic in the United States are listed below: 
- More than 130 people die every day from opioid-related overdoses in the US.
- Approximately 40% of opioid overdose deaths involve a prescription opioid.
- In 2019, an estimated 47,600 people died from opioid overdoses.
- More than 10 million Americans misused prescription opioids in 2018.
- 2 million Americans met the criteria for opioid use disorder in 2018.
- More than 800,000 Americans used heroin in 2018, of whom roughly 80,000 used it for the first time.
- More than 15,000 people died from overdosing on heroin in 2018–2019.
- More than 32,000 Americans died from overdosing on synthetic opioids in 2018–2019.
It is evident from the above figures that opioid abuse is having devastating consequences on the American population. This was an ongoing problem even before the COVID-19 pandemic hit the United States and the rest of the world in 2020.
The Opioid Crisis After COVID-19
The COVID-19 pandemic has presented unprecedented challenges to healthcare systems in the United States. Combined with the ongoing opioid epidemic, this has resulted in a complicated and potentially deadly situation. Reports from the national, state, and local levels indicate that there has been a spike in opioid-related mortality, particularly from illegally manufactured synthetic opioids like fentanyl. Reports from more than 40 states have shown an increase in death rates related to opioid abuse. The situation is particularly concerning for those with co-occurring mental illnesses and substance use disorders. 
Some of the primary concerns for individuals and families afflicted by addiction during the pandemic include: 
- Reduced access to treatment programs, including emergency departments
- Reduced access to social support systems such as Narcotics Anonymous
- Reduced access to harm-reduction programs like syringe/needle exchange programs
- Lost healthcare capacities due to staff falling sick, for example, at methadone clinics
- Increased social and economic stress (stress is a known risk factor for drug use and relapse)
- Increased risk of suicide, particularly in people addicted to opioids
Studies on COVID-19 and Addiction
Various studies have looked at the effects of the emergence of COVID-19, the consequent disruption in social safety nets and healthcare, and additional economic and social stressors. The authors of one study found there was an increase in the detection of illicit substances in 150,000 random samples ordered for urine drug tests by healthcare professionals. In particular, fentanyl and methamphetamine detection was found to be higher, and to a lesser extent, detection of heroin and cocaine.
Another study found that the number of opioid-related overdose visits in one Virginia emergency department increased by more than double, from 102 in March–June 2019 to 227 for the same period in 2020, despite the total number of ED visits being lower in 2020. Even more worrisome was the fact that only 10% of people who were seen in the ED were receiving any kind of outpatient treatment for opioid use disorder. 
Recommendations from the American Medical Association
To counteract the growing crisis, the American Medical Association has urged state governors to take the following actions: 
- Flexibility in evaluation and prescription requirements, for example, using telemedicine or telephone evaluations to issue buprenorphine prescriptions to new and existing patients with opioid use disorders. The Drug Enforcement Administration (DEA) has waived federal government requirements for in-person visits before a prescription for a controlled substance is given; state governments are being encouraged to do the same.
- Designation of opioid treatment medications (methadone, buprenorphine, naltrexone) as essential services to reduce roadblocks to access.
- Ensuring an adequate supply of naloxone and PPE to harm-reduction organizations to allow them to continue community distribution efforts.
- Removal of administrative barriers such as prior authorization and step therapy for medications used to treat opioid use disorders. States are encouraged to apply for a blanket exception from SAMHSA OTP (opioid treatment programs) to allow patients larger take-home doses.
- Enforcement of mental health and substance use disorder parity laws.
- Removal of barriers like quantity and refill restrictions and arbitrary dosing for patients with chronic pain in need of necessary medications. The recommendation is to allow 90-day prescriptions for buprenorphine and to suspend day limits on intensive outpatient and residential therapy.
- Implementation of harm reduction strategies like access to sterile syringes and needles.
- Removal of restrictions on Medicaid-preferred drug lists to prevent shortages, including methadone coverage for patients in opioid treatment programs.
- Temporary waiver of in-person counseling, check-ins, and drug tests by correctional and justice systems.
Actions Taken for Harm Reduction during COVID-19
Here are some examples of specific actions taken by physicians, clinics, healthcare organizations, and state governments to help people with opioid use disorder to get through the pandemic safely. 
- Clinics in Ohio, New Jersey, and Washington are providing doorstep or curbside delivery of buprenorphine and methadone for patients who are isolated or quarantined due to COVID-19 or are at risk due to older age or health issues.
- Clinics in Wisconsin, Washington, and New Hampshire have increased the use of telehealth and made use of mobile methadone units. This has enabled clinics to stay open for treatment, continue accepting new patients, and avoid unnecessary contact among patients.
- Emergency rules were extended in Texas to help established patients with chronic pain conditions gain access to necessary medications through telephone refills.
- Michigan has set an excellent example in providing naloxone to community groups to prevent opioid overdoses.
- Maine has adopted a new syringe/needle exchange policy which, according to the American Medical Association, is the best practice for reducing the spread of infectious diseases.
