Linked National Crises: Overdose in the Time of COVID-19

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Linked National Crises: Overdose in the Time of COVID-19

The global pandemic of COVID-19 threatens every nation, demanding urgent efforts to meet the changing health care needs of their populations. At the same time, the United States faces a concurrent epidemic of drug-related overdose deaths. The effects of COVID-19 are particularly severe for individuals and families facing substance use disorders. Considering substance use disorders and overdose deaths must be a part of the national response to COVID-19.

Prior to the COVID-19 pandemic, the number of overdose deaths in the US rose steadily from 1990 peaking in 2017 with over 70,000 overdose deaths. Largely because of an increase in overdose deaths and suicides, US life expectancy declined for three straight years, from 2015 to 2017– the first decline since 1918 when the nation faced the previously disastrous flu pandemic.¹ Overdoses were not a factor in the deaths recorded at that time. What is happening now is a new, and worrisome trend that threatens several years of focused national and local efforts to reduce overdose deaths. In 2018 the US experienced a modest decline in drug overdose deaths, with a drop to 68,557. New preliminary data from the Centers on Disease Control and Prevention shows that progress was lost. A new record in overdose deaths was set at 71,999 in 2019.^2,3 Data from the Overdose Detection Mapping Application Program (ODMAP) indicates that yet another new record will be set during the era of COVID-19.

ODMAP, which collects data on overdoses from communities across the country, reports that in 2020 all overdoses – both fatal and non-fatal – increased compared to the same months in 2019: an 18% increase in March, a 29% increase in April, and a 42% increase in May.^4,5,3 Other national indicators suggest that illicit drug use is increasing. Following the March 13, 2020 declaration of COVID-19 as a national emergency, urine drug testing positivity rates showed statistically significant increases for fentanyl, methamphetamine, and cocaine.⁶ The positivity rate for heroin also increased but did not reach statistical significance.

We are losing the limited but important progress previously made in the battle to curb the overdose epidemic for several reasons. First, the drug supply is lucrative, widespread, and adaptable to COVID-19 related changes in the marketplace. Second, the COVID-19 pandemic has hindered significantly and even closed many inpatient and outpatient substance use disorder treatment programs. Third, the pandemic has incapacitated many community-based recovery support networks including, but not limited to, Twelve Step fellowships of Alcoholics Anonymous and Narcotics Anonymous. Fourth, substance use is often social, but it is also solitary; the broad isolation the population faces during COVID-19 may increase substance use and subsequent risk of overdose. As warned by Nora Volkow, MD, Director of the National Institute on Drug Abuse (NIDA), “Social distancing will increase the likelihood of opioid overdoses happening when there are no observers who can administer naloxone to reverse them and thus when they are more likely to result in fatalities.”⁷ Perhaps not surprisingly, a comparison of overdoses reported to ODMAP during pre-stay-at-home orders and post-stay-at-home orders in 2020 showed a 17.5% increase in all fatal and non-fatal overdoses.⁵

What can be done about the national rise in overdose rates?

• Use discussions of COVID-19 to highlight the problem of addiction, which is often solitary and hidden. Encourage families and others to intervene strongly when their loved ones are actively engaged in substance use. Get them into treatment and engaged in recovery support.
• Recognize the added threats of relapse even among those in recovery from substance use disorders in the time of COVID-19.
• Use media outlets aggressively to educate the public about the health threat posed by substance use, the warning signs of overdoses, and how to access and use naloxone to reverse an opioid overdose.
• Fund substance use disorder treatment and support programs as they innovate care during the COVID-19 pandemic. The American Medical Association recently outlined several action steps⁸ for states to take, including adopting rules and guidance from the Substance Abuse and Mental Health Services Administration (SAMHSA)⁹ and Drug Enforcement Administration (DEA)¹⁰ for programs that treat individuals with opioid use disorders.

As the nation faces the linked crises of the COVID-19 pandemic and a resurgence in overdoses, we must identify, protect, and assist those who are the most vulnerable. This includes individuals with substance use problems.¹¹

Robert L. DuPont, MD, IBH President

Caroline DuPont, MD, IBH Vice President

Corinne Shea, MA, IBH Director of Programs and Communications

References

[1] Woolf, S. H., & Shoomaker, H. (2019, November 26). Life expectancy and mortality rates in the United States, 1959-2017. JAMA, 322(20), 1996-2016. doi:10.1001/jama.2019.16932

[2] Ahmad, F. B., Rossen, L. M. & Sutton, P. (2020). Provisional drug overdose death counts. National Center for Health Statistics, US Center for Disease Control and Prevention. Available: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

[3] Katz, J., Goodnough, A., & Sanger-Katz, M. (2020, July 15). In shadow of epidemic, U.S. drug overdose deaths resurge to record. The New York Times. Available: https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html

