The COVID-19 Pandemic and the Opioid Overdose Epidemic: A Perfect Storm for Workers?

September 14, 2020 by Jamie Osborne, MPH, CHES®; L. Casey Chosewood, MD; and John Howard, MD

Introduction

Before the pandemic took hold, the United States was already facing another public health crisis – alarming rates of opioid-related overdose deaths. In 2018, 46,802 deaths were attributed to opioids, which accounted for 69% of all drug overdose deaths.1 Based on provisional data, an estimated 50,828 Americans died of opioid overdose in 2019 — 70% of the total estimated drug overdose deaths last year. As COVID-19 has swept the nation and globe, the virus and its implications have had particularly harmful impacts on individuals struggling with opioid misuse, opioid use disorder (OUD), and overdose. The co-occurring COVID-19 pandemic and opioid overdose epidemic have created what some have called “the perfect storm for folks who are substance dependent.” The mortality rate for patients with a substance use disorder is predicted to be significantly higher than the general population, indicating that “epidemics don’t smolder during pandemics — they ignite.”2

Workers are facing additional stress and anxiety, stemming from uncertainty and fear, over possible job losses, reductions in income, significant work changes, and increased demands at home and work. These new challenges and stressors may lead to an increase in substance use or misuse. As the nation grapples with the implications and consequences of the COVID-19 pandemic, safety and health professionals, policymakers, and employers must be even more diligent in confronting the opioid overdose crisis by recognizing the unique factors impacting workers with OUD and protecting individuals who are at higher risk for OUD.

Interlinked Public Health Crises

The additive impacts of COVID-19 and the opioid crisis increase the likelihood of illness and death among workers struggling with OUD.3 Individuals with OUD are more likely to lack health knowledge and access to harm-reduction services.4 They may lack reliable Internet service to access information about the pandemic and may have difficulty accessing provisions needed for sheltering in place for an extended period, such as stable housing, food, and drug-use equipment.5 Additionally, opioids negatively impact lung and heart health, which coupled with a higher prevalence of underlying medical conditions and tobacco use,3 may put people with OUD at higher risk for severe illness from COVID-19. These individuals are often stigmatized and underserved in healthcare settings, and may experience even greater barriers to receiving care when hospitals and clinics are pushed to capacity with COVID-19 cases.

Closures of businesses and social distancing measures aimed at reducing the spread of COVID-19 may inadvertently increase harms related to OUD.3 In a survey conducted by the Addiction Policy Forum, 34% of respondents reported changes in access to treatment or recovery services. Closures of treatment clinics and other disruptions to harm reduction programs may lead to increased sharing of injection and non-injection equipment, increasing the risk of COVID-19 and other transmissible diseases like HIV.2,6 Pandemic measures have created a scarcity of healthcare resources, including access to medication for opioid use disorder (MOUD), also known as medication-assisted treatment (MAT), which may lead to discontinued treatment.7 Overdose rates have been shown to substantially increase after premature treatment cessation when compared with those who continued treatment7; thus, it is critical for providers to ensure continuation of care for individuals with OUD during COVID-19. Economic disruptions, like job loss, and social disruptions, like border crossing restrictions, may reduce access to the usual drug supply and lead to more harmful drug use patterns and greater exposure to more dangerous drugs.2,5,6 Social distancing, a key measure in preventing the spread of COVID-19, may lead to isolation and potentially conceal a surge of opioid misuse8 and mental health issues2 in individuals at higher risk for OUD. People with OUD have disproportionately higher rates of psychological trauma and mental health conditions, the effects of which may be exacerbated by isolation and exposure to a large-scale disaster, presenting an increased risk for opioid overdose.9 A tradeoff also exists in the choice to practice social distancing, which reduces the risk of COVID-19 exposure, but increases the risk of overdosing alone and decreases the opportunity for rescue through bystander administration of lifesaving naloxone.2,3,5,9

