As the pandemic ushered in isolation and financial hardship, overdose deaths reached new heights

Among the unrelenting death statistics flowing from the CDC last month, one grim non-Covid-19 statistic stood out: 81,003 deaths. That’s the number of people who died from drug overdoses in the 12-month period ending last June: a 20% increase and the highest number of fatal overdoses ever recorded in the U.S. in a single year.

The drug deaths started spiking last spring, as the coronavirus forced shutdowns, and more recent statistics from cities throughout the U.S. and Canada show the crisis has only deepened. In Colorado, overdose deaths were up 20% through the end of last year, and those involving fentanyl doubled; British Columbia officials reported nearly five overdose deaths per day in 2020, a 74% increase over the previous year; and a study released this month showed emergency room overdose visits increased up to 45% during the pandemic, even as total ER traffic slowed markedly.

The pandemic has ushered in stress, isolation, and economic upheaval — all known triggers for addiction and relapse — while robbing many people of treatment options and support systems. Addiction specialists across the country told STAT the overlapping health disasters — the historic Covid-19 pandemic colliding with a preexisting drug epidemic made deadlier by the potent synthetic opioid fentanyl — have been devastating for their patients. Many have simply disappeared; some have died; others have relapsed.

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“There’s all of these ways Covid-19 has hurt the folks we take care of,” said Stephen Taylor, a psychiatrist and addiction specialist in Birmingham, Ala., who serves as chief medical officer of the behavioral health division of Pathway Healthcare. “Efforts to get this under control have really been decimated by the pandemic.”

Taylor described a patient who spoke only Spanish and had been doing well in recovery from opioid addiction for several months. “He’d found this excellent all-Spanish AA meeting. But that group wasn’t able to go online,” Taylor said. “That guy was all of a sudden without his 12-step group, and he relapsed.”

The increase in opioid deaths is crushing to those who work in public health and addiction treatment, who were finally making headway, thanks to growing public attention and government funding. Overdose deaths had fallen in 2018 for the first time in years. But the spread of fentanyl began to erode those gains, and now the pandemic has severely undercut efforts to control the opioid epidemic; with public health officials focused so heavily on the coronavirus, suffering and death due to substance abuse has largely fallen off the radar.

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“While everyone’s focus is appropriately on the pandemic, we can’t lose sight of these other huge issues,” said Robert Rodriguez, an emergency room physician at Zuckerberg San Francisco General Hospital, who said his ER during the pandemic has seen far less trauma and victims of bar brawls, but far more cases of psychological distress and overdose. “Anecdotally, I can tell you drug abuse has definitely risen,” he said.

Even worse, addiction experts say, is that the financial toll of the pandemic means many cash-strapped health care systems are cutting addiction treatment programs just when they are needed most. “That feels like taking snow tires off as winter approaches,” said Charles Reznikoff, an addiction specialist with Minneapolis-based Hennepin Healthcare.

Covid-19 has exacerbated the opioid crisis — and escalated overdose deaths — in myriad ways. Larissa Mooney, an associate professor of psychiatry at UCLA, said she’s seen remarkable resilience in some patients, but also many who fell out of recovery as the pandemic dragged on. “It’s been a chronic situation that’s starting to wear people down,” she said. “There’s job loss, economic stress, and grief, all taking a toll.”

The particular way addiction can resculpt the brain has made the pandemic particularly challenging for those with substance use disorder. “People in recovery can have a hypersensitivity to stress and a diminished capacity to experience normal levels of reward. That’s a really tough combination,” said John Kelly, a professor of psychiatry in addiction medicine at Harvard Medical School and the founding director of the Recovery Research Institute at Massachusetts General Hospital.

Other pandemic-related factors may be increasing the death toll as well. As with other goods, supply chains for drugs have been unsettled during the pandemic. Experts said users turning to unknown suppliers can end up with counterfeit drugs that look like prescription pills but contain fentanyl, or with stimulants laced with fentanyl. With many restrooms and public spaces closed during the pandemic, people are now using drugs in more public areas, rushing and not always taking time to use test strips that can detect fentanyl, public health workers say.

