The Impact of COVID-19 on America’s Ongoing Opioid Epidemic
By Luke McCabe-O’Donnell DMSG Student Intern University of Colorado-Denver
COVID-19 has contributed to an alarming rise in opioid overdose deaths in the United States. The Centers for Disease Control and Prevention (CDC) report for the twelve-month period ending January 2021, there were 94,134 drug overdose deaths in the United States, setting a sobering record of the highest number of deaths and largest increase in one year (2021).
Figure 1. Monthly Drug Overdose Deaths In the United States
The unfortunate combination of lockdown, financial insecurity, job loss and stress has not only made it difficult for recovering addicts to sustain sobriety, but it has also pushed others into substance misuse. Robert Valuck PhD, RPh, an expert on the opioid crisis and Executive Director of The Colorado Consortium for Prescription Drug Abuse Prevention, shared in a recent interview that opioid overdose is currently a leading cause of death for Americans under the age of fifty. As a past guest speaker to the Denver Medical Study Group community in January 2018, Dr. Valuck has made it his life-long mission to raise awareness and combat increasing trends of opioid related overdose deaths. Dr. Valuck explains,
“a combination of stressors are contributing the rapid increase in opioid use and overdose deaths nationwide. Stressors are risk factors for opioid use disorder and COVID-19 has increased numerous types.”
Stressors and Risk Factors:
According to the CDC, as of June 2020, 13% of Americans reported starting or increasing substance use as a way of coping with stress or emotions related to COVID-19 (2021). In the State of Colorado the frequency of substance use has risen drastically. During the first six months since the World Health Organization declared the COVID-19 outbreak a public health emergency, common anxiety drug prescriptions have increased 35%, cannabis use has reportedly increased 38%, and alcohol consumption has increased 40%. Collectively, the overall increase in substance use is increasing the risk of developing opioid use disorder. Self-reported nonmedical use of opioids, as measured through the National Survey on Drug Use and Health, has increased 22%, the first increase after fifteen years of decline (2021).
Fentanyl and Synthetic Opioids:
Dr. Valuck explains the rapid increase in overdose deaths in the United states is primarily due to greater access to a tremendously lethal synthetic opioid called fentanyl. As recent as ten years ago fentanyl was only present in one in 500 overdose deaths and very difficult to obtain in the United States.
Figure 2. In Colorado, Fentanyl-Related Death Rates Per 100,000 People Have More Than Quadrupled Since 2016
The lethality of fentanyl is much greater than other synthetic opioids including and pain relievers such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, and morphine. The CDC estimates that fentanyl is 80 times as potent as heroin and hundreds of times more potent than morphine (CDC, 2021). Experts in opioid use disorder highlight that identifying fentanyl is becoming increasing difficult because it is often times cut into counterfeit versions of traditional prescription drugs and then reconstructed to mimic the appearance of an entirely different opioid.
Figure 3. Fentanyl in Counterfeit Prescription Pills
Preventing a Fourth Wave of Opioid Overdose Deaths:
Opioid overdose deaths have continued to increase since 1999. Experts in opioids describe three distinct waves that account for the continual increase in overdose deaths. The first three waves are described in Figure 4 below.
Figure 4. Three Waves of the Rise in Opioid Overdose Deaths
Experts from the CDC and Dr. Valuck warn against a likely fourth wave of overdose deaths due to COVID-19, fentanyl, and increased stressors. A fourth wave of overdose deaths will likely occur due to the natural progression of opioid addiction. Dr. Valuck explains it usually takes 7-10 years of lag time before nonmedical use of opioids progresses to opioid use disorder, and ultimately develops into actual overdose and death. Patients suffering from opioid use disorder likely experience two-four nonlethal overdoses before actually dying.
Although opioid use disorder takes time to develop, each opioid overdose has become more lethal with an increased presence of fentanyl in the United States. Combating the steady rise in overdose deaths is currently more important than ever as a fourth wave or COVID-19 cohort may be developing due to the standard lag time seen in opioid use disorder.
Removing Barriers in Opioid Treatment
The Colorado Consortium for Prescription Drug Abuse Prevention was created and designed to support a broad-based, ongoing effort to combat the steadily climbing rate of opioid overdoses.
