Eclipsed by Virus, Addiction Still Shadows the Land
"COVID-19 detrimentally impacts people with addiction and people in pain, making vulnerable people even more vulnerable," says sociologist Liz Chiarello.
Liz Chiarello, a 2019–2020 Radcliffe fellow and an associate professor of sociology at Saint Louis University, is the recipient of multiple awards from the American Sociological Association, including a Distinguished Article Award and a Junior Scholar Award. Her current research is supported by a National Science Foundation CAREER Award. Informed by years of data analysis and hundreds of interviews, she is working on a book examining how the opioid crisis has transformed law enforcement and health care in the United States.
Tell us what you’re hearing and seeing about the effects of COVID-19 on the opioid crisis. What are you most worried about in the coming months?
Despite being overshadowed by COVID-19, the opioid crisis has not disappeared. In many ways, it has gotten worse. Overdose deaths have spiked, resources to reduce harm are harder to access, and isolation has frayed social ties. COVID-19 has also limited the illicit drug supply. It is harder for drugs to get into the country, making drugs that are available more expensive and more likely to be cut with other, more dangerous substances. Many reporters have noted that COVID-19’s arrival has forced the United States to deal with two crises—a pandemic and an opioid crisis. This claim downplays our reality by ignoring a third crisis that COVID-19 exacerbates: the pain crisis. COVID-19 detrimentally impacts people with addiction and people in pain, making vulnerable people even more vulnerable. People of color, people in poverty, people without homes, and people in rural areas face extensive challenges confronting all three crises.
This raises a range of serious concerns.
I’m worried that pain patients will lack access to care. They already have to navigate a labyrinthine healthcare system that requires them to jump through numerous hoops—pain contracts, drug screens, prescription drug monitoring program reports—to get opioids. They face skeptical physicians and pharmacists, unwilling insurance companies, and federal guidelines that restrict opioid care. Beyond that, many pain treatments are hands-on—chiropractic, physical therapy, acupuncture, Rolfing, and massage all require physical contact. In isolation, without these treatments, pain patients will suffer considerably.
I’m worried that people who use drugs will be seen as disposable, as less worthy than other people suffering from this virus. When police officers first started carrying the overdose-reversal drug naloxone, or Narcan, some leaders stated publicly that there should be a limit on how many times someone can be revived. They endorsed the idea that if people were going to die anyway, helping them was a waste of resources. Similarly, as synthetic fentanyl has made its way into the drug supply, many police officers mistakenly believe that an officer can overdose simply by touching someone who has overdosed from fentanyl. The poisoned-body fentanyl myth paired with the reality of an easily transmittable deadly virus could easily undermine harm-reduction efforts.
I’m worried that people who use drugs will lack access to harm-reduction resources. Harm-reduction theories emphasize meeting people where they are at, focusing on any positive change, and minimizing negative outcomes from current behaviors. In the midst of a pandemic, people are poorly positioned to stop using drugs. However, there are resources available to prevent drug use from spreading disease and doing other forms of physical harm. Using sterile syringes, alcohol wipes, and cotton swabs for injecting drugs reduces the risk of spreading Hepatitis C and HIV/AIDS as well as the risk of painful abscesses at the injection site. Many programs that provide these resources are closed partly due to inadequate personal protective equipment for workers. This will put more people in harm’s way.
I’m worried that people transitioning out of institutional systems will not get the care they need. Moments of transition constitute particularly vulnerable times for people who use drugs. Moving out of hospitals, in-patient treatment centers, or prison or jail creates opportunities for relapse and for overdose deaths. Transition options are limited in the best of times, raising critical concerns about what it looks like today. Are people receiving warm hand-offs? If so, who is doing them and what do they look like? Now, more than ever, people are likely to fall through the cracks.
Experts are concerned that overdose rates will drastically increase during COVID-19. We’ve seen some measures put in place to counteract that risk, like an increase in telehealth efforts and allowances for extended supplies of medication. Are these measures working?
Addiction treatment is subject to unique and restrictive rules. For example, patients receiving methadone must show up for treatment every day, to the detriment of their lives and their jobs. In light of COVID-19, the Drug Enforcement Administration (DEA) and the Substance Abuse and Mental Health Services Administration relaxed rules around methadone and buprenorphine, or Suboxone. Specifically, they allow methadone prescribers to give patients up to 28 days’ worth, and permit buprenorphine prescribers to do initial appointments over phone or video instead of face-to-face. Both of these changes have expanded access to care—patients are no longer taxed with getting to the methadone clinic each day or with juggling childcare and limited public transportation, and people who need addiction treatment can reach providers anywhere in the United States when treatment options in their own areas are sparse. NPR reports that telemedicine has doubled provision of medications for addiction treatment in California and nine other states and that patients are far more likely to remain in treatment compared with in-person care models.
These measures are certainly encouraging, but challenges persist. First, insurance does not always reimburse for telehealth at the same rate as for in-person visits, so physicians may be hesitant to provide care this way. Second, patients without insurance or without high-speed internet struggle to find care. Third, many treatment facilities refuse to take advantage of the telehealth option, putting their patients at risk through in-person care. Finally, and most importantly, the only health-care providers permitted to offer telemedicine to treat addiction are those with an existing “X waiver,” a special exception through which the DEA allows providers to offer buprenorphine treatment for a limited number of patients. As a result, the telehealth change does not expand capacity as much as possible.
What more can be done?
Leaders should focus on expanding access to care using an all-hands-on-deck approach. One way to do this is to temporarily lift the X waiver; another is to ensure that naloxone and syringes are available at all pharmacies and to involve pharmacists in testing for COVID-19 and referral for addiction treatment services. A third is to support efforts for mobile naloxone and methadone distribution, increasing access for patients who cannot reach a treatment facility or who are unhoused. A fourth is to blanket communities of people who use drugs with life-saving resources such as syringes, naloxone, sterile supplies, and drug test strips. Test strips are important because COVID-19 is altering the drug supply by making it harder for illicit drugs to enter the country. This sounds like a good thing—fewer drugs could mean fewer overdoses—but eliminating drug supply does not eliminate drug demand. As a result, people who use drugs are likely to get drugs from unknown sources that may be cut with more dangerous substances. Giving people a way to test their drug supply reduces the risk of death.
There’s a stigma attached to substance use disorders. Do you worry that the stigma might increase as another health crisis takes priority?
Stigma plays a major role in which patients get access to care, who is deemed deserving and who is deemed undeserving. What the word “stigma” first brings to mind is discrimination. Health care providers often relegate people who use drugs and people with chronic pain to the undeserving category, conceiving of them as manipulators or malingerers. But stigma is not just interpersonal; it is structural. Unequal allocation of resources fundamentally breeds stigma. In a moment like this when health-care providers lack sufficient human power, protective equipment, and ventilators, they have to make tough decisions about who deserves access to care. These choices are not only grounded in perceptions of patients’ medical conditions but also in cultural constructions of worth grounded in race, class, and gender. The dehumanization of people who use drugs and people in pain is exacerbated when those people are poor and/or belong to minority groups. Multiple news reports have spotlighted people of color who died after being denied access to COVID-19 tests and treatment. Communities of color have disproportionately high fatality rates resulting from systemic inequality in jobs, housing dynamics, and access to healthcare.
Pain, addiction, and COVID-19 are not just biological but also social and political. But all is not lost—yet. We have the power to address these conditions in ways that affirm life and honor humanity. These are the standards to which we must hold our leaders accountable.
Interview was edited for clarity and length.