[4] Wan, W., & Long, H. (2020, July 1). ‘Cries for help’: drug overdoses are soaring during the coronavirus pandemic. The Washington Post. Available: https://www.washingtonpost.com/health/2020/07/01/coronavirus-drug-overdose/

[5] Alter, A., & Yeager, C. (2020, June). COVID-19 impacts on US national overdoses. Overdose Detection Mapping Application Program. Available: http://www.odmap.org/Content/docs/news/2020/ODMAP-Report-June-2020.pdf

[6] Millennium Health. (2020, July). COVID-19 Special Edition: Significant Changes in Drug Use During the Pandemic. Millennium Health Signals Report volume 2.1. Available: https://resource.millenniumhealth.com/signalsreportCOVID

[7] Volkow, N.D. (2020, April 2). Collision of the COVID-19 and addiction epidemics. Annals of Internal Medicine, 173(1), 61-62. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138334/

[8] American Medical Association. (2020, July 8). Issue brief: reports of increases in opioid-related overdose and other concerns during COVID pandemic. AMA Advocacy Resource Center. Available: https://www.ama-assn.org/system/files/2020-07/issue-brief-increases-in-opioid-related-overdose.pdf

[9] Substance Abuse and Mental Health Services Administration. (2020, March 19). Opioid treatment program (OTP) guidance. Available: https://www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf

[10] Drug Enforcement Administration. (2020, March 31). Prevoznik, Thomas W. Letter to DEA Qualifying Practitioners and DEA Qualifying Other Practitioners. Available: https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-022)(DEA068)%20DEA%20SAMHSA%20buprenorphine%20telemedicine%20%20(Final)%20+Esign.pdf

[11] Pfefferbaum, B., & North, C. S. (2020, April 13). Mental health and the Covid-19 pandemic. New England Journal of Medicine. Available: https://www.nejm.org/doi/full/10.1056/NEJMp2008017

World Drug Day 2020

IBH President Robert L. DuPont, MD represents North America as a Member of the Board of Directors of the World Federation Against Drugs (WFAD). At the request of WFAD he wrote the following statement to celebrate International Day Against Drug Abuse and Illicit Drug Trafficking, better known as World Drug Day on June 25, 2020.

Click here to download or print a PDF copy of this statement.

Although the challenges posed by the COVID-19 pandemic are dominating our lives, let us not forget the equally deadly pandemic that continues to rage across the globe: drug abuse. This modern scourge, started in the late 1960s, continues to enslave and kill people of all nations in ever-changing ways. In Sweden, one of the first places the drug use pandemic hit, psychiatrist and professor, Nils Bejerot worked with the Stockholm police to fight the rising tide of methamphetamine and heroin use. Dr. Bejerot saw that the government’s initial response of providing users with physician-prescribed opioids and stimulants was futile. Not only did this policy fail to reduce drug use, but many of those drugs were diverted by users and ended up being sold on the street, leading to increased levels of drug use overall. Based on his first-hand experience with hundreds of patients, Dr. Bejerot concluded that providing addicts with drugs only prolonged their addiction and encouraged the spread of drug use throughout Swedish society. He saw that the only way to free users from the grip of addiction was to insist that they remain abstinent from all drugs. The world owes a debt of gratitude to Dr. Bejerot. Thanks to the instrumentality of his efforts over 50 years ago, Sweden’s commitment to abstinence-based drug use prevention and treatment was born.

With such a history it comes as no surprise that in 2009 the World Federation Against Drugs was established in Stockholm to create a better drug policy vision for the world by building on the Swedish experience. This was a vision in stark contrast to the increasingly dominant view that the most appropriate public health response to addiction was “harm reduction.” That strategy sought to reduce some of the harm produced by addictive drug use while permitting and even sometimes encouraging continued drug use.

WFAD is not opposed to harm reduction programs as a part of the response to the modern drug epidemic—as part of a continuum of care ending in treatment. However, WFAD insists that these programs be evaluated on the basis of their ability to help addicts become drug-free. That means seeing harm reduction as a step toward eventual abstinence. Although facilitating drug use among addicts is better than allowing them to die from overdose, such use is not in their own long-term interest as it carries many serious risks to physical and mental health. Harm reduction without eventual recovery “enables” continued drug use and addiction. That is not in the interest of addicted people or the societies in which they live. WFAD supports the use of medication-assisted treatment (MAT) for people suffering from opioid use disorders. When medications such as buprenorphine and methadone are used as prescribed and there is no other recreational or illicit use of substances, MAT patients are considered to be drug-free.

