Drug overdose deaths have seen an alarming spike as the COVID-19 pandemic has disrupted treatment and aggravated the underlying causes of drug misuse, according to multiple data sources. Meanwhile, millions of people in the United States continue to face significant barriers to evidence-based addiction treatment as law enforcement restricts the supply of pharmaceutical opioids, forcing pain patients and drug users toward dangerous substitutes such as heroin and fentanyl that fuel high rates of fatal overdoses.
Reports gathered from across the country show a roughly 18 percent spike in drug overdoses in the two months following March 19 of this year, when many states began implementing stay-at-home orders, according to the Overdose Detection Mapping Application Program. Nearly 60 percent of participating counties reported an increase in drug overdoses during that time period.
After rising steadily for nearly a decade, the number of reported overdose deaths finally stabilized in 2018 and early 2019, only to begin rising again in late 2019 and 2020. Nationally, overdose deaths increased by 10 percent from March 2019 to March 2020 compared to the previous year, according to the Centers for Disease Control and Prevention. The number of deaths reported over 12-month periods ending in February and March 2020 increased by more than 5,000 compared to the same time periods a year before, reaching 72,000 for the first time in February and nearly 74,000 in March, according to analysis by the Drug Policy Alliance.
Since March, at least 40 states have reported an increase in opioid overdose deaths, according to the American Medical Association.
While illicit opioids such as heroin and fentanyl continue to fuel the crisis, the data show a slow but steady increase in overdoses from stimulants such as cocaine and methamphetamine, highlighting the need for diverse approaches to reducing the harms of drug use.
Some media outlets have focused on the role isolation and loneliness due to quarantine may play in increasing the number of overdoses in localized areas. Indeed, a common overdose prevention tactic is refraining from using drugs alone and, for opioid users, keeping the overdose reversal drug naloxone on hand. However, drug policy reformers and public health experts point to a number of structural factors exacerbated by COVID-19, including disruptions in the drug supply and reduced access to harm-reduction services and addiction treatment.
As Truthout has reported, the Trump administration continues to wage the failed war on drugs and people who use them, while failing to increase access to addiction treatment at levels necessary for reducing overdose deaths. Less than 20 percent of the estimated 21.6 million teenagers and adults with a substance use disorder received treatment in 2019, and only 2.6 percent received treatment at a specialized facility, according to federal data compiled by the American Society of Addiction Medicine (ASAM). These numbers may be an undercount because the federal data often excludes houseless and unstably housed people.
Like the war on drugs that has fueled mass incarceration for decades, the overdose crisis and COVID-19 both disproportionately impact low-income communities and communities of color.
“What we are seeing is the intersection of two different problems that are affecting low-income communities of color in particular,” said Jules Netherland, a managing research director at the Drug Policy Alliance, in an interview. “What COVID is doing is exacerbating problems that were already there when it came to dealing with the overdose crisis, so that it is even more difficult for people to get access to services.”
Netherland said harm-reduction strategies to reduce overdose deaths must include “broad-based” access to naloxone through syringe exchange programs and other sources, as well as broader access to substance abuse treatments, including methadone and buprenorphine, two drugs proven to treat opioid addiction. The government temporarily loosened some restrictions on accessing methadone and buprenorphine by telehealth to accommodate patients during the pandemic, and advocates argue these changes must be made permanent.
To reduce overdoses, the government must go further and lift restrictions on pharmacists and doctors who provide these lifesaving medicines, according to the Drug Policy Alliance. Advocates are also demanding an end to criminal penalties for using and possessing drugs and broad investment in meaningful treatment rather than court-ordered drug “rehabilitation” that doesn’t work.
When people are arrested by police and dragged into the criminal legal system, they are often incarcerated, another factor that can eventually put people at greater risk of overdose. Methadone and buprenorphine are still not available in most jails and prisons, and people recently released from incarceration are 40 times more likely to die from an opioid overdose than the rest of the population. Incarceration also puts people at increased risk of contracting COVID-19.
“To me getting [methadone and buprenorphine] into correctional settings is a no-brainer,” Netherland said. “Far better to release folks that don’t need to be there, but at minimum we could be providing them with the medication that would help.”
