By Dr. Nora Volkow
September is Recovery Month, an occasion to focus on the needs of the millions of people in the U.S. living with a substance use disorder (SUD) as well as celebrate those who are trying or succeeding in putting drug use behind them. The stress and isolation of the COVID-19 pandemic are presenting enormous challenges for these individuals, but ultimately the altered realities of healthcare may create opportunities to reach more people with services and possibly even increase the reach of recovery support systems.
Significant increases in many kinds of drug use have been recorded since March, when a national emergency was declared and our lives radically changed due to lockdown and the closure of businesses and schools. In late April/early May, the Addiction Policy Forum (APF) conducted a survey of 1,079 people with SUDs nationwide, on how they were being impacted by the pandemic. Twenty percent of the respondents reported that their own or a family member’s substance use had increased since the start of the pandemic. And an analysis of a nationwide sample of 500,000 urine drug test results conducted by Millennium Health also showed steep increases following mid-March for cocaine (up 10 percent), heroin (up 13 percent), methamphetamine (up 20 percent) and non-prescribed fentanyl (up 32 percent).
Comprehensive national data are not yet available on overdoses, but data from some states such as Kentucky and Georgia as well as anecdotal reports suggest increases in overdose deaths and drug-related emergency room admissions in the first half of 2020 compared to last year. The Overdose Detection Mapping Application Program, a surveillance tool developed by the Washington/Baltimore High Intensity Drug Trafficking Area (HIDTA), reported increases in overdose reports in 62 percent of participating counties nationwide, and that overall overdose report submissions increased by 18 percent after stay-at-home orders commenced in mid-March. Clusters of overdoses seemed to shift from urban centers to suburban and rural locations. (One state, Kentucky, subsequently experienced a decline in overdoses after the state reopened.) In the APF survey, 4 percent of respondents reported an overdose since the beginning of the pandemic.
There are many anecdotal reports that people with SUDs are having to wait longer to obtain treatment, and closures of treatment centers have also limited access. More than a third (34%) of the respondents in the survey by APF had experienced disruptions accessing treatment or recovery support since the start of the pandemic, and 14 percent said they were unable to obtain needed services. There are reasons to expect that lower-income people and minorities could be especially affected. Despite implementing widespread COVID-19 testing, community health centers, which predominantly serve disadvantaged populations, are seeing declines in patient visits and are experiencing staffing problems.
The good news is that policy changes facilitating telehealth and expanding access to medications for opioid use disorder may compensate somewhat for these problems. People with opioid use disorders can now begin treatment with buprenorphine without an initial in-person doctor visit, which used to be the rule. Methadone treatment previously required daily supervised dosing with tightly controlled take-home options, but patients deemed stable may now obtain 28 days of take-home doses; others may receive 14 days of doses. Changes to Medicare and Medicaid rules are also enabling telemedicine consultations for SUD to be reimbursed more easily. These developments may particularly benefit people who live in rural areas or who otherwise have had trouble accessing treatment in the past, and NIDA has provided supplemental funds to grantees to evaluate the impact of such changes. Inevitably, since many people with SUDs do not have computers or smartphones, other innovative methods, such as combining telemedicine with street outreach, will be critical to ensuring that all people receive the care they need.
The stresses of the pandemic and the social isolation resulting from distancing measures may take an especially great toll on people trying to achieve or in recovery from an SUD. Three quarters of the APF survey respondents reported emotional changes since the beginning of the pandemic, especially increased worry (62%), sadness (51%), fear (51%), and loneliness (42%). These emotions increase the risk for relapse, and unfortunately, circumstances since the pandemic have made peer support, for instance in 12-step meetings and similar groups, much more difficult.
While online recovery supports may not be an option for all and cannot fully capture the in-person experience, here, as in the realm of treatment, teleconferencing tools and smartphone apps are helping some people adapt to restrictions on physical gatherings. Several of the startups NIDA has helped through our Office of Translational initiatives and Program Innovations, for instance, have now adapted their tools to deliver counseling or facilitate peer connection during COVID-19.
COVID-19 continues to be an uncertain, ever-evolving reality, and its impacts are particularly being felt among those with addiction and those in recovery from substance use disorders. At this point, there is very sparse data on how SUDs are affecting COVID-19 susceptibility and outcomes, although findings are emerging and I will address them in a future blog. As we think about and support this community, this month and every month, we need to imagine and implement new ways of facilitating treatment delivery and needed recovery supports under these new circumstances.