As we know, substance use does not end in the midst of a crisis. If anything, the conditions are in place to amplify potential harm. From Denver residents lining up for alcohol at the thought of possible closures to the social isolation of stay-at-home orders, we explore some of the implications of COVID19 on those with substance use disorder and potential strategies in Colorado.

Research is still emerging on both COVID-19 and even further on its connection with substance use. While we are far from the quality of research we would like on this issue (i.e. systematic reviews, meta-analysis or even singular studies,) we can discuss some possible implications.

Social distancing and stay-at-home measures are key public health interventions to “flatten the curve.” While maintaining important public health measures, we can be aware of possible effects.

Potential for higher risk of overdose

Diminished lung capacity from COVID-19 may increase one’s risk for overdose

Opioids act in the brainstem to slow breathing. Chronic respiratory disease is known to increase overdose mortality risk for people taking opioids. Similarly, COVID-19 can cause shortage of breath and lower oxygen levels. Individuals who use opioids, especially in combination with other depressants such as alcohol, could be at higher risk for overdose.

First responders may have less capacity to respond to overdose

Emergency medical personnel may have less capacity to respond due to high volumes. Some law enforcement agencies have protocols preventing them from entering a house until emergency medical personnel arrive. This may stall the use of the life-saving antidote, naloxone, which most law enforcement agencies in Colorado carry.

Mixing substances increases risk of overdose

Restrictions on movement can lead to disruptions of the illicit drug supply. Individuals may be more likely to use a drug that they are less accustomed to, limiting their ability to self-moderate. Or the drug supply can be compromised with adulterants such as fentanyl. People may increase use of alcohol, which acts as a depressant and can increase risk for overdose.

People may be less likely to have a bystander witness their overdose

Due to social distancing and stay-at-home orders, which are key public health measures, a person who overdoses may be less likely to have a person nearby that can notice that they have overdosed and be available to administer naloxone.

Potential for increased substance use

Social isolation is known to increase the risk for mental health and substance use issues

Social support is crucial for people in recovery for substance use disorders. A risk factor for relapse is isolation.

Lack of social structure, routine and accountability

People can turn to substances to manage anxiety, reduce boredom, or as a coping device. With increased work from home, the standard accountability mechanisms such a daily routine can be lost to prevent increase problematic substance use.

Loss of job and economic hardship

With more than 22 million Americans unemployed, economic hardship can be a driving factor for relapse and substance use.

 

Higher risk for more severe outcomes from COVID-19

Those who use drugs may be immunocompromised and thus be at higher risk for more severe outcomes of COVID-19.

The prevalence of chronic obstructive pulmonary diseases (COPD) and asthma tend to be higher among individuals in drug treatment. Smoking heroin or crack cocaine can aggravate these conditions. For those using stimulants, there is a higher incidence of cardiovascular disease, which is a risk factor for COVID-19. HIV, viral hepatitis, and liver cancer all lead to weakened immune systems. These are all higher due to risks associated with injecting drugs.

Early studies from China suggest that smoking and vaping can put one at higher risk for severe outcomes of COVID-19

Persons whose lungs may be compromised from vaping nicotine or tetrahydrocannabinol (or even just flavorings) may be at higher risk for complications of COVID-19.

 

Many efforts to address risks are underway in Colorado

Treatment providers are working hard to maintain continuity of care for their patients.

Federal regulations have provided expanded flexibility for take-home medication-assisted treatment.  Opioid treatment providers (OTPs) are working hard to address diversion concerns and identify new means for using telehealth with patients.

The state’s Medicaid agency is quickly identifying means to get individuals connected to Medicaid and accessing needed care.

Recovery groups are meeting online. From Alcoholics Anonymous, to Heroin Anonymous, to new programs like SoberAF that have virtual meetings, recovery support has a presence online. Daily new, free groups are being developed to provide support and community.

All behavioral healthcare and substance use treatment providers are considered “essential services” during the stay-at-home order. A person can get substance use treatment without concerns of violating the order. Most treatment providers are maintaining services. Many have found new accommodations through tele-health. All walk-in-crisis centers are open to the public and the Colorado Crisis Hotline is taking calls 24/7.

Key practices for providers

Ensure continuity of care for individuals with substance use disorders

Opioid treatment providers are continuing to provide services and make accommodations to increase social distancing. Syringe access providers are continuing to provide services with some changes to hours.

Follow recommended guidance for protecting staff and clients (See OBH and HCPF guidance)

See the Office of Behavioral Health website for updated information about dispensing, billing, and regulatory changes.

Identify recovery support communities

Many online recovery support communities exist. Peer recovery coaches can be particularly valuable to do online and virtual outreach to ensure individuals are connected to support systems. See link for resources for recovery support

Identify virtual training opportunities

Some apps like Opi-Rescue can be used in place of in-person naloxone education. Some groups are doing online CRAFT classes. Identify measures to continue services through online learning. One benefit of this crisis is the rapid expansion of telemedicine.

Combat discrimination against people who use substances

As with any crisis, often those most marginalized have limited access to services and support. Discrimination can compound these factors.

 

What we can all do

Prioritize mental health for yourself

Reach out to friends and family for social support and to check on how doing

Don’t forget the very valuable work you are doing to address substance use – it may be more important now than ever!

 

References 

European Monitoring Centre for Drugs and Drug Addiction (2020), ‘COVID19 and people who use drugs’

European Centre for Disease Prevention and Control and European Monitoring Centre for Drugs and Drug Addiction (2018), ‘Guidance in Brief: Prevention and control of blood-borne viruses in prison settings’.

European Monitoring Centre for Drugs and Drug Addiction (2017), ‘Health and social responses to drug problems: a European guide’.

National Institute of Drug Abuse (2020), ‘COVID-19: Potential Implications for Individuals with Substance Use Disorders.’

Palmer, F., Jaffray, M., Moffat, M. A., Matheson, C., McLernon, D. J., Coutts, A. and Haughney, J. (2012), ‘Prevalence of common chronic respiratory diseases in drug misusers: a cohort study’, Primary Care Respiratory Journal 21(4), pp. 377–83.

Sacerdote, P. (2006), ‘Opioids and the immune system’, Palliative Medicine 20 Suppl 1, pp. s9-15.

Schwartz, B. G., Rezkalla, S. and Kloner, R. A. (2010), ‘Cardiovascular Effects of Cocaine’, Circulation 122(24), pp. 2558–69.

Thylstrup, B., Clausen, T. and Hesse, M. (2015), ‘Cardiovascular disease among people with drug use disorders’, International Journal of Public Health 60(6), pp. 659–68.