Meanwhile, ASAM reports a “critical gap” between the number of people who need addiction treatment and the number of qualified doctors and medical professionals available to provide evidence-based treatment. The gap is high in several states that have refused to expand Medicaid under the Affordable Care Act, including Texas, Florida, Georgia and South Carolina, according to a 2016 study by Pew Charitable Trusts. Medicaid has helped combat the opioid and overdose crisis in states where it was expanded by providing health coverage for lower income people, but there are other factors behind the shortage of addiction treatment providers.
While there is social stigma around people who use drugs and live with addiction, federal regulations and law enforcement also play a role in discouraging providers from effectively treating drug addiction. For example, doctors must obtain a special federal waiver to prescribe buprenorphine, a drug proven to treat opioid addiction, and federal law restricts them from providing it for more than 100 patients at a time. Today, the vast majority of doctors do not have a buprenorphine waiver, but they are legally allowed to prescribe other opioid drugs such as painkillers.
The Drug Enforcement Agency (DEA) is also waging a nationwide crackdown on distributors and providers of prescription opioids – including on methadone and buprenorphine, which are technically opioids used to temper withdrawal symptoms and cravings. As a result, more people with chronic pain or untreated opioid addiction may be turning to illicit opioids such as heroin and fentanyl, which are far more dangerous than pharmaceuticals and are a driving force behind the overdose epidemic.
For a decade, the DEA has come under heavy fire for failing to control the pharmaceutical supply of opioid painkillers, and narratives around painkiller overprescribing shaped public perceptions of the overdose epidemic in its early days. However, rates of fatal overdose from prescription opioids continues to drop while rates of deaths from heroin and fentanyl have skyrocketed.
The DEA and lawmakers have responded to the overdose epidemic by putting restrictions on opioid prescribing and allowing the DEA and other law enforcement to closely surveil patients and their prescriptions through electronic databases set up by most states. The DEA has raided and shut down pain and addiction treatment clinics as well as specialty pharmacies across the country, erecting massive barriers to care for patients. In its most recent annual report, the DEA boasts that the number of prescription opioids available at pharmacies has dropped to its lowest level since 2006.
“If their ability to address their withdrawal symptoms in a way that is legal is cut off, I would imagine that a lot of people would turn to whatever they can get their hands on to help them get through that pain and discomfort,” said Molly Doernberg, a project manager at the Icahn School of Medicine at Mount Sinai who studies how people use buprenorphine, in an interview.
The DEA says it’s rooting out “pill mills” that fuel the overdose epidemic, but well-respected doctors and pharmacists say they have been unfairly targeted, and their patients forced to search for lifesaving services somewhere else. As a result, doctors and pharmacies are discouraged from serving pain and addiction patients out of fear that they could be targeted by the DEA. Pain patients have been forced to taper off their medications amid the crackdown, and some have filed class-action lawsuits against major retail pharmacies that refused to fill their prescriptions.
In West Virginia, a state hard hit by the overdose crisis, the DEA raided and temporarily revoked a dispensing license for the Oak Hill Hometown Pharmacy last year until a federal court intervened. The pharmacy dispenses buprenorphine, and a federal judge agreed that DEA’s actions created barriers to lifesaving addiction treatment in an area with few providers. Martin Njoku, the pharmacy’s manager, said the license suspension and legal costs nearly put the pharmacy out of business.
“We have a lot of people trying to recover from opioid addiction. The drug I was dispensing was just for the recovery. It does not enhance the addiction,” Njoku said in a recent interview.
The DEA’s annual report acknowledges that people turn to illicit opioids when pharmaceutical opioids are not available, and some drug traffickers even make pills that look like pharmaceuticals but contain fentanyl and other more dangerous opioid analogues. The DEA’s press office did not immediately respond to a request for comment.
“What we know is that supply-side crackdowns, without changing the environment and providing people with more harm-reduction and treatment options, is probably not going to be a successful strategy, and these data show that clearly,” Netherland said. “As pharmaceutical opioids become less available, rates of fentanyl overdose increase.”