Pandemic versus Epidemic: The State of the Opioid Epidemic in the Wake of the COVID-19 Pandemic

In recent years, the opioid epidemic in the United States has gained significant attention from mainstream media as death rates steadily climbed and pharmaceutical corporations were brought to court. Emergency Medicine Physicians (EPs) are no strangers to the consequences of this epidemic; many have been quick to champion emergency department (ED)-initiated advocacy and treatment programs for opioid use disorder (OUD). However, when healthcare focus shifted suddenly and necessarily to the COVID-19 pandemic in early 2020, the opioid epidemic, like many other disease and conditions, was given a backseat; this position and the milieu created by the pandemic was not, however, without consequence. An article posted in the New York Times in April 2021 focused on a preliminary report released the by Centers for Disease Control and Prevention (CDC) highlighting an alarming statistic: In the 12-month period from October 2019 to September 2020, overdose deaths increased by 29% compared with the previous 12-months.[1], [2] This equates to a total of 87,000 Americans who died from drug overdoses (ODs), the most in any 12-month period in well over a decade. As we begin to consider the ‘light at the end of the pandemic tunnel,’ and take stock of the additional sequalae of COVID, what have those on the frontlines seen over the past year with regards to opioids?

During Summer 2020, one of the first manuscripts focusing on how the COVID-19 pandemic is affecting the opioid epidemic warned of an increase in opioid ODs in Kentucky and called for shared observations and analyses from other regions in the US.[3] In San Francisco, it was found that ED presentations and deaths related to opioid ODs increased following social distancing mandates from January 2020 to April 2020.[4] In Virginia the number of nonfatal opioid OD visits increased by 125 from March to June 2020 compared to March to June 2019. [5] These results suggest that during the early stages of the pandemic, when perhaps the strictest social distancing mandates were in place, there was an increase in ODs presenting to the ED while overall ED volumes had dropped significantly. Speculation about reasons for this include a decrease of witnessed ODs in private and public settings and/or increased stressors contributing to opioid use in higher frequency and/or quantity. In Alabama it was found that patients with OUD, overall, visiting a major academic ED had dropped about 60% over the course of just one month from March to April 2020. [6] This adds an additional concern that patients who are suffering from OUD may not have been seeking help in EDs during the early months of the COVID-19 pandemic. EDs often serve as a healthcare safety net for patients with OUD in crisis. Expanding on these studies, a collaborative effort amongst 6 US Healthcare Systems analyzed a larger cohort and geographical region over a 12-month period and found that overall ED visits had dropped while the number and rates of opioid OD-related ED visits had increased.[7] Furthermore, the disparities amongst different patient populations may have also been exacerbated by the pandemic. In Philadelphia it was found that during the pandemic there was an increase in opioid OD among non-Hispanic Black patients whereas there was a decrease among non-Hispanic white patients.[8] This was the first time in recent history in Philadelphia that the net amount of deaths was higher among non-Hispanic Black patients than among non-Hispanic white patients.

In Fall of 2020, SocialEMpact highlighted an article published in the New England Journal of Medicine Catalyst which described EPs on the frontlines, in the midst, witnessing the impact of the COVID-19 pandemic on patients with OUD. It called for accelerated reform, elimination of barriers, and an end to the quality gap that exists in ED-based treatment of OUD.[9] Another commentary highlighted the features that regulatory agencies achieved during the pandemic to temporarily decrease the barriers for patients to receive medication-assisted treatment (MAT) such as (1) Substance Abuse and Mental Health Services Administration (SAMHSA) allowing states to permit all stable patients to receive 28 days of take-home methadone and (2) the Drug Enforcement Agency (DEA) allowing buprenorphine treatment initiation after consultation with a provider via telemedicine. [10] It goes without saying that these ‘temporary’ changes should be made permanent. Prior to the pandemic, many EDs and EPs engaged in the treatment of patients with OUD utilizing SBIRT (screening for, brief intervention, and referral to treatment) and Medication-Assisted Treatment (MAT) initiation (e.g. buprenorphine/naloxone). These were increasingly accepted as viable and effective treatments, however, had not been universally adopted. Significant treatment barriers, for both providers and patients, namely MAT training, and secure follow-up options, respectively, impeded broader uptake.

