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By Christian Heidbreder, Ph.D. 

Understanding the issue

The Covid-19 pandemic continues to present severe critical treatment and access challenges for people struggling with substance use disorders. As we move into the second year of the pandemic, patients and physicians are struggling to combat these twin public health crises. For patients in treatment, as well as those trying to initiate treatment for the first time, substance use disorder (SUD) treatment regimens and access to them have been disrupted — and this is an issue that further exacerbates the existing challenges presented by the opioid epidemic.1 While researchers continue to advance new technologies to help mitigate the spread of Covid-19 and reduce the burden on our healthcare system, new challenges in SUD management for healthcare providers are also arising.

The Covid-19 pandemic disrupted how patients access care and critical medicines, including medicines used to treat SUD — especially patients with comorbid mental illnesses, who are at a higher risk of Covid-19 related complications and SUD misuse.2 In-office visits are shifted to telehealth appointments and providers have been unable to maintain routine, in-person appointments to manage patients’ SUD needs and medication regimens.3,1 Patients are experiencing longer wait times to get the care they rely on, and often, they might need to see a new physician who is unfamiliar with their medical history.4,5,6 While these changes were necessary to limit community spread of Covid-19 infections, hospitalizations, and death, every action has a consequential reaction, creating more hurdles for people with SUD to treat their illness and start (or stay on) the path to recovery.1

Changes in drug markets drive changes in drug-taking behavior

Shortages of several drugs at the street level, price increases for consumers on the black market, as well as reductions in purity, likelihood of adulteration, and contamination of heroin supply with synthetic opioids has triggered an increase in misuse of illicit substances and revealed shifts to more at-risk drug-taking behaviors and polysubstance use.7 We are seeing an increased availability of inexpensive, illicitly manufactured fentanyl and methamphetamine.8 The ease and cost-effectiveness of producing illicit fentanyl and synthetic opioids (often developed with higher potency) and methamphetamine shifted drug-taking behaviors in tandem with pandemic-induced economic hardships.9 During Covid, non-prescribed fentanyl use increased by 35%, non-prescribed use of amphetamine-type stimulants increased by 89%, and non-prescribed benzodiazepine use increased by 48%.9 Further, a rapid-response study in December 2020 identified a 41.3% increase in cannabis use in both previous and novel users.10 The increase in SUD misuse may be rooted in: stressors inflicted by the pandemic, the availability of inexpensive drugs, and the difficulty of accessing treatment.

Increase in substance use disorder diagnoses

These changes in drug-taking behaviors appear to correlate with an increase in SUD diagnoses.11 Consequently, patients are adapting in how they live with SUD7 amidst the inability to access consistent and reliable care. An analysis of electronic health records revealed that out of an overall total of 7.5 million SUD diagnosis, 722,370 of those were newly diagnosed Individuals.2

Patients with SUD at higher risk of contracting Covid-19

People with SUD are at higher risk of contracting Covid-19 and have a higher risk of negative outcomes.11 African Americans and Latinos are particularly susceptible,2,11 and treatment disparities were glaring prior to additional difficulties induced by the pandemic.12 In one study comparing outcomes of Covid-19 patients with and without SUD, those with SUD had more negative outcomes compared to Covid-19 patients without SUD.2 Death rates among African American Covid-19 patients with SUD were 6.4% higher than Caucasian Covid-19 patients with SUD.2

The increased risk in SUD patients for contracting Covid-19 is rooted in risk-taking, drug-seeking, and drug-using behaviors.2,13 SUD-related pre-existing cardio-pulmonary morbidities, mucociliary dysfunction, compromised immune system, vitamin deficiency, heightened risk of aspiration pneumonia, associated liver and cardiometabolic diseases, or increased risk of thrombosis make SUD patients at heightened health risks during the Covid-19 pandemic.14 The respiratory symptoms and sequelae of a Covid-19 infection coupled with the physiologic impacts of illicit drug use are colliding in Covid-19 patients with an active SUD to increase the risk of negative outcomes.2 Higher dosages of drugs such as benzodiazepines, opioids, and illicit fentanyl depress respiration and result in obtunded states of consciousness, therefore increasing the likelihood of pneumonia — risk factors further magnified by Covid-19.11

While observing these trends are essential for data collection, the debate and delay in social science research and enhancing inpatient and outpatient care do not favor positive outcomes where increases in substance use are already observed alongside increases in overdose deaths.15 Instead, pragmatic, and thoughtful calls to action have the potential to be more advantageous. First, we need to focus on developing clinical and policy strategies to expand access to medication-assisted treatment for people with SUD, especially those in early recovery who are at the highest risks of relapse, overdose, and death. Second, we must  utilize the vast resources and abilities of evidence-based medicine to target populations that are at the highest risk with funding, including:  medication access programs, public health campaigns, and effective treatments. Third, more research is required to understand the ways in which policy adaptations or changes during the pandemic have affected access to SUD treatment and patient outcomes. This research will help to  guide effective action plans to the current and  future unanticipated events that might impact SUD treatment. Fourth, although the age of telehealth is a boon to care delivery, low rates of identification of risk for SUD at screening, low rates of referral to telemedicine, digital device and internet access issues, and insurance coverage remain major barriers;16 furthermore, telehealth can burden patients in need of multimodal treatment, such as those with mental health needs and SUD. Finally, ensuring traditional medical delivery models are readily available for biopsychosocial disorders are essential to the health and recovery of high-risk and vulnerable populations.

What is the path forward?

The collision of the opioid epidemic and the Covid-19 pandemic has severe consequences for people struggling with SUD. The pressure of the pandemic resulted in changes in drug-taking behaviors, which was further compounded by the availability of more potent and less expensive drugs.9 For people in treatment and those who were trying to initiate SUD treatment, the shift to telemedicine was an additional barrier to care.1 Supply chains became strained, hospital resources were stretched to their breaking points, and physicians took on even more complex comorbidities. Consequently, patients likely adapted their drug taking patterns because of their isolation, anxiety, and depression during the pandemic, presenting even greater challenges for treatment providers trying to manage SUD. While the introduction and expansion of critical measures to help end the pandemic are continuing to roll out in the forms of expanded Covid-19 testing, vaccinations, and supportive care, we must not forget that the opioid epidemic’s demands are also expanding. Stigma toward drug use and even sometimes toward the use of pharmacotherapies has led to stigma codified into laws or regulatory frameworks that govern access to treatment. The current pandemic is an opportunity to destigmatize SUD and remove restrictions that have translated into barriers to treatment access. Healthcare leaders and policymakers should therefore be inspired to embrace SUD treatment in a collaborative spirit and focus on strategies that best serve the needs of patients who are disproportionately affected by SUD and other comorbid conditions. Developing targeted, evidence-based strategies for helping people with SUD begin and remain on the recovery journey has the potential to improve outcomes and reduce the burden on our healthcare system as our nation recovers from Covid-19.

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Christian Heidbreder, Ph.D., is the Chief Scientific Officer of Indivior Inc.
E: [email protected] 


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