The UN Treaty on the Rights of the Child, the only UN treaty to focus on youth drug use, calls on all nations to help protect children from drugs. WFAD has the same clear goal for youth prevention as the ideal outlined in the treaty: that children be able grow up drug-free. For youth, there is no safe or healthy recreational use of drugs, including alcohol, nicotine, or marijuana. This drug-free, no-use, goal is based on the recognition of the unique vulnerability of the developing adolescent brain to drug addiction.

WFAD celebrates and supports the growing Recovery Movement worldwide. The recent emergence of millions of people who have overcome their own drug addiction not only inspires a world confronted by epidemic levels of deadly drug use, but it also reinforces the notion that true recovery is drug-free. People in recovery are the pathfinders for modern drug policy; this large and rapidly growing population offers hope to all addicted people.

WFAD is a world leader in promoting drug-free solutions for health and well-being. Composed of a diverse global array of organizations and individuals working together to combat drug addiction, WFAD is the antidote to the modern drug epidemic.

Should physicians with opioid use disorders be offered an option of opioid agonist treatment?

A new article published in the Journal of the Neurological Sciences reviews neuropsychological impairment associated with substance use by physicians; describes common neurocognitive deficits following use of various drug classes; and reviews the neurocognitive impact of pharmaceutical treatments for opioid use disorder (OUD). Authors emphasize the importance of continued testing/monitoring for physicians with substance use disorders (SUDs) following acute treatment.

In response to this review article, Robert L. DuPont, MD and Mark S. Gold, MD authored a commentary published in Clinical Psychiatry News, noting that to understand the controversy over the use of medication-assisted treatment (MAT) in the care management of physicians with OUDs requires: 

• An understanding of state PHPs and how those programs oversee the care of physicians diagnosed with SUDs, including OUDs; 

• Recognition that medical practice in relationship to SUDs is treated by state licensing boards as a safety-sensitive job; and

• An understanding of the historical context of the unique system of care management for physicians which began in the early 1970s.

"Dr. Polles and colleagues call attention to the unique care management of the PHP for all SUDs, not just for OUDs, because the PHPs set the standard for returning physicians to work who have the fitness and cognitive skills to first do no harm. They emphasize the importance of making sustained recovery the expected outcome of SUD treatment. There is a robust literature on the ways in which this distinctive system of care management shows the path forward for addiction treatment generally to regularly achieve 5-year recovery. The current controversy over the potential use of buprenorphine and buprenorphine plus naloxone in PHPs is a useful entry into this far larger issue of the potential for PHPs to show the path forward for the addiction treatment field." Read more.

Teen Binge Drinking, Misuse of Opioid Medications Linked to Other Risky Behaviors

An article published by Reuters highlights two new studies from Pediatrics, the journal of the American Academy of Pediatrics, that report a close association between adolescent substance use and other risky behaviors.

Compared to their non-using peers, high school students who reported lifetime misuse of prescription opioids were significantly more likely to have engaged in all 22 risky behaviors examined by researchers:

More: Prescription Opioid Misuse and Risky Adolescent Behavior

A screenshot from the Pediatrics video abstract showing lifetime misuse of opioids was strongly associated with lifetime use of other substances.

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In the second study, researchers showed that binge drinking in 12th grade is a robust predictor of early adulthood driving while impaired (DWI), riding with an impaired driver (RWI), blackout, extreme binge drinking, and risky driving. Authors conclude, “Our study suggests that ongoing parental practices could be protective against DWI, RWI, and blackouts once adolescents transition from high school into early adulthood. Prevention programs that incorporate binge drinking-focused screening and bolster parental practices may reduce the likelihood of later major alcohol-related health-risk behaviors and consequences in emerging adults.”

More: Longitudinal Associations of 12th-Grade Binge Drinking With Risky Driving and High-Risk Drinking

These findings complement those of IBH’s own studies about adolescent substance use behaviors and defining as a new health standard for youth prevention as One Choice.

Denormalizing Drug and Alcohol Use on the American College Campus

Higher Ed Now, the podcast of the American Council of Trustees and Alumni, welcomed IBH President Robert L. DuPont, MD, for a passionate discussion on recovery, prevention, and what college leaders need to know to save students' lives and help them succeed.

Dr. DuPont headlined ACTA’s 2019 Everything to Gain conference on campus substance use held in Boston, MA.

Health Care Professionals and Families Must Focus on Youth Substance Use Prevention

The peer-reviewed journal JAMA Network Open asked Robert L. DuPont, MD and Caroline DuPont, MD, President and Vice President, respectively, of IBH, to respond to a new research study by Bertha K. Madras, et al., "Associations of parental marijuana use with offspring marijuana, tobacco, and alcohol use and opioid misuse."