- Pennsylvania has distributed 6,000 doses of opioid overdose reversal drugs to county jails.
Some of these policies, if made permanent, could potentially mitigate the longstanding barriers to accessing effective treatments for opioid use disorder.
Opioid Abuse and COVID-19 Risks
Certain groups of people are at high risk of contracting coronavirus infection. If infected, these people are at risk of suffering worse consequences compared to others. Vulnerable populations for COVID-19 include older people and those with underlying health problems. Also at risk are people with a history of lung damage or pulmonary compromise, for example, due to smoking. People with opioid use disorder are another high-risk group for COVID-19 for various reasons, some of which are listed below.  
Lung damage: Opioid drugs affect multiple systems in the body, including the lungs. Opioids depress respiration (slow down breathing) and produce hypoxia (decreased oxygen supply), thereby compromising the pulmonary system. This makes it much easier for the coronavirus to infect opioid-addicted people. Also, once infected, the outcomes from COVID-19 are worse in people who have underlying lung disease. In other words, people with opioid addiction are more likely to get infected by the virus and more likely to die from COVID-19 compared to healthy people with no history of opioid drug use. The case fatality rate for COVID-19 is 6.3% in people with chronic lung disease compared to 2.3% in the general population. 
Mortality: As noted, opioid drugs affect respiratory health by slowing breathing and leading to a harmful decrease in oxygen levels. As a result, people with opioid addiction often have diminished lung capacity. Chronic respiratory disease is a known risk of higher overdose mortality in opioid addicts. If an opioid-addicted person were to contract the coronavirus, the resulting diminishment in lung capacity from COVID-19 may increase their risk of death from an opioid overdose.
Immunity: Opioid drugs are known to interfere with the immune system. People with opioid addiction often have low immunity, putting them at increased risk of coronavirus infection. This is especially true for those with long-term opioid use. Also, if infected by the virus, immunosuppressed opioid addicts are likely to have worse outcomes from COVID-19. 
Drug Absorption: Many people receive opioid pain relievers by prescription to manage chronic pain conditions. Certain opioids like fentanyl and buprenorphine can be administered via the transdermal route (via skin patches). This drug delivery system provides controlled amounts of the medication through the skin for a specified duration. Elevated body temperature can potentially disrupt the controlled, steady delivery of the opioid drug. Fever is a common symptom in people with a viral illness like COVID-19. This puts prescription opioid drug users with COVID-19 at increased risk of overdose.
Opioid Misuse: Prescription opioid pain relievers are extremely effective in controlling chronic pain when used as directed. Many people rely on these medications to control their pain and remain functional. Due to the COVID-19 pandemic and efforts to stop the spread of the virus, people on opioid medications for chronic pain have suffered treatment delays. Telehealth consultations have been made available in some places, but they do not include a physical exam. Moreover, imaging studies like MRIs and CT scans have been deferred. Patients waiting to undergo elective surgeries, for example, knee arthroplasty, have had their procedures delayed and need to have their pain managed with medications. Also, interventional pain management procedures such as nerve blocks have been put on hold. What’s more, sources of pain such as stress have amplified. Physical therapy programs that are used to manage chronic pain have been halted. As a result of all these changes, people with chronic pain are at high risk of misusing prescription opioid pain relievers to keep their pain under control. The true impact of the COVID-19 pandemic on opioid misuse will reveal itself in the months and years to come.
Social Risks for Opioid Abusers during the Pandemic
Exposure: It takes at least 2 years for a recovering opioid addict to build up “bottle privileges” where they are allowed to take home a month’s supply of methadone. Therefore, people with opioid addiction may have increased exposure to the virus at methadone clinics that put people together in small spaces and require daily visits as a standard of treatment. To reduce the risk of virus spread at crowded methadone clinics, federal guidelines have been changed during the pandemic. Patients can now take 14 to 28 doses of methadone home at a time, depending on their stability.
Access to Healthcare: Due to the pandemic, many opioid addiction treatment centers and methadone clinics have closed down, putting opioid-addicted people at life-threatening risk of withdrawal and overdose. While there has been a loosening of restrictions in medication management protocols for opioid use disorders, for example, with telehealth consultations and larger take-home doses, these reduced controls put opioid users at higher risk of overdose.
Stigma: People struggling with opioid addiction have a lower likelihood of seeking healthcare due to the stigma associated with substance abuse. Also, with clinics and hospitals pushed to capacity due to COVID-19, stigmatized and marginalized populations like people with addiction are experiencing even greater barriers to accessing healthcare.
Insurance: The percentage of people with substance use disorders who have health insurance is much lower compared to the general population. This means opioid-addicted people often have untreated chronic medical conditions. These medical conditions can increase the risk of getting COVID-19 and suffering poorer outcomes from the infection.