Those who temporarily lose their supply because of the pandemic, or relapse and start using again, are susceptible to overdose because their tolerance can fall sharply. “I was taking 30 Vicodin a day and a fifth of booze,” said Fred, a former lawyer who is recovering from opioid use disorder and lives in the Pacific Northwest. He asked that only his first name be used. “If I had stopped and then taken 30, I would have died.”

It’s the isolation, though, that experts pointed to as the major contributor to the rising number of deaths. It keeps people from their social support networks and gives them more privacy to use substances. “People can’t be around friends, go outside to gyms and restaurants, all of those everyday activities that might mitigate anxiety and depression,” said Carla Marienfeld, a psychiatrist who directs the addiction recovery and treatment program at UC San Diego Health. “Addiction thrives in secrecy and in the pandemic, you have more people alone and not accountable to friends and family.”

That can be fatal for someone using drugs: If they overdose, no one is nearby to administer the antidote naloxone or summon help. Danny Vigliano, 35, a victim of both addiction and pandemic isolation, was found alone on the ground of a commuter rail station near Boston last August with fentanyl in his system. Moises Cruz, 45, overdosed alone on the streets of Philadelphia’s Kensington neighborhood in May.

“I have a disease that wants to get me alone and kill me and the pandemic is so isolating,” said Fred, who served two jail terms for stealing prescription opioids from open houses before entering recovery. “It’s a horrible disease. It’s not easy to manage in the best of times.”

Megan McAllister
McAllister works  in the Kensington neighborhood of Philadelphia. Hannah Yoon for STAT
Megan McAllister
McAllister carries a clipboard and paperwork for her outreach work. Hannah Yoon for STAT

The past year has been challenging for organizations that provide treatment and other support for people in recovery. Megan McAllister, a case manager with a Philadelphia nonprofit, knows this all too well. A 37-year-old mother of two and college graduate, she spent eight days in a coma after a 2016 overdose and is now three years into recovery from heroin addiction. What’s helping her get through the pandemic is helping others: Her employer, Prevention Point, has remained open throughout the pandemic despite the risk to its staff.

McAllister, who works in close quarters in a van with two colleagues and with clients, was infected with the coronavirus in November. She’s better now, and back to work. But because of social distancing requirements, clients must now line up outside the van and wait for services, even in the bitter cold.

“Only one person can come in at a time and it’s freezing outside and they’re waiting out there with barely a jacket and no hat and one shoe,” McAllister said. When temperatures dipped below 20 degrees, known in Philadelphia as a “Code Blue,” unhoused people used to be offered indoor space wherever it was available. “We put people upstairs, we put people downstairs. We put people wherever we can, but we can’t do that anymore,” she said.

Appointments are now required to safely space out patients in clinics. But it’s hard to make appointments without a working phone and the pandemic has shuttered many of the libraries and coffee shops that served as places for homeless clients to charge phones. “A lot of these people don’t have a phone or it’s been stolen,” McAllister said, meaning they can’t call if they run out of Suboxone, an addiction-treatment medication.

“Then they’re sick. It’s so unfair,” she said. “It’s always been bad, but with Covid it’s worse.”

The pandemic also forced her to cancel the in-person methadone maintenance support meetings she runs — critical because people who use methadone are not welcome at many AA meetings. McAllister said substance use is not just a problem on the gritty urban blocks where she works, but all over her city, including the wealthier suburbs. “With wine and spirits, it’s the same thing,” she said. “The pandemic may be the ultimate gateway drug.”

The pandemic has left many patients too frightened to leave home to seek care. Marvin Seppala, chief medical officer for the Hazelden Betty Ford Foundation, said calls to the foundation’s centers dropped dramatically once the pandemic started. “The people who did call were the most desperate they’d ever heard,” he said. “They were desperate to get into treatment, but scared to do so.”

Due in part to planning for an upcoming pilot study of virtual care, Hazelden Betty Ford was able to offer virtual therapy to 1,500 patients in a matter of days last spring. Patients could even meet requirements — like taking spit tests to prove they had not been using drugs — virtually. “We had them do the test while we watched,” Seppala said.

Inpatient services proved more challenging. Seppala’s centers didn’t limit occupancy in rooms — they have singles, doubles, triples, and quads — but tried to ensure safety by testing patients before admission.

At the beginning of the pandemic, it could take seven to 10 days to obtain test results for patients seeking inpatient services, Seppala said. People who had been admitted into medical units for observation or detox had to remain there until Covid tests came back negative, he said.