In their commentary, Drs. DuPont note that this study showed that when parents used marijuana, their children had increased risk of using marijuana too. "This underscores the need for engagement by both parents and health care professionals in youth substance use prevention and parental substance use disorder treatment." Drs. DuPont then connect the findings to IBH's own youth prevention work:

The association of parent use of marijuana with offspring use of marijuana and tobacco complements a recent finding suggesting that there is a common liability for substance use among adolescents. Among young people aged 12 to 17 years, the use of one substance is positively associated with the use of others, and nonuse of any one substance is positively associated with non-use of others. There is also evidence that there is a large and steadily increasing number of American youth who do not use any substances, including alcohol, tobacco, or marijuana. More than half (52%) of high school seniors have not used any substance in the past month and more than one-quarter (26%) have not used any substance in their lifetime, up from lows in 1982 of 16% and 3%, respectively. Together, these facts can empower parents when they are educated about their own substance use choices affecting the risks of their children using substances. They can also inform health care professionals that no use of alcohol, nicotine, marijuana, or other drugs is not only the health standard for youth but that nonuse by young patients is common and achievable.

This commentary extends the work of IBH to set a new health standard for youth prevention of One Choice: no use of any alcohol, nicotine, marijuana or other drugs by youth under age 21.

NEW REPORT: Fentanyl as Sentinel - The Emerging Threat of Synthetic and Counterfeit Drugs

Authored by John J. Coleman, PhD and Robert L. DuPont, MD, and published by The Heritage Foundation

This compelling report outlines the story of fentanyl and identifies key policy recommendations to address the national drug epidemic. 

Fentanyl is a sentinel calling our attention to the potential for a slew of laboratory-based drugs produced by an ever-expanding illegal global drug market to meet a growing demand. Included in this threat are the fentanyl-laced counterfeit drugs manufactured to look like well-known and trusted pharmaceutical products but containing deadly amounts of fentanyl instead of the expected active pharmaceutical ingredient. Unrestrained by regulatory controls and labeling requirements, today’s drug trafficker-entrepreneur poses a serious threat to patients and non-patients alike. If we hope to meet these challenges successfully, we will need radically new thinking, better data systems, and improved technology to keep counterfeit drugs and deadly fentanyl analogs out of our communities and medicinal drug supplies.

Read the Full Report and print a PDF copy here.

Podcast: IBH President Robert L. DuPont, MD interviewed on the 50th anniversary of Nixon’s Special Message on Control of Narcotics and Dangerous Drugs

As the second White House “Drug Czar” and the first Director of the National Institute on Drug Abuse (NIDA), Dr. DuPont was in the midst of a concerted effort by President Nixon and Congress to address the rising heroin and marijuana epidemics of the 1960s and 70s. He was recently asked by the Nixon Foundation to discuss his unique perspective on the 50th anniversary of the July 14th, 1969 Special Message to the Congress on Control of Narcotics and Dangerous Drugs, in which Nixon insisted that “A national awareness of the gravity of the situation is needed; a new urgency and concerted national policy are needed at the Federal level to begin to cope with this growing menace to the general welfare of the United States.”

Looking back, Dr. DuPont sees Nixon’s Message as a “remarkable document” that anticipated and drove the development of many aspects and institutions of research, law enforcement, treatment, and international cooperation that still form the core of US drug policy to this day. In particular, Dr. DuPont observes that Nixon’s Message broke new ground in two areas that were key in Dr. DuPont’s own career: the recognition that law enforcement and treatment are synergistic rather than competing components of effective drug policy, and the promotion of medically-assisted treatment (MAT), which Dr. DuPont helped pioneer in 1969 with the first large-scale MAT program in Washington, DC.

The interview concludes with Dr. DuPont offering his perspective on today’s drug policy landscape, including the marked shift from “cultivated” drugs to “synthetic” drugs, the drug legalization movement, and the new threat of what he calls “commercialized recreational pharmacology”, with businesses now a key driver of developing and marketing stronger, more addictive drugs and new delivery systems such as vaping and edibles. As he succinctly observed in a 2018 interview with Opiod Watch, “drug users are able to buy more drugs, at higher potency, and lower prices, with more convenient delivery, than ever before.”

Panel Discussion: The Health Risks and Policy Problems of Marijuana Legalization

IBH President Robert L. DuPont, MD recently participated in a panel discussion at the American Enterprise Institute (AEI) centered around the book, Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence by Alex Berenson. Mr. Berenson and Dr. DuPont were joined by Jonathan Caulkins, PhD of Carnegie Mellon University, and AEI Resident Scholar Sally Satel, MD.

Although the discussion began with the issue of psychosis and mental illness, the panel covered a wide range of topics, including the impact of marijuana commercialization and the various marijuana policy options available, the Parents’ Movement, individual and societal risks of marijuana, and public attitudes towards the negative impacts of nicotine, alcohol, and opioids compared to marijuana.