Important recent progress has been made on these barriers however; in December 2020, the American College of Emergency Physician (ACEP) released a statement acknowledging the progress made by the DEA, who announced they would allow ED physicians without an X-waiver to dispense up to a three-day supply of buprenorphine from the ED (currently effective June 9th, 2021). In April 2021, the Department of Health and Human Services (HHS) announced that any qualified practitioner with a DEA license can submit a ‘Notice of Intent’ to administer, dispense, and prescribe buprenorphine for up to 30 patients at a time. In an ‘all hands on deck’ response to the alarming increase in overdoses, this move allows practitioners to be exempt from the 8-plus hour CME training previously required to obtain an X-waiver. ACEP again quickly responded and released a statement applauding the Biden administration for expanding access but reiterated that removing the X-waiver completely and reducing other barriers to treating OUD remains a major priority. There is also a discussion about whether EPs prescribing Take Home Naloxone (THN) in the ED is more effective than discharging patients with instructions to obtain Naloxone elsewhere; this practice is becoming increasingly routine in EDs and health departments across the nation who have demonstrated an effective harm reduction model which should be considered, even when ED-initiated MAT is not available.[11]

Though our regulatory agencies may be moving in the right direction, they need to do so at a quicker pace. The mainstream media is exposing the frightening affect that the COVID-19 pandemic is having on the opioid epidemic. Now that the ball is rolling again, it will be increasingly important for EPs to continue their previous work and expand in this role as well as engage with local community networks to spearhead change towards creating equitable and easy access to treatments for OUD. Opioid-related death and disease are increasing. We can help reverse this trend now. Let’s get it done.

[1] A. Goodnough, “Overdose Deaths Have Sured During the Pandemic, C.D.C Data Shows,” New York Times, Apr. 14, 2021.

[2] F. Ahmad, L. Rossen, and P. Sutton, “Provisional drug overdose death counts,” 2021. [Online]. Available: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.

[3] S. Slavova, P. Rock, H. M. Bush, D. Quesinberry, and S. L. Walsh, “Signal of increased opioid overdose during COVID-19 from emergency medical services data,” Drug Alcohol Depend., vol. 214, 2020, doi: 10.1016/j.drugalcdep.2020.108176.

[4] L. N. Rodda, K. L. West, and K. T. LeSaint, “Opioid Overdose–Related Emergency Department Visits and Accidental Deaths during the COVID-19 Pandemic,” J. Urban Heal., vol. 97, no. 6, pp. 808–813, 2020, doi: 10.1007/s11524-020-00486-y.

[5] T. A. Ochalek, K. L. Cumpston, B. K. Wills, T. S. Gal, and F. G. Moeller, “Nonfatal Opioid Overdoses at an Urban Emergency Department during the COVID-19 Pandemic,” JAMA - Journal of the American Medical Association, vol. 324, no. 16. 2020, doi: 10.1001/jama.2020.17477.

[6] L. A. Walter and L. Li, “Opioid Use Disorder in the Emergency Department Amid COVID-19,” Journal of addiction medicine, vol. 14, no. 6. 2020, doi: 10.1097/ADM.0000000000000717.

[7] W. E. Soares et al., “Emergency Department Visits for Nonfatal Opioid Overdose during the COVID-19 Pandemic across 6 US Healthcare Systems,” Ann. Emerg. Med., 2021, doi: 10.1016/j.annemergmed.2021.03.013.

[8] U. G. Khatri et al., “Racial/Ethnic Disparities in Unintentional Fatal and Nonfatal Emergency Medical Services-Attended Opioid Overdoses during the COVID-19 Pandemic in Philadelphia,” JAMA Netw. Open, vol. 4, no. 1, 2021, doi: 10.1001/jamanetworkopen.2020.34878.

[9] G. D’Onofrio, A. Venkatesh, and K. Hawk, “The Adverse Impact of Covid-19 on Individuals with OUD Highlights the Urgent Need for Reform to Leverage Emergency Department–Based Treatment.,” Nejm Catal. Innov. Care Deliv., no. May, 2020.

[10] C. S. Davis and E. A. Samuels, “Opioid Policy Changes During the COVID-19 Pandemic - and Beyond,” J. Addict. Med., vol. 14, no. 4, 2020, doi: 10.1097/ADM.0000000000000679.

[11] S. G. Weiner and J. A. Hoppe, “Prescribing Naloxone to High-Risk Patients in the Emergency Department: Is it Enough?,” Jt. Comm. J. Qual. Patient Saf., 2021, doi: 10.1016/j.jcjq.2021.03.012.

John PurakalMay 9, 2021