The Opioid Crisis, Fueled By Covid, Is Worse Than Ever

The 57-year-old Navy veteran lost his kitchen job at Hooters in March because of the pandemic. Hungry and desperate, he eventually resorted to asking strangers for spare change on the streets of Cocoa, Fla.

In what he calls a “small moment of weakness,” in late July he accepted an offer of what he now believes was heroin mixed with fentanyl. The slip put an end to more than three years of sobriety and led to a near-fatal overdose.

“Next thing I knew, the paramedics said that I was extremely purple, wasn’t breathing, and … I would have been dead very quickly if they didn’t come,” Mullen says.

The opioid epidemic has been eclipsed in the public consciousness by Covid-19, but it hasn’t abated. The pandemic has only exacerbated the crisis, piling stress and grief on top of substance-abuse problems and jeopardizing efforts at recovery.

People are “living in tents because they lost their spot in sober homes because they lost their job,” says Charlotte Bismuth, a former assistant district attorney in the New York County district attorney’s office who prosecuted the doctor who was New York City’s most prolific opioid prescriber. “It’s so much worse than it was when Covid began.”

Drug overdoses of all kinds killed nearly 84,000 people in the U.S. from August 2019 to July 2020. That’s 23% more than in the previous 12-month period, and the highest number of overdose deaths ever recorded in a single year. Opioids accounted for more than 61,000, or 73%, of those deaths.

Chelsi Cheatom, program manager at Trac-B Exchange, a Las Vegas-based safe-needle program, says she expected to see demand drop during the pandemic because of public transportation cuts and calls for people to shelter in place. The reality was the opposite: “We have a line outside of our door,” she says.

On the campaign trail, Joe Biden proposed a $125 billion investment in prevention of substance abuse, treatment, and recovery, to be paid over 10 years with taxes on the pharmaceutical industry.

For the president, after all, it’s personal: He has talked openly about his son Hunter’s struggle with addiction, tying the issue to mental health rather than a flawed character.

A March 2020 Government Accountability Office report on drug misuse appeared to call out both the Obama and Trump administrations for inaction, noting that it had made more than 80 recommendations since 2015 to multiple agencies responsible for addressing the drug crisis—of which more than 60 had yet to be implemented.

In 2017, Trump appointed an opioid commission, led by former New Jersey Governor Chris Christie, and declared the opioid crisis a national public health emergency. By December of that year, the commission was disbanded. The Trump administration also tried to cut the Office of National Drug Control Policy’s budget by 95% and ultimately left oversight of the issue to senior counselor Kellyanne Conway.

“If what we’ve been doing was working, we wouldn’t be where we’re at right now with overdose deaths,” says Ryan Hampton, who helped develop addiction policy for Biden’s campaign as a volunteer and is himself in recovery for opioid addiction.

On the campaign trail last year, Biden outlined his priorities for tackling the crisis, which include addressing racial inequity in drug policy by diverting people to drug courts and treatment rather than sending them to jail. He has emphasized harm reduction, a philosophy focused on minimizing the negative consequences associated with drug use. Along those lines, Biden aims to improve access to needle exchanges and to Narcan, a medication used to rapidly reverse opioid overdoses.

Biden has also called to create peer support networks for those in treatment and long-term recovery and to plan for the lifelong needs of babies born dependent on opioids—a rapidly growing population. Babies with neonatal abstinence syndrome are “clearly one of the most expensive aspects of drug misuse that perhaps we know the least about,” says Rahul Gupta, chief medical officer of the March of Dimes and former public health commissioner of West Virginia.

Advocates have welcomed some Biden appointments and nominations, including those of Regina LaBelle (acting director of the Office of National Drug Control Policy, or “drug czar”), Surgeon General nominee Vivek Murthy, and nominee for Health and Human Services Secretary Xavier Becerra.

Addiction treatment organizations objected to the appointment of Janet Woodcock as acting director of the Food and Drug Administration. In a joint letter sent in late January, they alleged she was too easy on opioid manufacturers in her past role at the agency’s Center for Drug Evaluation and Research, which approves new prescription opioids.

Biden has also drawn heat from patient advocates for reversing Trump’s order just prior to leaving office to loosen requirements for doctors to prescribe buprenorphine and methadone. These medications help keep patients from relapsing by staving off withdrawal without getting them high, and many health leaders had praised Trump for lowering an unnecessary barrier to treatment.

The Biden administration was concerned that Trump didn’t have the legal authority to expand access to these treatments via the update to federal guidelines the last administration issued days before the inauguration. Bismuth says that while “technical reasons” may be behind Biden’s reversal, there should nevertheless be “sustained and immediate efforts to increase the availability of buprenorphine treatment” because it has been critical in combating addiction.

Legal and health experts say that Biden’s campaign plan focuses too much on combating overprescribing. Prescription opioid use declined nationwide by 60% from 2011 to 2020, according to a report by the IQVIA Institute for Human Data Science. The plan doesn’t address how to help people in states that haven’t expanded Medicaid—and thus access to mental health and addiction treatment—under the Affordable Care Act, experts also point out. In that gap are people whose jobs don’t offer health insurance and who can’t afford to buy coverage in their state marketplace, but don’t qualify for Medicaid under their state’s income standards.

“Policy solutions that focus predominantly or exclusively on overprescribing also ignore the root causes of drug crises,” Jennifer Oliva, an attorney and public health policy professor at Seton Hall Law School in New Jersey, said by email, “such as economic deprivation, social isolation, and failure of the health-care system to effectively address complex pain and substance use disorders.” All of those problems have worsened with Covid, Oliva added.

Biden called on Congress last month to set aside $4 billion for HHS to expand drug treatment access during the pandemic. And within his first 30 days, he hired six senior staffers for the Office of National Drug Control Policy (ONDCP), which Trump had gutted.

Advocates want to see the office funded at least at pre-Trump levels. Just as critical is how that money will be spent. The drug czar, whom Biden is expected to appoint soon, has budgetary authority over more than a dozen federal agencies in the National Drug Control Program.

“Less than 50% of ONDCP’s annual $25 billion budget is allocated to treatment and prevention,” said Oliva. “The majority of that budget is spent on law enforcement and interdiction. I would urge the new drug czar to reverse these priorities.”

Treatment will be an emphasis, but enforcement will not go away, LaBelle, the acting drug czar, says. “Drug interdiction, international drug trafficking and precursor chemicals, and the future of drug trafficking and the shift toward synthetics is another issue that has to be taken on.”

Frontline workers around the country say they need funding for less visible long-term recovery support systems—such things as housing, therapy, job placement, and peer support. For any of it to work, mental health care and addiction treatment will need to be widely available and cheap or free.

“If we can get someone on the recovery journey and they can sustain that for five years, they have an 85% chance of sustaining that recovery for the rest of their lives,” says Hampton, the Biden campaign adviser, citing findings from a 2016 surgeon general’s report.

In the days following his overdose, Florida’s Mullen says, robust support was “very critical.” He lost his apartment when his landlord found out about the relapse, but the nonprofit Volunteers of America helped him find new housing, therapy, and a regular source of food. Now he’s turning his life around—again.

“Thanks to Narcan, praise the Lord, I woke up,” he says.
 
Read next: Missed Doctor Visits Have Created Covid’s Shadow Health Crisis

©2021 Bloomberg L.P.