These are unprecedented times. As the planet continues grappling with Coronavirus our species faces an enigmatic outlook of previously unforeseen proportions. On some level America’s drug epidemic seems to have gotten lost in the shuffle of this unparalleled uncertainty. However a quick Google search of the keywords, “Covid-19 and Addiction” yields about 27,100,000 results; while the keywords “Coronavirus and Addiction” produces around 41,100,000. The union between the viral pandemic presently at the forefront of society, and the opioid epidemic of yesterday, have united. The byproduct of these two horrors have created a particularly deadly outcome for the most at-risk cross section of society.
According to The Washington Post the nation’s number of suspected overdoses climbed 18% in March, 29% in April, and 42% in May. It should be noted that nationwide death tolls are unexpectedly high across the board for a number of reasons unrelated to Coronavirus including from heart attacks, strokes, and cancer. Troubling times indeed, (all the while challenging the capabilities of our medical infrastructure). This post looks to examine some of the questions behind the impact Coronavirus is having on addiction. Why has the pandemic escalated the opioid epidemic? Will the lingering psychological effects take a toll on the next generation’s susceptibility to addiction? What impact will this pandemic have on the healthcare system, specifically regarding treatment for address substance abuse disorder, long term?
The WHY Behind COVID & Addiction
Sorrow, isolation, anxiety, depression, fear of the unknown, money problems, uncertainty both professionally and personally, and unending feelings of hopelessness; all of these might act as the ideal catalyst for combustion to someone with an addiction as well as the perfect tipping point for those who might develop one. A number of variables contribute to the relationship between Coronavirus and the rise of overdose nationwide. You don’t have to look far to see the “why” behind Covid and addiction. Covid’s collision with addiction isn’t theory. Studies have scientifically proven the population struggling, “with substance abuse disorder are at greater risk of worse outcomes from coronavirus”. (COVID-19 and Addiction)
Mandated stay-at-home orders led to a sharp decline in business, resulting in widespread unemployment, which we’ll discuss more in-depth in the next section. This is of significance due to the accompanying decline in feelings of purpose and self-worth that followed. Social distancing, one of the primary tools used to help combat the spread of the virus, can have an adverse effect on individuals dealing with a substance use disorder. Before the rise of Covid recovering addicts frequently addressed their triggers through their social circle by attending a meeting or support group or connecting with a peer for coffee or lunch. Additionally, it’s common to combat the stress brought about by triggers through regular social activities like working out at a gym. Unfortunately these avenues of release are no longer available due to the reality of the pandemic.
The heavy burden Coronavirus places on our healthcare system, In the form of overcrowded hospitals and varying degrees of shutdowns, also contributes to the problem. “Rehab centers often have shared spaces, double-occupancy bedrooms and group therapy, all of which are problematic during these times of strict social distancing,” says Dr. Nicholas Goeders professor and chairman of Pharmacology, Toxicology and Neuroscience at LSU Health Shreveport. “The fear of going to treatment centers or meetings combined with stress and other mental health issues associated with Covid-19 has created a catastrophic situation for those struggling with drug addiction.”
While social distancing and the restrictions placed on a facility’s capacity to provide treatment are two of the major hurdles brought on by Coronavirus they aren’t the only ones the virus has thrown at our healthcare system.Along with the necessary forms of treatment, the medications essential to a struggling addict’s chance of success are being impacted.
Leon Wittner shares an example of this through the story of his daughter, Sara Wittner, with PBS. After successfully completing a 30-day treatment program in January it seemed Sara was on her way to getting her life back. She was planning her wedding for the fall and working at a local health association. During this time she was utilizing Vivitrolas a form of medically assisted treatment. Vivitrol, which requires injection monthly, prevents a person from having the ability to get high on opioids.
The drug also aids in decreasing the cravings of opioids. Sara normally had appointments every 30 days so the shot could be administered. However, her appointment was pushed back to 45 days as a result of the pandemic. “She passed away on Thursday morning. And the real unfortunate piece for us is, her doctor’s appointment for the shot was Friday,” according to Sara’s father, Leon. “So, it was like she was going to make it too that last — that one last time, I will be fine, and then I will get to the doctor, and I will be OK”.
