To the Editor:
We read with interest your Journal's commentary describing the impact of the COVID-19 pandemic on access to needle and syringe programs1 and recommendations for policies to improve the treatment of substance use disorders (SUDs) with telehealth.2 Here, we consider these topics in the context of overdoses, treatment, and service access during the pandemic.
To address potentially catastrophic interactions between the overdose epidemic and COVID-19 pandemic, clinicians have rapidly provided alternative and additional services. However, preliminary evidence suggests overdoses may be increasing.3 Between April 27 and May 13, 2020, the Addiction Policy Forum fielded to their US network of patients, families, and survivors of SUDs an IRB-approved anonymized survey (n = 1148 consenting respondents) assessing COVID-19-related impacts.4 To identify possible factors linked to overdoses, we describe responses from individuals experiencing overdoses during the pandemic (Table 1).
TABLE 1.
Demographic and COVID-19 Variables
| None (n = 1079) | Overdose (n = 47) | P, (OR)∗ | |
| Sex (%) | 0.942 | ||
| Female | 677 (65.6) | 28 (70.0) | |
| Male | 333 (32.3) | 12 (30.0) | |
| Other | 22 (2.1) | 0 (0.0) | |
| Age (%) | 0.334 | ||
| 18–25 | 43 (4.2) | 3 (7.3) | |
| 26–40 | 344 (33.3) | 16 (39.0) | |
| 41–60 | 467 (45.2) | 18 (43.9) | |
| 61–64 | 90 (8.7) | 1 (2.4) | |
| 65–74 | 80 (7.7) | 2 (4.9) | |
| 75 yrs or older | 9 (0.9) | 1 (2.4) | |
| Hispanic or Latino Ethnicity (%) | 81 (7.9) | 1 (2.3) | 0.246 (0.28) |
| Race/Ethnicity (%) | 0.176 | ||
| American Indian/Alaskan Native | 17 (1.7) | 0 (0.0) | |
| Asian | 12 (1.2) | 1 (2.3) | |
| Black or African American | 46 (4.5) | 1 (2.3) | |
| Native Hawaiian/Pacific Islander | 1 (0.1) | 1 (2.3) | |
| Other | 47 (4.6) | 2 (4.7) | |
| White | 900 (88.0) | 38 (88.4) | |
| Education (%) | 0.018 | ||
| Less than high school | 11 (1.1) | 1 (2.3) | |
| High school/equivalent | 120 (11.6) | 6 (14.0) | |
| Some college, no degree | 242 (23.5) | 15 (34.9) | |
| Associate degree | 108 (10.5) | 9 (20.9) | |
| Bachelor's degree | 283 (27.4) | 6 (14.0) | |
| Graduate or professional degree | 267 (25.9) | 6 (14.0) | |
| Involved Substances | |||
| Polysubstance (%) | 704 (66.0) | 36 (76.6) | 0.156 (1.68) |
| Alcohol (%) | 700 (65.6) | 30 (63.8) | 0.876 (0.93) |
| Nicotine (%) | 426 (39.9) | 26 (55.3) | 0.047 (1.86) |
| Stimulants (%) | 450 (42.2) | 25 (53.2) | 0.174 (1.56) |
| Opioids (%) | 492 (46.1) | 34 (72.3) | <0.001 (3.05) |
| Sedatives (%) | 228 (21.4) | 11 (23.4) | 0.718 (0.92) |
| Marijuana (%) | 406 (38.1) | 17 (36.2) | 0.879 (1.12) |
| Other substances (%) | 95 (8.9) | 7 (14.9) | 0.189 (1.79) |
| Personal Involvement | |||
| Family member (%) | 423 (39.4) | 25 (53.2) | 0.068 (1.75) |
| In recovery (%) | 582 (54.2) | 18 (38.3) | 0.037 (0.53) |
| Currently using (%) | 111 (10.3) | 10 (21.3) | 0.028 (2.34) |
| In treatment (%) | 80 (7.4) | 4 (8.5) | 0.775 (1.15) |
| COVID status (%) | 0.030 | ||
| Never tested, no symptoms | 915 (85.0) | 34 (72.3) | |
| Never tested, yes symptoms | 96 (8.9) | 5 (10.6) | |
| Tested and diagnosed | 2 (0.2) | 0 (0.0) | |
| Tested negative | 64 (5.9) | 8 (17.0) | |
| COVID impacts | |||
| Substance use has increased (%) | 203 (19.0) | 26 (60.5) | <0.001 (6.52) |
| Yes, COVID impacted services (%) | 340 (33.1) | 28 (66.7) | <0.001 (4.04) |
| Accessed telehealth (%) | 188 (18.4) | 11 (28.2) | 0.141 (1.75) |
| Accessed more doses (%) | 30 (2.9) | 5 (12.8) | 0.007 (4.85) |
| Accessed curbside medication (%) | 43 (4.2) | 5 (12.8) | 0.027 (3.34) |
| Unable to access naloxone (%) | 23 (2.2) | 6 (15.4) | <0.001 (7.88) |
| Unable to access syringes (%) | 18 (1.8) | 6 (15.4) | <0.001 (10.1) |
| Unable to access needed services (%) | 139 (13.6) | 12 (30.8) | 0.008 (2.82) |
P value calculated by Fisher exact test due to small cell sizes. Odds ratios given for 2 × 2 tables.
