A CRISIS WITHIN A CRISIS: OPIOID AND COVID-19

A CRISIS WITHIN A CRISIS

THE OPIOD EPIDEMIC AND THE COVID-19 PANDEMIC

By Sanjana Rao Anna Argulian

The COVID-19 pandemic has devastated the United States, killing approximately 225,000 people over the last 10 months. However, over the two decades before COVID-19 reached American shores, a more insidious epidemic has been ravaging the country. In 2018, it was estimated that 128 people died of an opioid overdose every day, leading to an overall total of 450,000 opioid related overdoses from 1999 to 2018. Among those who survived, chronic opioid abuse has been shown to inflict critical damage to their pulmonary and respiratory health, placing them at high risk of developing severe symptoms should they contract COVID-19. Moreover, many such individuals are already at risk from a socioeconomic standpoint, as a large majority are either homeless or incarcerated. The opioid crisis in the USA has not disappeared under the onslaught of COVID-19. On the contrary, affected individuals are now more vulnerable than ever.

Opioids refer to a class of drugs that bind to opioid receptors, blocking pain signals from the brain and stimulating the release of dopamine, resulting in feelings of euphoria. Users find themselves craving the drug, as it strongly reinforces the wish to repeat the experience. Commonly abused opioids include Hydrocodone (Vicodin®), Oxycodone, Fentanyl, Morphine, Codeine, and Heroin, some of which are prescribed as pain medication. Substance Use Disorder (SUD), or more specifically, Opioid Use Disorder (OUD), is highly prevalent in the United States, with an estimated 2 million suffering from it and more than 10 million people misusing or abusing opioids. OUD has been associated with a long list of adverse effects, including chronic kidney, liver, and lung diseases, as well as cardiovascular diseases, type 2 diabetes, obesity, and cancer. Chronic opioid misuse is associated with disordered breathing, which can result in hypoxia, or low oxygen levels in the brain. Similarly, studies show that up to 10% of patients who take opioids over long periods develop hypoxemia, which is an oxyhemoglobin saturation of lower than 90%. Low oxygen levels can lead to permanent brain damage and can severely damage the workings of several organs, including the lungs and heart. A recent study among Medicare patients suffering from arthritis that compared the effects of opioid prescriptions with NSAIDs and COX-2 inhibitors found that opioid therapy was correlated with a 77% increased risk of cardiovascular events. COVID-19 has been demonstrated to have (according to data from the Chinese Center for Disease Control and Prevention) a fatality rate of triple the normal fatality rate in patients with chronic respiratory disease. Further data from the CDC indicates that patients with comorbidities are at a higher risk of hospitalization with COVID-19, as well as fatal complications. Moreover,

various opioids, especially fentanyl and morphine, have been shown to have immunosuppressive properties—as they behave like cytokines, modulating immune responses by binding to the μ-opioid receptor on immune cells. Thus, a great percentage of the population is potentially at a higher risk of developing more severe symptoms of COVID-19. It is important to note that the COVID-19/opioid epidemic overlap cuts both ways. As opioid use often results in slow breathing and lower oxygen levels, compromised lung function due to COVID-19 could potentially increase the risk of a fatal overdose even among those who use opioids in a purely therapeutic manner.

These populations are not only vulnerable from a scientific standpoint. Several indirect factors, such as housing instability and stress can increase their risk of contracting both OUD and COVID-19, and as many as 35 million people may face eviction this October as a result of the economic and housing crises that accompanied the rise of COVID-19. Disturbance of the financial stability of families can often serve as a trigger for a downward spiral that both increases the risk of developing a substance use disorder as well as relapse. A large percentage of those suffering from OUD are already either homeless or incarcerated, both of which increase their likelihood of catching COVID-19 as they lack access to personal protective equipment, sanitation, and social distanced shelters. Demographics play a role as well in determining the likelihood of COVID-19 complications. A study published in September 2020 demonstrated that African American individuals with substance use disorders, specifically OUD, have significantly adverse outcomes as compared with Caucasian (both healthy and with OUD) individuals, in terms of fatality and hospitalization. Moreover, 60% of those with OUD declared incomes equal to or below 200% of the federal poverty level in 2017, leading to another socioeconomic concern that plagues this population: access to insurance. An estimated 18% of the 2 million middle-aged adults with OUD lack insurance. This provides a large roadblock in the efforts to contain both crises as multiple studies have shown that individuals without health coverage are unlikely to seek treatments recommended to them. This suggests that those who are uninsured and suffering from OUD and COVID are unlikely to get the treatment that they most likely require.

Preventing relapse and facilitating healthy recovery were essential components of the fight against

the opioid crisis before COVID-19. However, as mentioned previously, the stress and instability sparked by the pandemic has increased the likelihood of relapses. Unfortunately, COVID-19 has severely impacted the efficacy and logistics of rehabilitation programs in various ways. Firstly, rehabilitation programs rely on objective methods of assessment such as breathalyzer and urine tests to measure a patient’s progress and to serve as a deterrent against relapse. As these tests involve contact with bodily fluids and in-person collection, they increase the likelihood of spreading COVID-19 resulting in their discontinuation by multiple rehabilitation centers for the time being. Other challenges that rehabilitation centers face include the obstacles posed by social distancing measures which hinder efforts to foster a stress-free communal environment. Virtual programming has its own complications, and in-person and socially distanced events lack the supportive atmosphere of pre-COVID rehabilitation procedures, which often involved hugs and physical support. Visitors and even their family members have been limited or barred entirely from numerous facilities, increasing the isolation of patients and impairing their recoveries. In the event of an overdose, social distancing decreases the likelihood of the individual being found and treated, increasing the probability that the overdose results in a fatality. Naloxone, a drug that reverses the effects of an opioid overdose, is also less likely to be administered as it is commonly administered via the nose, which would put bystanders at risk of contracting the virus. In addition, due to FDA regulations, most treatments for OUD must be picked up in person, increasing individuals’ risk of catching COVID-19.

A large percentage of our population is in a highly vulnerable state, at the crossroads of multiple crises. The solution to this problem requires a multi-pronged approach, from improving sanitation and infrastructure for the homeless to ensuring at-risk individuals receive the medications and treatment they need. Policy must be implemented to save the millions of people who are on the edges of or are directly in the center of the opioid epidemic and have the threat of COVID-19 looming over their heads.

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