Unemployment’s Inadvertent Contribution
To add to the problem, historically high numbers of US citizens are finding themselves out of work during these uncertain times. Through the first two months of the pandemic 36 million Americans filed for unemployment. This has a multifaceted impact on people struggling during. “Rising unemployment is also cutting people off from society. If you’re trying to achieve recovery, one of the components is that you want to integrate yourself to everyday life, and now it’s much harder to get jobs.” says Dr. Nora Volkow, director of the National Institute on Drug Abuse. “Isolation is particularly hard for people suffering from substance use disorders… Withdrawal and isolation actually just in general exacerbates the problem”.
The link between increased levels of unemployment and drug abuse is not a new phenomenon. In 2013 The Federal Reserve Bank of St. Louis examined substance abuse between 2005 and 2011 marking the time period before, during and after the Great Recession from the housing market crash. The study found unemployed people to be much more likely to engage in drug abuse. According to the study, “Illegal drug use was 18% for the unemployed, followed by 10% for part-time workers, 8% for full-time workers and less than 6% for those in the ‘other’ category, which includes retirees.”
Also of significance is the passing of the HEROES Act on May 15 providing unemployment recipients an additional $600 in weekly benefits. While $600 may not seem like a lot to some people, for others (those most susceptible to addiction I would argue) it can be like hitting the lottery. What might you expect to happen in the event that you decrease the opportunity and likelihood for employment of a person, while at the same time handing them over a significantly large sum of money twice every month? That’s without mentioning the unequaled levels of mental anguish brought about under the circumstances of something like a global pandemic. Of note, that additional $600 paid out through unemployment expires July 31st.
Will Covid Create a New Wave of Addicts?
It’s commonly said in rehab facilities and among addicts that the opposite of addiction is connection. Johann Hari, in a TED Talk from 2015, popularized the phrase. Knowing that, it becomes easy to see how the circumstances brought about by Coronavirus might result in the perfect breeding ground for addiction to take hold. We call addiction a progressive disease because it follows a sequence or “roadmap” in how it develops.
Use can begin in one of a number of ways: ranging from experimentally picking up as the result of peer pressure, curiosity, or a genuine need among other reasons. Dabbling experimentally might turn into recreational substance abuse if you begin using habitually. Addiction occurs on a spectrum and sooner or later habitual use will lead to chemical dependency which eventually turns into addiction for some people. As you might imagine there are fine lines between substance use, abuse, chemical dependency, and addiction.
It seems obvious that the emotional toll the virus takes on a person fighting through recovery would bring about cravings of relapse to some degree. But what impact might this have on the impressionable population going into these uncharted times? “When you think about the close quarters people are being forced to adhere to and the ways that they need or choose to cope with it, it’s no surprise that we’re breeding basically the next generation of addicts,” says Michael Lewis, a financial planner who specializes in addiction cost planning and has a son in long-term recovery (indyweek.com). Boredom and isolation blur the lines of addiction making it easy to go from using recreationally to habitually. Coronavirus, and the ensuing quarantine that we find ourselves under, will undoubtedly have a fascinating influence on addiction.
One of the most terrifying realities presently facing us might be that we’re incapable of escaping the virus entirely. Every day we’re inundated with nonstop reports on the ever increasing numbers of new cases and fatalities from the media, the internet, friends, family and virtually everywhere else in between. The stress resulting from this new reality can bring about feelings of imprisonment and produce a wide range of negative emotions ranging from depression, aggression, and misery. Exactly the sort of painful emotions that people do whatever they can to avoid.
Coincidentally, self-medicating through substance abuse is a very effective method to numb such pain, and a common catalyst behind addiction developing. Furthermore, the feelings mentioned above can turn into widespread hysteria or even PTSD. That’s precisely the rationale that someone might provide in order to justify their use of more drugs. Unbridled anxiety or trepidation validate addiction. Since Coronavirus feels inescapable and appears seemingly inevitable it might act as the perfect incubator for substance abuse disorder.
While most of this is speculation, there are potential indicators in support of such notions. The massive explosion of alcohol sales during the pandemic, going up as much as 55% in one week, as well as major increases in the sale of other substances as a means of coping are two such examples. Although, admittedly, that isn’t necessarily indicative of addiction it is evidence of increases in other kinds of drug use.