Such delays pushed Seppala to procure his own rapid testing machines. Testing led to another surprise: Less than 1% of incoming patients tested positive for Covid, far fewer than Seppala expected. “It’s just bizarre, I can’t explain it,” he said. “Addiction can be a very isolating disease. That may have helped prevent outbreaks.”

The stringent testing helped prevent outbreaks within facilities, but despite assurances of safety, many patients remain afraid to seek in-person care. “Our residential program admission drops precipitously with any surge that comes along,” said Seppala, whose program has 17 locations across the country.

UCSD’s Marienfeld said beds for inpatient treatment in San Diego remain limited because of social distancing requirements. Unlike Hazelden Betty Ford, Marienfeld’s facility saw far more interest from patients during surges. “When conditions are worsening, people are worried about all kinds of things,” she said. “Then we have times where we don’t get a single patient referral for weeks. We’ve really seen an ebb and flow.”

The need for care clearly remains high, however. “People are coming in really needing help at a critical level because they are waiting as long as they can,” Seppala said. “We’re expecting to have a long waiting list when this settles down.”

Zac Talbott, who is in recovery from an opioid addiction that started with prescriptions for minor knee and back pain nearly two decades ago, now operates opioid treatment programs in the southern U.S. Early in the pandemic, he and his patients lived through months of anxiety; his nurses made their own masks as patients came to the clinic in person daily to take their addiction medication in front of providers. “The rest of the world was shuttered and here our patients were traipsing to the clinic every day. They kept asking, ‘Can we have take homes?’” he said.

Things are easier now that federal restrictions for addiction medication have been loosened and his staff has received their Covid-19 vaccines. The need for services remains high. Talbott is about to open a new center in his hometown of Maryville, Tenn., outside of Knoxville. “Other businesses are closing their doors,” he said, “and I’m opening a new clinic — in the middle of the pandemic.”

“The people who did call were the most desperate they’d ever heard. … They were desperate to get into treatment, but scared to do so.”

Marvin Seppala, Hazelden Betty Ford Foundation

As with other areas of medicine during the pandemic, the ability to deliver medical and support services for addiction virtually has been transformative but imperfect. On the plus side, those in the field say the new technologies they sped into use could help them provide treatment to the estimated 90% of people with substance use disorder who go untreated.

While he wants to see more research to prove that virtual therapy can be as effective as in-person sessions, Harvard’s Kelly said he’s been won over. “We’ve all been awakened by this,” he said. “Zoom is a fantastic second best.”

But it’s not for everyone. While it might work for established patients, Kelly said it is much harder to develop rapport and earn trust with new patients over a screen. “You think about how stigmatized people with opioid use disorder are. They know they’re going to be judged, so gaining trust is a little bit harder when you’re not in an office where you can close the door.”

Marienfeld said video visits have been useful, but phone visits less so. “There’s a lot to be said for what you see,” she said, including if patients are agitated or intoxicated. When she’s worried about withdrawal or medical issues, she said, she asks patients to come in.

UCLA’s Mooney said she was pleasantly surprised with how virtual therapy worked out despite steep learning curves for both patients and providers, “People were coming on time and making their appointments,” she said. “Being in LA, we have a lot of traffic, and those barriers were removed.”

Mooney remains concerned about those who struggle with addiction in rural areas, who must often drive great distances to reach clinics, but generally have the least access to broadband. ”This is a population that can really benefit from telehealth, but we have to address these barriers,” she said. To get a Wi-Fi signal, said Taylor in Alabama, “we have people who sit in a McDonald’s parking lot so they can do Zoom meetings.”

People who have participated in support groups via Zoom say many regular in-person attendees have literally dropped off the screen, either because they don’t have internet bandwidth, they’ve relapsed, or they just don’t like meeting via the internet.

“There is so much to be gained from sitting in a room with other people, sharing, seeing their body language. There’s an intimacy and commonality I haven’t seen in other areas of life, it’s very rich,” said Fred, the recovering opioid user. “There’s something inherently dissatisfying about Zoom. You miss the warmth.”

“If it was totally safe, I’d go to a meeting,” he said. “That’s the first thing I’d do.”

Source: STAT