Forty-seven individuals (4.17%) reported that they or their family members had experienced an overdose during the COVID-19 period. The most commonly reported educational attainment among individuals reporting an overdose was some college but no degree (34%). Fifty-five percent of individuals who overdosed reported using nicotine, 72% reported opioid use. Among those reporting an overdose, 53% identified as a family member of someone impacted by substance use, 38% identified as in recovery, and 21% reported current use. Regarding COVID-19 status, 72% reported they were never tested and had no symptoms or diagnosis.
Individuals who reported an overdose reported changes or disruptions in treatment (67%) and that substance use had increased due to the pandemic (61%). Some of these individuals reported access to greater take-home doses (13%) and curbside medication pickup (13%), but also reported inability to access naloxone (15%), needle exchange services (15%), or general needed services (31%).
Survey limitations include the small convenience sample and online self-report format which did not distinguish between individuals who had personally overdosed and those whose family members had overdosed. These findings may not indicate which individuals may have been at greater risk for overdose during this period, as we did not recruit matched cohorts of equivalent baseline overdose risks. Rather, they suggest some initial factors to explore in future research of the relationship between COVID-19 and overdoses. They suggest that educational attainment, a proxy for socioeconomic status, is linked to overdose during the COVID-19 period, as has previously been shown in analyses of overdoses before the COVID-19 pandemic.5 The information suggests that disruptions in care and increased substance use are important to target to reduce likelihoods of overdoses. Importantly, naloxone and syringe exchange disruptions were more common among those who reported an overdose, as was usage of spatially distanced services such as curbside pick-up and extended take-home medications. This underscores the need to expand access to naloxone and other overdose reduction services and evaluate the efficacies of specific interventions as in-person interactions are reduced.
Footnotes
Supported in part by the National Institute on Drug Abuse (NIDA), National Institutes of Health (NIH), U.S. Department of Health and Human Services (HHS).
The authors report no conflicts of interest.
Dr Potenza has consulted for and advised the Addiction Policy Forum, Game Day Data, AXA, Idorsia, and Opiant/Lakelight Therapeutics; received research support from the Mohegan Sun Casino and the National Center for Responsible Gaming (now the International Center for Responsible Gaming participated in surveys, mailings, or telephone consultations related to drug addiction, impulse-control disorders, or other health topics; consulted for legal and gambling entities on issues related to impulse-control and addictive disorders; performed grant reviews for the National Institutes of Health and other agencies; edited journals and journal sections; given academic lectures in grand rounds, CME events, and other clinical/scientific venues; and generated books or chapters for publishers of mental health texts. The other authors report no disclosures. The views presented in this manuscript represent those of the authors and not necessarily those of the funding agencies.
REFERENCES
- 1.Chayama KL, Ng C, McNeil R. Calls for access to safe injecting supplies as a critical public health measure during the COVID-19 pandemic. J Addict Med 2020; 14 (5):e142–e143. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Drake C, Yu J, Lurie N, Kraemer K, Polsky D, Chaiyachati KH. Policies to improve substance use disorder treatment with telehealth during the COVID-19 pandemic and beyond. J Addict Med 2020; 14 (5):e139–e141. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Haley DF, Saitz R. The opioid epidemic during the COVID-19 pandemic. JAMA 2020; 324 (16):1615–1617. [DOI] [PubMed] [Google Scholar]
- 4.Mellis AM, Potenza MN, Hulsey JN. COVID-19-related treatment service disruptions among people with single- and polysubstance use concerns. J Subst Abuse Treat 2021; 121:108180. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Aram J, Johnson NJ, Lee M-LT, Slopen N. Drug overdose mortality is associated with employment status and occupation in the National Longitudinal Mortality Study. Am J Drug Alcohol Abuse 2020; 46 (6):769–776. [DOI] [PubMed] [Google Scholar]