Nonetheless, addiction rates as a result of covid-19 are more difficult to quantify. “I think that the shelter-in-place aspect of COVID-19 has had devastating, long-term effects—effects that we possibly haven’t seen the results of yet.” according to Kurtis Taylor, executive director of The Alcohol and Drug Council of North Carolina. “When things get back to some sense of—for lack of a better term—normalcy, I think that we’ll find that people will emerge with issues that are not easily shaken,” (indyweek.com).
COVID-19 on the Drug Trade
The pandemic caused a major disruption on the illicit global drug trade. Wuhan China’s commonly known to be ground zero, the original epicenter, for the Covid-19 outbreak. What’s less commonly known is that prior to the coronavirus outbreak Wuhan was one of China’s “fentanyl capitals” a leading distributor of the chemicals necessary to manufacture the powerful opioid. According to Louise Shelley, director of the Terrorism, Transnational Crime and Corruption Center at George Mason University, “Huge amounts of these mail-order components (the raw materials necessary to produce fantanyl) can be traced to a single, state-subsidized company in Wuhan that shut down after the outbreak earlier this year.”
The shift from natural opiates like heroin to synthetic ones like fentanyl was underway long before people began contracting Covid. That’s why when it comes to the “War on Drugs” fentanyl has become public enemy number one in recent years. Drug Cartels are becoming less reliant on the “natural” substances (the ones that need to be planted, grown, and harvested) like marijuana and heroin. Instead they’re focusing on synthetics ones like fentanyl because they’re exponentially more powerful, can be manufactured year round, and as a result are significantly more profitable.
The obvious impact the pandemics having on the drug trade centers around supply and demand. Borders closings have severed supply chains between China and traffickers leading to a steep spike in the cost of illicit drugs. “Cocaine prices are up 20 percent or more in some cities. Heroin has become harder to find in Denver and Chicago, while supplies of fentanyl are falling in Houston and Philadelphia. In Los Angeles, the price of methamphetamine has more than doubled in recent weeks to $1,800 per pound,” (abcnewsgo.com). Hotels, nightclubs, concert venues, and bars- all the typical places you’d associate with being hotspots for drug dealers to operate out of- are shut down. Additionally,restrictions on the number of people allowed to attend gatherings decreases the likelihood of house parties being a potential avenue for transactions. In other words, the opportunity costs for drug deals have taken a major blow.
While supply chain is the easy answer behind corona’s impact it’s only part of it. In order to understand the long-term impact it’s having first you need to understand the role facilities like the one in Wuhan play in the global drug trade. In years past Chinese companies would ship fentanyl directly to Mexico and other countries, however stricter laws recently implemented have made this more difficult. Drug Cartels are smart, so in order to circumvent international law they began purchasing the raw materials needed to manufacture the synthetic drugs instead of buying the finished product.
When coronavirus hit this model was no longer feasible for a number of cartels due to costs. “Advertised prices across China for precursors of fentanyl, methamphetamine and cutting agents have risen between 25% and 400% since late February,” says Logan Pauley, (quote courtesy of abcnewsgo.com) an analyst at the Washington-based security research nonprofit the Center for Advanced Defense Studies. In response some carels began shifting more and more of their processing in house. With that being said, a sizable amount of the processing still comes from overseas facilities. In any event, the disruption Coronaviruses had on the global black market drug trade outlined above helps explain why a May report put out by the United Nations warns that batches of drugs are more likely than ever before to be tainted and have “reductions in purity”.
To summarize: the pandemic greatly disrupted supply and demand along with the supply chain of the illegal global drug trade.While this slowed the drug trade down to a trickle it also resulted in major price gouging to what was left. In response to the huge price spike Chinese companies put on the chemicals necessary to process synthetic drugs cartels moved to process the drugs in house. They did this in an effort to decrease their dependence on overseas processors. As a result of the cartels “in house” processing we’ve seen an uptick in substances that are tainted or have reduced purity. This, in turn, contributes to the spike in overdose fatalities.
Revising Treatment Approaches
Beyond a shadow of a doubt, coronavirus is straining to test the boundaries on all facets of the current healthcare system. In no way are addiction treatment programs and recovery services immune to this as they are being forced to rethink approaches during these anomalous times. “It’s hard to underestimate the effects of the pandemic on the community with opioid use disorder,” according to Dr. Caleb Alexander, professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health. “The pandemic has profoundly disrupted the drug markets. Normally that would drive more people to treatment. Yet treatment is harder to come by.”
