The Other U.S. Epidemic Grows in Silence

After hundreds of thousands of deaths and countless lives ruined, there were glimmers of hope that the opioid epidemic’s darkest days were over. In 2019, we saw the first dip in fatal overdoses in decades.

Then the COVID-19 pandemic hit. And as we focus on stopping one epidemic, the other has not gone away. Opioid addiction continues to ravage the United States, killing almost 50,000 people each year.

Around the country, we are already seeing significant spikes in overdose deaths. More than 40 states have reported an increase in overdose deaths in 2020. An increase in substance use, much like the worsening of mental health symptoms, is an inevitable consequence of social isolation, fear and uncertainty. Those with substance use disorders are among the most vulnerable – often suffering in figurative silence out of guilt and shame, they are now suffering in literal silence alone and isolated from the world.

The threat of COVID-19 is tremendous, and it must be taken seriously. And yet, for many fighting opioid use disorder, using opioids alone at home is more dangerous than venturing out for treatment and support. Fighting the opioid epidemic amid this new normal means weighing the risks of exposure to COVID-19 against the benefits of seeking help. As we begin to lift societal restrictions, we must ensure that people struggling with substance use disorders have access to the support they need.

COVID-19 has created a variety of factors to make a bad situation worse. Stress, job loss and social isolation all increase the risk of relapse and worsening substance use. In addition, many of the tools used to fight substance use disorders – in-person meetings, methadone clinics, outpatient treatment programs – have been shut down or significantly curtailed.

Yet even as these options start to become available again, a significant obstacle will be getting people back to treatment. Even under ideal conditions, it is often challenging to motivate those with substance use disorders to initiate and continue treatment. A symptom of the illness is to create obstacles to treatment, which in turn allows the substance use to continue. Now the COVID-19 pandemic will provide more reasons not to seek help. The disease process does not want the patient to get better.

During the pandemic, we have seen people forego medical treatment for various medical problems, assumingly due to apprehension over visiting medical facilities. Nationally, health care facilities are reporting a drop of anywhere between 10 percent to 40 percent in patients presenting with conditions like heart attacks, strokes, seizures and cancer.

This seems to be even more prevalent among people suffering from opioid use disorder and other mental health emergencies. The psychiatric emergency room at VA Connecticut saw a decrease in the number of presentations of up to 50 percent at the pandemic peak and my discussions with colleagues confirm similar patterns. Mental health problems and substance use disorders still exist. In fact, evidence suggests that the problem is growing graver, and yet we see fewer and fewer people accessing the care that is available.

Opioid use disorder is generally a chronic illness that worsens without ongoing treatment. When treatment resources become unavailable or reduced and those resources that are available become underutilized, the illness is likely to progress. While some may overdose acutely, others may increase their use or spiral into depression, anxiety or other mental health problems. These patients will ultimately return to treatment.

I expect a significant surge in emergency psychiatric patients for three reasons: first, those who were reluctant to seek help during the prior few months will begin to come seek help again; second, those who would normally seek help will continue to; and, third, due to stress related to COVID-19, many patients with new onset psychiatric and substance use disorders will also present. This surge in patient volume may represent a challenge to the mental health system’s capacity.

To mitigate the risk associated with a sudden surge in patient volume, we must increase our efforts to reach those struggling with substance use disorders. Physicians and community groups must educate people that they can and should come to medical facilities to treat their opioid use and mental health symptoms.

Family and friends must also be increasingly diligent during this time. They should check in frequently with anyone who is at home alone and encourage them to seek treatment when appropriate. Hospitals have made great strides in stopping the spread of COVID-19, and may be a more sterile environment than many other public establishments. Of course, everyone should continue to be cautious and use the appropriate protection measures.

We should also ensure that naloxone, a treatment that reverses an opioid overdose, is widely available during this period. Pharmacies are open and naloxone is available, even without a physician’s prescription. Those taking prescription opioids should also keep naloxone on hand in case of an accidental overdose. First responders should continue to carry and use naloxone when needed, while taking the appropriate protective measures against COVID-19. Even though naloxone is not a substitute for emergency medical care and repeat doses may be necessary, during an overdose, minutes can make the difference between life and death.

Recently, a patient presented to the emergency room following a relapse on alcohol after years of sobriety. He attributed it to the temporary closure of his Alcoholics Anonymous groups, something he relied upon greatly for support. He apologized to me profusely for ”wasting medical services” on him during the pandemic. I thanked him for having the courage to come forward for help despite these feelings and encouraged him to reach out to anyone else who may be struggling alone with feelings of shame.

We need to help people with substance use disorders by continuing to offer them the treatment options they need to recover, even during these challenging times. We cannot forget one epidemic in the face of another.

Dr. Brian Fuehrlein, MD, PhD, is an associate professor of psychiatry at Yale School of Medicine and the director of the Psychiatric Emergency Room of the VA Connecticut Healthcare System.

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