Pill bottles.

During the COVID-19 Pandemic, the Opioid Epidemic Continues

By Laura Karas

“The boy’s first outcry was a rueful laugh,

As he swung toward them holding up the hand

Half in appeal, but half as if to keep

The life from spilling. Then the boy saw all—

Since he was old enough to know, big boy

Doing a man’s work, though a child at heart—

He saw all spoiled. . . .

He lay and puffed his lips out with his breath.

And then—the watcher at his pulse took fright.

No one believed. They listened at his heart.

Little—less—nothing!—and that ended it.

No more to build on there. And they, since they

Were not the one dead, turned to their affairs.”

This except from Robert Frost’s 1916 poem “Out, Out—,” which portrays the sudden death of a young boy after a woodcutting accident and the onlookers’ casual acceptance of his tragic death, is particularly apropos today, more than one hundred years later, in an America that looks very different than that of Frost’s time. Between the opioid crisis and the COVID-19 pandemic, America now suffers from a surplus of needless, untimely deaths.

Just as the protagonist of Frost’s poem became the casualty of a tragic accident, so too do the many victims of the opioid epidemic become casualties in a losing battle — lives “spoiled” by substance use disorder and cut short by tragic overdose. In this post I explore the status of the opioid epidemic in light of the COVID-19 pandemic and ongoing initiatives to address opioid use disorder (OUD).

Synthetic Opioids Have Become Leading Causes of Opioid Overdose Deaths

In September of this year, the Centers for Disease Control and Prevention (CDC) released its latest report of drug overdose deaths, finding an increase in drug overdose deaths in 2019 as compared to the year prior, and finding that more than 80% of overdose deaths in the first half of 2019 involved illicit opioids. Notably, a bystander was present for more than 30% of deaths, and more than 60% presented at least one opportunity for intervention.

Though opioid prescribing has declined in recent years, overdose deaths from synthetic opioids have been growing, with illicitly manufactured fentanyl (IMF) and heroin playing a major role in overdose deaths. In particular, deaths from IMF and fentanyl analogues increased more than 500% between 2015 and 2019.

In a recent podcast, the American Medical Association (AMA) convened a group of physicians to discuss the exacerbation of opioid misuse during the COVID-19 pandemic, a phenomenon fueled by prolonged social isolation, job loss, and disruption of traditional healthcare services and illicit drug markets.

The AMA podcast noted, however, that the pandemic has facilitated increased flexibility for opioid prescribing via telemedicine, which may have beneficial effects for those managing chronic pain or undergoing treatment for OUD. As of late March, health care providers may prescribe a controlled substance to a new patient after a two-way, real-time telemedicine visit, relaxing the requirement for an in-person assessment. And authorized providers are now permitted to prescribe buprenorphine after telephone evaluation, eliminating the need for an in-person or telemedicine visit for new patients.

Importantly, the AMA’s podcast underscored the disproportionate impact that COVID-19 is likely to have on vulnerable populations suffering from OUD, including those who are homeless, incarcerated, or recently released from an institutional setting.

Civil and Criminal Liability for Opioid Manufacturers Can Begin to Mend the Damage

Despite greater restraint in opioid prescribing in recent years, the opioid epidemic is all the more tragic because of the undeniable role of the pharmaceutical industry and medical establishment in creating and fueling the crisis. The grave responsibility for treating and healing those with OUD should weigh on the very actors who had a hand in generating the ongoing tragedy.

Fortunately, there is some indication that those actors will be forced to pay their dues. On October 21, the Department of Justice announced that Purdue Pharma LP has agreed to a guilty plea for “one count of dual-object conspiracy to defraud the United States and to violate the Food, Drug, and Cosmetic Act, and two counts of conspiracy to violate the Federal Anti-Kickback Statute.” Purdue faces more than $3.5 billion in criminal fines and $2 billion in criminal forfeiture, in addition to a $2.8 billion settlement of civil liability under the False Claims Act.

Though civil and criminal liability can help generate funds to address the opioid epidemic, public health and community leadership at the local and state level are equally essential to directing an effective public health response to the crisis. There are several public health strategies with proven effectiveness to reduce the risk of opioid-related deaths and counteract associated health risks.

Syringe Exchange and Community Naloxone Distribution Are Proven Harm-Reduction Strategies

Injection-drug users of illicit opioids are at risk of contracting HIV and viral hepatitis, among other blood-borne diseases. Needle exchange programs, which have shown particular effectiveness in reducing transmission rates of HIV, offer similar promise to minimize the spread of infectious diseases among illicit opioid users. Decades of research back the effectiveness of syringe exchange in facilitating safe disposal of drug paraphernalia, reducing transmission of blood-borne diseases, and even improving access to primary care services among drug users. The link between syringe programs and enhanced entry of users into drug treatment is key; these programs provide a crucial entry point to the healthcare system.

Syringe exchange programs are a form of harm reduction, a public health strategy that, as the National Harm Reduction Coalition describes, “[a]ccepts, for better or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.”

Another harm-reduction strategy that has become a key facet of local responses to the opioid crisis is community distribution of naloxone, an opioid overdose antidote. Data from recent initiatives have been promising. The Narcan® Distribution Collaborative in Hamilton County, Ohio, for example, distributed more than 11,000 cartons of naloxone locally and effected a 30% reduction in drug overdose deaths eight months after its implementation, as compared to eight months prior to program implementation.

Treatment of Underlying Mental Health Problems and Medication-Assisted Treatment for OUD Remain Essential

Harm reduction is an indispensable component of the public health response to the opioid crisis. Just as essential is access to treatment for underlying mental health problems that complicate and exacerbate OUD. In addition, medication-assisted treatment (MAT) with buprenorphine, methadone, or naltrexone increasingly forms part of a comprehensive OUD treatment plan, alongside behavioral therapy.

Though the number of prescribers with a waiver permitting buprenorphine treatment has increased in recent years, access to MAT remains difficult, especially in rural areas. Even when access exists, a lack of insurance coverage and reimbursement for MAT often stands in the way of care. Medicare’s bundled payments for OUD treatment and the requirement for Medicaid coverage of MAT, which took effect October 1 of this year as a result of the SUPPORT Act of 2018, may help turn the tide.

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Laura Karas

Dr. Laura Karas is a student at Harvard Law School and a Petrie-Flom Student Fellow for the 2020-21 academic year.

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