As the COVID-19 pandemic in the USA has eased, the extent of devastation caused during this period by the opioid epidemic is no longer obscured. Data released by the National Center for Health Statistics on July 14 show a steep rise in overdose deaths. Between December, 2019, and December, 2020—the peak of the pandemic in the USA—more than 93 000 Americans died from drug overdoses, up 29·4% over the previous 12 months. This figure equates to roughly 255 overdose deaths per day; national daily COVID-19 deaths currently hover at around the same number. And with 2020 seeing the largest year-on-year increase in overdose deaths (21 000), it is the pivotal moment to re-examine the opioid crisis response.
Over 500 000 deaths have been attributed to opioids since the mid-1990s, fuelled by economic recession, corporate greed, and shifting attitudes about pain management. Years of aggressive and misleading promotion by Purdue Pharma entrenched misinformation that opioids were without risk, influencing medical education and ensuring less restrictive legislation through lobbying and campaign contributions. Combined with the influx of cheaper illicit opioids, such as heroin and fentanyl, under-resourced state and local governments were outmanoeuvred. The federal response was slow; the opioid crisis was officially declared by the US Department of Health and Human Services (DHHS) only in 2017.
But the opioid epidemic has not unfolded unchecked. Over the past decade, successful state-level policies have included prescription drug monitoring programmes and increased availability of naloxone to prevent overdose. Endorsement of medication-assisted therapy for treatment of substance abuse and overdose prevention has also increased. In April, 2021, the so-called X-waiver was rolled back by the DHHS, enabling more health-care providers to prescribe buprenorphine for opioid use disorder. But stigma around addiction, and restrictive regulation and persistent reluctance by medical professionals to prescribe medication-assisted therapy have hampered progress.
It is promising, then, that the Biden Administration has nominated Rahul Gupta as head of the Office of National Drug Control Policy. If confirmed, Gupta—former health commissioner of West Virginia—will be the first physician to take the role, signifying less focus on legal and law enforcement approaches to drug policy and an increased emphasis on addiction treatment and expanded health-care services.
His appointment comes at a vital time. The 2020 data suggest that the COVID-19 pandemic has been a potent accelerant of opioid-related overdose deaths. The mechanisms are unclear, but it is likely that disruptions in available treatment services and reduced access to harm reduction practices, such as closures of safe injection sites, will have played a role. The data also highlight important demographic points. West Virginia, the epicentre of the crisis, continues to have the highest number of overdose deaths, but urban areas have overtaken rural areas for age-adjusted death rates. The number of 45–64-year-old non-Hispanic Black people in urban areas dying from synthetic opioid overdose has been rising swiftly, a population who are also at greater risk of dying from COVID-19. Although white, rural, middle-aged people are still severely affected by the opioid crisis, it would be unwise and counterproductive to consider overdose deaths their sole preserve. A major test for Gupta will be how to increase financing of addiction prevention and treatment services within the often fragmented infrastructure funded by public health insurance. He will need to reinforce resources in the regions that have been hardest hit by COVID-19, and equitably target emerging regional and group vulnerabilities to opioid use.
Bolstering efforts to identify cohesive, evidence-based strategies for curtailing the opioid crisis, the Stanford–Lancet Commission on the North American Opioid Crisis was convened in February, 2020. Led by Keith Humphreys, it will investigate the causes and chart a course to curb not only fatalities but also disabilities and comorbidities associated with addiction, as well as wider impacts on affected communities. The Commission also aims to prevent the spread of the opioid crisis. Canada too has had a huge increase in overdose deaths during the COVID-19 pandemic (British Columbia reported over 1700 deaths since 2019, up 74%). With the goal to equip policy makers and health-care providers, a report of its recommendations will be published at the end of 2021. The direction of the opioid crisis necessitates viewing the epidemic from new perspectives, and demands updated and equitable policies in response.
For the National Center for Health Statistics drug overdose data see https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
For data on rural versus urban opioid deaths in the USA see https://www.cdc.gov/nchs/data/databriefs/db403-H.pdf
For more on the opioid crisis in Black/African American populations see https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-05-02-001_508%20Final.pdf
For data on overdose deaths in Canada see https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/
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