The pandemic may fuel the next wave of the opioid crisis

There’s usually a stream of people headed into the unassuming brick building in the Cedar Rapids neighborhood where Sarah Ziegenhorn runs the Iowa Harm Reduction Coalition. In 2016 when she moved back to Iowa to begin medical school, Ziegenhorn started the small nonprofit to help people who use drugs. Today, the drop-in center provides medical testing, counseling, and free supplies to more than 5,000 people a year.

But during the COVID-19 pandemic, that work has only gotten harder, both in Iowa and nationwide. Amid widespread strains on the health-care system, the United States remains in an overdose crisis—more than two million Americans use opioids, and half a million use meth every week. A staggering 46,000 Americans died of overdoses in 2018. While COVID-19 has a disproportionate impact on various vulnerable populations, people with drug addictions are facing unique challenges in response to COVID-19.

Among those challenges, people who use drugs are more likely to be alienated from traditional news sources, and so are not as likely to hear information about risks and best practices during a pandemic. Some users also are skeptical of authority due to previous interactions with law enforcement, and they distrust the government’s health advisories.

Even when users do receive public health messages urging social distancing or frequent handwashing, they may lack the resources to adopt such practices if they’re financially insecure, living in shelters, or incarcerated. People with addictions are also more likely to be immunocompromised and have reduced access to healthcare.

In short, “the people who are already the most vulnerable are made even more vulnerable in a pandemic,” says Corey Davis, a public health lawyer at the Network for Public Health Law.

Dangers of withdrawal

Border closures and travel restrictions spurred by COVID-19 likely are disrupting drug markets. So some harm reduction clinics have been preparing their clients for interruptions in the supply of illicit substances.

“Overdoses go up, paradoxically, as supply goes down,” says Daniel Ciccarone, a professor at the UCSF School of Medicine. During shortfalls, people will substitute drugs they’re less familiar with, or change their habits, making dosing less reliable and potentially causing a spike in overdoses. A chagrined Ciccarone predicts that the pandemic may usher in a fifth wave of the opioid crisis.

Tom Sloben, a former heroin user who started using meth after his partner died of an overdose, says COVID-19 has made it harder to buy illicit drugs. He’s now struggling with the fallout of reduced meth use: “It’s like you got two 300-pound weights on each side of your body—it just brings you down,” he says.

Suddenly stopping crystal meth can cause intense anxiety and depression, and withdrawal from heroin and fentanyl are notoriously difficult. “I know people who have killed themselves going through it,” Ziegenhorn says.

For people with dependencies, there’s also risk associated with reduced access to legal drugs such as alcohol. When liquor stores shut down—as happened for several weeks in Pennsylvania in March—people are more at risk of withdrawal seizures, which can be fatal, says Kimberly Sue, New York-based medical director at the national nonprofit Harm Reduction Coalition.

That’s why harm reduction organizations have long advocated for easier access to medications such as methadone and buprenorphine, which can help minimize withdrawal symptoms, reduce cravings, and prevent opioid overdoses. In the United States, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Administration (DEA) regulate access to these medications, and their requirements have long presented obstacles to accessing the drugs.

Previously, people who wanted to take methadone, for instance, had to visit an authorized opioid treatment program, where the drug can be administered under daily supervision. That can be impossible for people who have childcare issues or inflexible work hours, or who don’t live near the clinic. Physicians also faced hurdles in providing patients buprenorphine, because the DEA required additional training and a waiver in order to prescribe it.

Over the last month, SAMHSA and the DEA have eased these restrictions to help reduce the spread of the novel coronavirus. People who are in treatment for addiction but considered “stable” are now allowed to take home up to 28 days of methadone, and get a new buprenorphine prescription after a telephone call rather than an in-person visit.

“We were hearing from some of our states that they were seeing clinics having trouble maximizing the amount of care they could provide, because they had staff getting sick,” says Assistant Secretary Elinore McCance-Katz, the head of SAMHSA. She says she hopes the eased restrictions on telehealth become permanent. Compared to the same time period a year ago, the administration’s disaster distress helpline has seen a nearly 900 percent increase in calls over the past month, McCance-Katz says.

But advocates say that treatment programs have been slow to adopt the new guidelines, and the rollout has varied by state. Daliah Heller, director of drug use initiatives at Vital Strategies, a global public health organization, calls COVID-19 “the perfect storm for folks who are substance dependent.”

Problems in prisons

Not only does COVID-19 make addiction services harder to access; people who use drugs may be at higher risk of infection given the dangerous overlap between addiction, incarceration, and the rapid spread of infections within confined spaces. The Rikers Island jail complex in New York has already reported at least 365 COVID-19 cases—roughly nine percent of its population.

Campaigns to get nonviolent drug offenders released during the pandemic may not be sufficient, says Leo Beletsky, professor of law and health sciences at Northeastern University. He says prisoner re-entry into regular society is difficult and dangerous from a health perspective, even during normal times. As the economy collapses, shelters and food banks have been overwhelmed, with already limited resources stretched thin.

Family support structures may also be vanishing during the pandemic, says Jonathan Giftos, the medical director of addiction medicine at the nonprofit Project Renewal. During COVID-19, “people’s lives are more difficult in ways that make it harder to be supportive of family struggling with addiction—which is already baseline challenging.”

Even when self-isolation is possible, it can be hazardous for drug users, who may overdose with no one around to help them. That’s a tragedy Ziegenhorn has experienced personally.

She met her fiancé, Andy Beeler, just after he was released from prison for drug-related crimes, and not long after the IHRC launched. They bonded over the common goal of “keeping people alive,” she says, and frequently talked about harm reduction advocacy over the phone. The first time they met in person, “I thought, OK, we’re going to get married,” says Ziegenhorn.

Beeler tried to overcome his occasional heroin use, but it was a struggle. Because he was on parole, he worried about taking medications such as methadone or buprenorphine and having a false-positive drug test. The couple had been together a year when Beeler fell on the ice, dislocated his shoulder, and quickly became opioid dependent again.

Ziegenhorn caught and reversed Beeler’s overdoses several times. Then one day, she had to go to the hospital early for a surgery rotation. Beeler was still asleep when she left. Later that day he didn’t reply to her texts. Ziegenhorn asked a friend to go check on him. Beeler was dead; he had overdosed.

Knowing that “unbelievable, unimaginable pain” of losing a loved one, Ziegenhorn and her co-workers are keeping the Iowa clinic running during the pandemic, offering services even with the heightened risks that they face. She fears that if the clinic closes, the people it helps won’t have anywhere safe to turn.