In order to successfully treat opioid use disorder at a state level, leadership and government officials must work together to remove barriers in opioid treatment. Dr. Valuck states,
“The opioid epidemic is a long-term, ongoing issue that cannot be solved by one or two pieces of legislation. It cannot be combated with annual summit meetings where we share data. The consortium participates in creating policies and maintaining partnerships with Colorado based organizations and acts as the glue to foster collaboration in all state efforts. “
Figure 5. All Work Groups-Colorado Consortium for Prescription Drug Abuse Prevention
One of the primary goals of the consortium is to close the treatment gap and improve the process for initiating opioid use disorder treatment. This difficult task is accomplished through ten individual work groups. The work groups highlighted in Figure 5 work together to systematically improve access to resources for patients suffering from opioid use disorder. Dr. Valuck summarizes,
“The opioid crisis is multifaceted and has many causes, and we believe must thus be addressed from multiple perspectives. Our Work Groups were created as focus areas, and when all of these areas are addressed and improved, we believe things will improve.”
Sadly many patients who want and need treatment cannot receive it in the United States. Currently in Colorado, 70% of people suffering from opioid use disorder are not able to receive the resources necessary to detox from opioids. The large treatment gap in Colorado exists due to a number of different factors. Shortage of legally trained providers, stigma, income and coverage barriers, geographic limitations, readily accessible telehealth, lack of public awareness, and people not knowing where to go to seek or obtain treatment are all reasons why the treatment gap is so large. On average throughout the United States the treatment gap is as high as 80-85%.
Access to medication assisted treatment for opioid use disorder (MAT) is essential for people that are striving to detox from opioids. The onset of COVID-19 made the initial MAT treatment possible through telemedicine or even telephone in the state of Colorado. Removing the barrier of an in-person office visit to start MAT is a positive change and the Consortium is in favor of legislature to make the policy permanent.
Medical experts agree that opioid use disorder is not a crime, it is a diagnosis and it must be treated immediately when it is found present in patients. Improving access to MAT treatment for patients in jails and emergency rooms are just two potential avenues to improve access to MAT treatment. In addition to improving access concerns, it is vital to eliminate the stigma surrounding opioid use disorder. Policy makers must help eliminate the stigma, unnecessary steps, and anxiety for providers to be able to treat patients suffering from opioid use disorder.
An example of a hurdle for providers in opioid treatment is registration with the Drug Enforcement Administration to prescribe MAT. Providers are currently required to complete an X-waiver that requires one-three days of additional training before providers are able to treat patients suffering from opioid use disorder. The consortium believes that removing the stigma of opioid treatment and eliminating the X-waiver will greatly improve access to care for patients. Providers are currently able to prescribe opioids as pain medications but need special clearance to prescribe MAT. The X-waiver has created a general shortage of providers legally able to prescribe MAT treatment for opioid use disorder and is greatly impacting access to care for patients in need.
Increasing funding for groups like the Colorado Consortium for Prescription Drug Abuse Prevention and decreasing the general public’s access to fentanyl are the two biggest factors to prevent a fourth wave in the American opioid epidemic. Decreasing overdose deaths and treating patients while accommodating new COVID-19 protocols will be a challenging task for state governments. The Colorado Consortium for Prescription Drug Abuse Prevention is continuing to strive to reduce the treatment gap for patients suffering from opioid use disorder but resources are vastly underfunded.
Just as insulin dependent patients suffering from diabetes require ongoing medication and medical instruction to maintain healthy blood sugar levels, patients suffering from opioid use disorder require MAT to manage the difficulties of withdrawal. Eliminating the stigma associated with treatment for opioid use disorder will occur when the disease is treated more like a diagnoses and less like amoral failing.
To put spending costs into perspective, during the Aids crisis in the early 1980’s the United States spent ten times the inflation adjusted per capita spending to combat the spread of HIV. Since opioid overdoses are the leading cause of death for American’s under the age of fifty, it is not unreasonable to become more aggressive in increasing funding. Dr. Valuck explains,
“100 percent of patients suffering from opioid use disorder should have access to resources to abstain from opioid use. ‘We’re overspending’, is a concept that should never happen”.
The uncertainty of the delta variant of COVID-19, the increasing presence of fentanyl, and the typical seven-year delay associated with opioid use disorder add to the difficulty of preventing the fourth wave of opioid overdose deaths. Raising awareness and prioritizing support for organizations like the Colorado Consortium for Prescription Drug Abuse Prevention will greatly impact the future of the opioid epidemic.
The Denver Medical Study Group is excited to announce that Dr. Valuck will return as a guest speaker in 2022.
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About the Author:
Luke McCabe-O’Donnell is a Student Intern with Denver Medical Study Group. He is currently obtaining his Master’s in Business Administration with a specialization in Healthcare Administration at University of Colorado-Denver. (Expected graduation date: Spring 2022)