For the purposes of this post, the impact the pandemic’s having on addiction treatment has been broken down into four elements: Telehealth Services, Outpatient Services, Inpatient Services,and Network or Support Services. While in practice Telehealth Services and Network/Support Services overlap with the other elements the distinction is important.
Telehealth services are at the forefront of the fight against the combined foe that is Covid-19 and addiction. Essentially they account for the overarching element that’s driving the entirety of the new approach. From virtual therapy, online Narcotics Anonymous meetings, and doctor’s appointments to geotagging patients in order to verify their location and remote drug tests Telehealth is turning into a vital player in our future approaches to treatment. Practically overnight the treatment community shifted to a Telehealth model for all appropriate services because of the improved accessibility it offers. While some early indicators seem to be promising, others appear concerning. For starters, we’re just not sure just how effective these treatments are proving to be due to their relative newness. A primary concern and shortcoming to Telehealth Services comes from their inherent lack of personability. Due to the technological nature of these services they won’t be for everyone.
Sara Wittner’s story above outlines one of the major issues that come along with the current revisions to outpatient services. Rolling back some of the barriers presented to outpatient services are a good thing, however people need to be able to receive the necessary treatment. Other restrictions placed on medically assisted treatment, specifically methadone and buprenorphine (Suboxone), have been significantly rolled back by the Federal Substance Abuse and Mental Health Services Administration. Methadone and buprenorphine are both types of synthetic opioids that alleviate the symptoms associated with detox and decrease long-term cravings. Since these clinics treat thousands of patients each day they’re possible hotbeds for spreading Coronavirus. Patients considered “stable” now are permitted to receive up to 28 days worth of doses to be stored at home.
Inpatient services have dealt with the most significant financial ramifications as a result of changes. Simply put, the current system in place is unsustainable and will eventually collapse without significant change. That’s the price you have to pay when it comes to social distancing. Facilities that were placing two or three patients in a room now are required to give people their own rooms. Due to this group therapy situations are seeing significant change as a result of having much smaller groups. Facilities deciding to leave rooms vacant in the event a patient begins showing symptoms of Covid (resulting in the need to isolate) have further burdened the demands for living space.
The National Council for Behavioral Health consists of more than 600 service providers. The Council found that over 70% of their clients were forced to either cancel services, reschedule them, or deny services entirely to patients over the last three months all in the name of maintaining social distancing. Other facilities have denied patients outright or postponed services because they arrived displaying symptoms of the virus. According to National Council president Chuck Ingoglia, “fewer patients has meant less revenue this year, and more than 40% of the organizations represented could be out of money in six months,” (pbs.org). Ingoglia goes on to mention that the Council represents more than 3,000 treatment organizations around the country.
The greatest (non-financial) obstacle facing new-age virtual Telehealth Services in the realm of substance abuse treatment comes at the individual level with the Network and Support Services. Simply put, finding virtual meetings and developing a responsive social support network can prove to be incredibly difficult. “We found that telehealth is not for everybody,” according to Candace Hodgkins, president of Gateway Community Services, a recovery center in Jacksonville, Florida. Sure, some favor the comfort that comes along with being able to hop on your phone, tablet, or laptop at home to catch a meeting. Others, a significant portion of people, simply don’t receive the same benefits that would come along with the face-to-face interactions; the handshakes, hugs, and smiles found in the rooms of a traditional meeting.
Shon Myers qualified as one of countless individuals unable to find benefit from the virtual new Telehealth Service model. After more than a year in sobriety Shon died of a relapse on April 13th. According to his girlfriend, Claire Hanley, Shon wasn’t a “techie person,” nonetheless; she helped him learn to use Zoom so he’d still have meetings to be a part of online. Despite a handful of tries Myers became disappointed in the virtual setup, “It’s not the same,” he told Claire. “Shon was a fisherman, a very salt-of-the-earth-type person,” she says.
