In marginalized populations, the 2019 coronavirus disease (COVID-19) pandemic has exacerbated existing problems and created new challenges at the same time. The results show that COVID-19 has had a greater negative impact on economic and work-related factors among women, racial and ethnic minorities, and low-income workers
For people who use drugs (PWUD), illegal drug use behavior can become even more risky due to COVID-related circumstances, increasing the exposure to infectious diseases and the risk of overdose. A recent study showed an increase in cardiac arrest-related overdose reported in a national emergency medical services database. Rates were approximately 50% higher during the pandemic months than they were before the pandemic. 2
Social distancing requirements can make people more likely to use drugs on their own, which has been linked to an increased risk of death from an overdose. Meanwhile, tightened international border restrictions have increased the variability and potential toxicity of the illicit drug supply. Additionally, there has been less access to harm reduction and addiction treatment services since the beginning of the pandemic
The convergence of these public health emergencies (rising overdose rates, COVID-19) with the ongoing risk of HIV and hepatitis C virus infections in PWUD represents a growing syndem, according to a study published in the Journal of Studies on Alcohol and Drugs.3A Dar syndemia can “worsen or accelerate the progression of the disease and its social consequences,” wrote Matthew Bonn of the Canadian Association of Drug Users in Nova Scotia and researcher at several Canadian universities.
While the study’s authors pointed to the need to expand existing services, including syringe distribution services, takeaway naloxone, and addiction treatment, they suggested that innovative approaches are needed to effectively prevent overdose deaths and infectious diseases from PWUD. They stated that implementing compassionate responses, including decriminalizing personal drug use, could reduce the effects of the syndeme on PWUD.
These steps would result in a lower rate of medical complications than those related to criminalization of drug use, while reducing stigma and improving timely access to health services, including harm reduction services and substance abuse treatments. Such efforts can also reduce the risk of incarceration and help prevent the spread of COVID-19 in prisons.
Another proposed action is to provide PWUD with a safe supply of pharmaceutical grade drugs such as hydromorphone, diazepam, methylphenidate and diacetylmorphine. Pointing out the high rate of overdose deaths associated with illicit fentanyl and fentanyl analogs, access to pharmaceutical grade drugs would ensure that they are appropriately dosed and not adulterated, allowing PWUD to reduce the risk of accidental overdose due to toxic illicit drug supply, “Schreiber Bonn et al. They discussed the need to remove various barriers to decriminalization, including conflicts with standard vendor prescribing practices.
“This pandemic is not only a public health crisis, but also an opportunity to develop and sustain equitable and sustainable solutions to the harms associated with drug criminalization,” the authors concluded.
For an additional perspective on this topic, we asked Dr. Anna Lembke, Associate Professor and Medical Director of Addiction Medicine in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in California. Dr. Lembke wrote a comment on the article by Bonn et al. Which was published in the same journal. 4
How is PWUD uniquely affected by the COVID-19 pandemic?
The pandemic and the slowdown in our global economy have disrupted the illicit drug supply and, to some extent, even the legal drug supply. As a result, some PWUD are turning to new sources, not always reliable sources (e.g. fentanyl fortified medicines), and in some cases new medicines. Unstable drug supplies, coupled with increased isolation and variable access to drug addiction treatment facilities, may contribute to an increase in overdose deaths.
Do you see evidence for the syndemic Bonn et al mentioned in your paper?
I have let a patient die of a fentanyl overdose since the pandemic started. It’s hard to know if this would have happened without the pandemic – it certainly is possible. I’ve also seen an increase in the number of people seeking treatment. This could be one of the silver linings of the pandemic. International data show an increase in the number of people seeking addiction treatment around the world since the beginning of the pandemic
The bottom line is that it’s too early to say how COVID-19 will fully affect PWUD. Early reports of overdose deaths vary by region, with some regions reporting an increase in overdose deaths and others a decrease. As above, preliminary reports suggest an increase in people seeking addiction treatment. In other words, just as there have been winners and losers in the global economy since the pandemic, we are likely to see different results in people who use drugs too.
What do you think of some of the Bonn et al. Suggested solutions, such as expanding existing services, temporarily decriminalizing illicit drugs, and providing safe drug supplies to address some of the effects of the pandemic on PWUD? What other solutions do you consider necessary?
Even before the pandemic, we as a country had to expand existing addiction treatment services. Less than 1 in 10 addicts in the United States have access to addiction treatment.6 Ironically, the pandemic improved access to addiction treatment overnight by enabling the immediate use of telehealth services, thereby significantly increasing addiction treatment services for people living in rural, geographically remote and remote areas underserved communities that are another silver lining.
I suspect telehealth will remain a mainstay of addiction treatment even after the pandemic ends, which means we need to rethink the way we deliver services. One of the bigger challenges in telehealth is drug surveillance. Urine toxicology, for example, is an important part of ensuring a safe supply of prescription drugs. Since the beginning of the pandemic, regular urine toxicology examinations have fallen by the wayside. We need more telemedicine-friendly methods of collecting biological samples for drug monitoring.
I do not believe that decriminalizing illicit drugs and providing so-called “safe care”, even temporarily, is a solution to our drug addiction and COVID-19 pandemics. The decriminalization of hard drugs such as cocaine, methamphetamine, and heroin is certain to contribute to increased use, and thus increased morbidity and death. Providing hard illegal drugs to PWUD in isolation increases the risk of death from overdose. Even now, we continue to struggle with the abuse, addiction, and distraction from prescription opioids, a major culprit and trigger of our current opioid epidemic. What we need instead is sensible and safe monitoring of prescription drugs and a criminal justice system that incentivizes treatment for those who use illicit drugs.
What are the recommendations for clinicians on how to support these patients in practice and advocate for them on a broader scale?
Understand addiction as a disease and help destigmatize treatment. Realize that prescription opioids are just as addicting as heroin. Avoid new beginnings and maintenance doses, except in rare, extreme, palliative cases. Participate in telemedicine to support our most isolated and marginalized patients.
1. Kantamneni N. The Impact of the COVID-19 Pandemic on Marginalized Populations in the United States: A Research Agenda. J Vocat Behav. 2020; 119: 103439. doi: 10.1016 / j.jvb.2020.103439
2. Friedman J., Beletsky L., Schriger DL. Overdose-related cardiac arrests observed by emergency services during the U.S. COVID-19 epidemic. JAMA psychiatry. Published online on December 3, 2020. doi: 10.1001 / jamapsychiatry.2020.4218
3. Bonn M., Palayew A., Bartlett S., Brothers TD, Touesnard N., Tyndall M. Combating the syndrome of HIV, hepatitis C, overdose, and COVID-19 in drug users: the possible roles for decriminalization and safe care. J Stud Alcohol Drugs. 2020; 81 (5): 556- 560. doi: 10.15288 / jsad.2020.81.556
4. Lembke A. Insecure Supply: Why Providing Controlled Prescription Drugs For Unattended Use Is Not For The Syndrome Of HIV, Hepatitis C, Overdose, And COVID-19: A Commentary On Bonn et al. J Stud Alcohol Drugs. 2020; 81 (5): 564- 565. doi: 10.15288 / jsad.2020.81.564
5. United Nations Office on Drugs and Crime (UNODC). Research report: COVID-19 and the drug supply chain: from production to trade to use. Published on May 7, 2020. Available online January 7, 2021.
6. US Department of Health. Summary: Surgeon General’s Report on Alcohol, Drugs, and Health. Accessed online on January 7, 2021.
This article originally appeared on Infectious Disease Advisor