Health Disparities and Compounding Health Issues

While highlighting long-standing systemic health inequities in communities of color, the COVID-19 pandemic has also amplified some social and economic factors that contribute to poor health outcomes. Rates of identified cases, hospitalizations, and deaths due to COVID-19 are disproportionately higher among American Indian or Alaska Native, Black or African American, and Hispanic or Latino persons. Compared to White Americans, people from racial and ethnic minority groups are at a disproportionately higher risk for serious COVID-19 illness due to higher rates of underlying health conditions. They are also more likely to be uninsured, work in essential jobs that increase risk of exposure, require use of public transportation, are particularly at risk for loss of income, and live in housing situations that make social distancing or self-isolation difficult. In addition to these factors contributing to increased risk for COVID-19 contraction and complications, Black or African American persons and Hispanic or Latino persons face compounding risks surrounding substance misuse and substance use disorder. For example, while Black or African American persons have similar rates of opioid misuse as the general population, in recent years they have experienced the greatest increase in rate for overdose deaths from non-methadone synthetic opioids. People of color are also more likely to be uninsured, have lower access to behavioral health care and substance-use treatment services, and often experience less culturally responsive care and/or terminate treatment prematurely.

Given the interlinked nature of the COVID-19 pandemic and the opioid overdose epidemic, it is important that health disparities are identified and acknowledged, and efforts are implemented to protect workers who are at higher risk for OUD. The Substance Abuse and Mental Health Services Administration (SAMHSA) outlines action steps for addressing these disparities, including policy efforts; communication, health literacy, and public awareness; partnerships with leaders in communities and institutions; and health care workforce and practice efforts, e.g. virtual and telehealth opportunities, an augmented workforce, and peer navigators, coaches, and recovery supports services. These action steps closely align with the National Institute for Occupational Safety and Health (NIOSH) Workplace Supported Recovery considerations to prevent substance misuse and encourage substance use disorder treatment and recovery among workers.

Lessons Learned and Moving Forward

Federal Funding. Federal funding has been leveraged to support individuals with substance use disorder during the COVID-19 pandemic, including $200 million for the COVID-19 Telehealth Program to help health care providers provide connected care services to patients at their homes or mobile locations. SAMHSA has released $110 million in emergency grants, and an additional $450 million through the Fiscal Year 2020 CCBHC Expansion Grants to increase access to, and improve the quality of, mental and substance use disorder treatment services. Overdose Data to Action, which began in September 2019, is funding states, cities, and territories for overdose surveillance and prevention efforts while also navigating COVID-19. SAMHSA provides information on State Opioid Treatment Authorities. Employers should strive to identify and utilize available Federal, national, state, and local financial resources to support individuals with substance use disorders during the pandemic.

Priorities. The White House Office of National Drug Control Policy (ONDCP) released an outline of their priorities along with links to resources and guidance from several other federal agencies. ONDCP priorities emphasize access to controlled substance raw materials and prescriptions; access to treatment and programs that ensures safety for patients and providers; increased flexibility for electronic prescribing and take-home treatment options; and expanded use of telemedicine and virtual recovery support services, particularly in support of rural communities facing unique barriers such as limited cell phone and internet coverage and limited access to devices such as smartphones or computers9.

Pandemic conditions have brought forth valuable insights concerning the effectiveness of strategies for combatting the opioid overdose crisis. Given that social distancing may bolster the opioid overdose epidemic, behaviors and activities that foster social connection and resiliency may strengthen our response.8 The U.S. will continue grappling with the aftermath of the pandemic long after the spread of the virus has slowed, but we must not lose sight of lessons learned as we battle against the opioid overdose crisis. All Americans, including workers struggling with opioid misuse, OUD, and overdose, can help control this pandemic by practicing social distancing, wearing masks, practicing hand hygiene, and staying home when sick. CDC offers guidance on managing stress and resources to strengthen social, emotional, and mental health resilience during COVID-19, including a specific Q&A for individuals with substance use disorder. NIOSH will continue to provide updated information and resources regarding opioid use disorder, treatment, and recovery through the Opioids in the Workplace and Workplace Supported Recovery webpages.

Jamie Osborne, MPH, CHES® is a Public Health Analyst with the NIOSH Office of the Director.

L. Casey Chosewood, MD, is the Director of the NIOSH Office for Total Worker Health®.

John Howard, MD, is the Director of the National Institute for Occupational Safety and Health (NIOSH).

References

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