“He relied on that in-person connection, handshakes, hugs. He had a lot of friends in the Portland recovery community. It was almost like his church. So I think he missed seeing his sober friends.” Hanley’s convinced that her boyfriend died indirectly as a result of Covid-19. “With an addict like that, I know there’s no guarantee he would have never relapsed,” says Hanley. “But I don’t think he would have relapsed right now. I do think he would still be alive” (prevention.com).
Suffice it to say that after the pandemic of Covid-19 the world as we know it will never be the same. The two most significant health crises of the 21st Century have resulted in a horrifying compounding effect on the at-risk population. It’s easy to see the why behind the devastation of the co-occurring crises. People feel hopeless. Unparalleled levels of unemployment are negatively impacting the psyche of the American public at large. Intentional overdoses, as well as other forms of attempted suicide, are particularly concerning to healthcare providers. In April the National Endowment for Financial Education released a study finding almost 9 out of 10 Americans presently feel anxious regarding money. Issues ranging from job security, income stability, and being able to pay the bills (utilities, rent, and mortgage) were listed among their top concerns.
This virus caused a lot of really weird things to happen. While a disruption to the illicit drug trade usually funnels people into seeking treatment, this pandemic’s having exactly the opposite effect. Due to quarantining people are told to stay to themselves as much as possible, thus paving the way for isolation, panic, and worry. As such, over the past four months we’ve faced far less scrutiny, accountability, and peer inquiry than ever before. Additionally, the circumstances allow for considerably more free time. As they say, downtime is the Devil’s time. All of this provides increased justification and opportunity for infrequent or social use to become habitual, and once it turns consistent you run an increased risk of developing an addiction.
Undoubtedly, access to treatment facilities has been disrupted by the pandemic. Some potential patients are likely apprehensive over contacting the virus so instead they avoid seeking treatment. According to Doug Denton, an at Homeward Bounds Dallas inpatient facility, “I’m anticipating a wave of admissions as fears recede and people begin to recognize they’re in trouble with their addiction.” Day after day the Coronavirus pandemic ravages our country. What will the toll of the pandemic have on the nation long-term? The lingering effects are the really scary part of this whole thing. Pandemics make for traumatic experiences and we know there’s a linkbetween childhood trauma and the future development of a substance use disorder as well as numerous other negative mental health effects. Our handling of this pandemic will, beyond a shadow of a doubt, have traumatic repercussions on children.
Concurrent health crises require multi-faceted comprehensive solutions, and our healthcare system’s current approach to treatment is neither working nor sustainable. “To keep moving revenue, you have to keep admitting new clients as well as earning money while you treat the clients that you have,” says Michael Festinger, president of The Better Way of Miami, an inpatient residential program. “The math is pretty simple.” The pandemic forced the Better Way to reduce their residential capacity by 30% (as have countless other programs) and as currently constructed the math doesn’t work.
Furthermore, stories like Shon’s (mentioned above) illustrate precisely the shortcomings that come along with overly relying on Telehealth Services. “Even after people complete alcohol rehab, many still need support groups to maintain sobriety. Alcoholics Anonymous, Celebrate Recovery and related 12-step programs rely on face-to-face group meetings to maintain anonymity and promote feelings of safety where people can freely express themselves and work on their personal struggles in ways that are next to impossible in social isolation,” says Dr. Nicholas Goeders.
As of the writing of this post the entire situation is a collection of complicated paradox: use among people will continue to climb, a resulting byproduct to the feelings of dread brought on by the pandemic. Treatment facilities cannot survive running at the decreased capacity, however the decreased capacity is supposedly necessary to combat the virus. The opposite of addiction is connection and human interaction is paramount in feeling that connection in order for treatment to be most effective. The list goes on and on.
When you view the war on drugs in this light, trying to eliminate the drugs—the addictive chemicals—will never end addiction completely because it avoids a deeper problem in society—a lack of connection. There is an alternative. You can build a system that is designed to help drug addicts to reconnect with the world—and so leave behind their addictions.
When it comes down to it we have a pretty good idea, in theory, of what would help. Suzanne Brown, an addiction specialist in Chapel Hill, concurs with Hari’s assessment and says it best. “The key to combating addiction during Covid is connection because substance use increases when people feel isolated. People need to find ways to authentically connect, whether that means doing things together or asking deeper questions about well-being.” (indyweek.com) It’s in practice where this becomes difficult. What are your thoughts?