Mental Health: The COVID-19 pandemic has created a unique situation in terms of physical distancing and shelter-at-home orders, leading to social isolation for sustained periods. This has affected the psychological well-being of everyone, but especially those with underlying mental health conditions. Confinement to the home, anxiety about job loss and income, and fear of contracting the virus could potentially trigger relapses in opioid drug users.
Drug Use Behaviors: Practices such as vaping, smoking, and injecting can increase the community spread of the virus.
Homelessness: People with opioid use disorder and other drug use disorders are more likely to experience homelessness compared to the general population. Homelessness poses unique challenges in terms of transmission of the virus and access to healthcare.
Incarceration: People who use illegal opioid drugs like heroin often find themselves in prisons and jail systems, where the virus can spread rapidly, putting them at higher risk compared to those sheltering at home. However, it’s a catch-22 situation. Due to the pandemic, many states are releasing non-violent offenders into communities to reduce the risk of virus spread in prisons. Many of these people are rejected by their families and are finding it difficult to get a job during the pandemic. Therefore, releasing opioid-addicted people into the community without a treatment program or social support system in place can lead to very poor outcomes.
Changes in Opioid Addiction Treatment during COVID-19
Since 1999, the opioid crisis has claimed 750,000 American lives. As of October 2020, more than 225,000 Americans have succumbed to COVID-19. These two distinct crises have one thing in common—they have both caused suffering and death. The full impact of the combined COVID-19–opioid crisis will be revealed in the coming years. In the meantime, the intersection of the opioid epidemic and the COVID-19 pandemic in the United States has raised many thought-provoking questions about opioid addiction treatment. First, let’s take a look at some of the key changes made in the treatment of opioid use disorders during the COVID-19 pandemic. 
- Opioid treatment programs (OTPs) are exempted from performing in-person physical evaluations for patients who will be treated with buprenorphine, provided the licensed prescribing physician feels that adequate evaluation can be accomplished via telemedicine. However, this exemption does not apply to new patients who will be treated with methadone.
- OTPs can continue treating existing patients with methadone or buprenorphine using telehealth.
- Under the national health emergency, OTPs can provide methadone or buprenorphine with a blanket exemption of up to 14 doses for patients who are less clinically stable and up to 28 doses for patients who are more clinically stable.
- Mid-level practitioners can prescribe MAT (medication-assisted treatment) for opioid use disorder even in the absence of a supervising physician, provided the mid-level practitioner is licensed under the appropriate state and federal laws to dispense opioid drugs.
Opioid Addiction Treatment: Lessons from the Pandemic for the Future
The COVID-19 pandemic has been a life-changing event for most Americans. Like many such events, it has forced us to examine ourselves. For the medical community, the pandemic has thrown light on the shortcomings of the US healthcare system and social support structures. Addiction treatment is no exception. Interestingly, some of the changes brought about in opioid addiction treatment as a result of COVID-19 may be worth continuing in the future when the pandemic is behind us. Some important considerations in this regard are discussed below. 
Addiction treatment in general and opioid addiction treatment in particular are burdened with protocols. Many of these protocols, rules, and regulations are punitive in nature rather than evidence-based practices. For example, methadone and buprenorphine are known to significantly reduce the risk of opioid overdose, but these medications remain highly regulated and inaccessible to many people with opioid use disorder.
The strict regulation of medications like methadone and buprenorphine is often said to be necessary to promote safety and prevent illicit diversion. However, there is a culture of criminalization and stigma that limits their adequate use. Many of the rules regarding buprenorphine and methadone maintenance were relaxed overnight during the COVID-19 pandemic, revealing an alternate reality in which people with opioid use disorders have greater access to treatment, easier treatment initiation, and larger take-home doses. Also, mandatory urine drug screens and in-person counseling sessions have been done away with and adapted to remote monitoring and telemedicine. The question for the future is whether the high vigilance of patients on opioid maintenance is necessary, realistic, and sustainable or whether it is merely a barrier to accessing care.
Addiction treatment via telemedicine can help overcome many of the obstacles that opioid users face, such as transportation problems, arranging childcare, managing work, and waiting in long lines at treatment centers to provide urine samples for drug tests under supervision. Without these barriers, there may be better initiation and retention in opioid addiction treatment. Only time will tell what effects on opioid drug use will result from reduced regulation and lower threshold addiction treatment with opioid agonist medications like methadone and buprenorphine.
Another interesting fallout of the COVID-19 pandemic has been that thousands of incarcerated people who were housed in prisons on low-level drug charges have been released to prevent the spread of the virus in detention centers. This has raised questions about whether such offenders needed to be incarcerated in the first place. Incarceration of opioid users and other drug users often gives them minimal or no access to addiction treatment. The health risks associated with crowded prisons and navigation of the criminal justice system did not arise from COVID-19. Rather, they have been present for decades and are known to increase the risk of relapse and overdose, increase homelessness, and reduce access to healthcare. COVID-19 offers an opportunity to reflect on these changes and create a more equitable system that is focused on harm reduction rather than punitive measures.
Publication date: November 3, 2020
Last updated: March 9, 2023
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