COVID-19 and the Opioid Crisis: Dueling Epidemics Illustrate the Need for Future Action

Although telehealth access has increased throughout the course of the COVID-19 pandemic, people living with chronic pain have frequently been left behind due to barriers placed on access to opioids and elective surgical procedures, according to a review published in Pain Therapy.

“The COVID-19 pandemic has led to a simultaneously deep and abrupt economic recession in the United States,” the study authors wrote. “While the opioid epidemic has not gone away, the management of chronic pain patients has been hampered by the restriction of interventional techniques and office visits. This has significantly affected chronic pain patient management and caused severe restrictions in non-opioid therapy.”

Chronic Pain and Concurrent Epidemics

Chronic pain typically affects society in an outsize way, leading to an increased consumption of health care resources, disability, and economic challenges. Despite its frequency, there is no one agreed upon method to manage chronic pain, and prior to the onset of the pandemic, utilization of interventional pain management techniques had been decreasing since 2009. Researchers noted a similar decrease in opioid prescriptions (40%) between 2013 and 2019.

According to the review authors, the full extent of untreated chronic pain during the pandemic is “not yet…fully appreciated.” The “decimation” of multiple health care services, including interventional pain management techniques and elective surgeries, may ultimately lead pain patients to seek alternate, potentially inappropriate or harmful treatments.

Consequences of receiving inadequate pain treatment are numerous, and include significant psychosocial impacts, increasing disability rates, and the use or abuse of prescription and illicit drugs.

These challenges come at a time where the United States is still dealing with the opioid epidemic, independent of the pandemic. While overdose death rates have decreased by 14.5% and 3% for prescription opioids and heroin, respectively, and prescriptions for opioids decreased by 40% between 2013 and 2019, the US still continues to experience more opioid-related deaths than any other country.

The psychosocial impact of COVID-19 — including the uncertainty, the burden of quarantining, and inadequate health care services — cannot be understated. Although undoubtedly an important disease mitigation strategy, nationwide lockdowns produced acute panic, anxiety, obsessive behavior, paranoia, depression, and post-traumatic stress disorder (PTSD), in both the short- and long-term. Frontline health care workers are at risk of experiencing even more negative psychosocial outcomes, due to the increased risk of contracting COVID-19 and feelings of burnout, anxiety, and PTSD.

Taken together, the country is facing 2 concurrent epidemics: COVID-19 and the opioid crisis. Record overdose deaths were counted during 2020 and are continuing to climb, attributed to the pandemic. Drug deaths, according to the study authors, rose an average of 13% through June 2020 compared with the previous year.

Addressing the Opioid Epidemic

Several schools of thought describe how the opioid epidemic might be addressed. Some believe that curtailing opioid prescription rates will eliminate the epidemic, although data disagree. Others believe that the crisis is “fundamentally fueled” by economic and social issues — all of which were negatively impacted by the coronavirus crisis.

“We have to resolve the issue of the crisis trajectory through the intertwined use of opioid analgesics, heroin and fentanyl analogs, and engaging in structural determinants to address this formidable public health emergency,” the researchers wrote. “While we sort out the differences coming out of this economic and health care recession, certain measures must be initiated and implemented immediately.”

These measures, of course, include the appropriate monitoring and interruption of the illicit drug supply, as well as the identification and proactive management of risk factors. Continuation of buprenorphine through telehealth or telephone-only services — particularly for patients on Medicare — throughout the remainder of the public health emergency is paramount, as is flexibility on the part of insurers and payers. Prescribed opioid use may need to temporarily increase as elective surgeries return to full capacity, and a nationwide effort should be undertaken to address current barriers to prescribing and refilling controlled substances for people in pain during the pandemic.

“In addition to major suffering from COVID-19…with the numerous consequences of lockdown and decimation of surgical and procedural services, patients with chronic pain and opioid disorders have suffered substantially related to limited access to treatment,” the researchers concluded. “It is essential to formulate appropriate principles to provide appropriate opioid therapy and control the opioid epidemic without curbing access to therapeutic opioids and treatment of substance use disorders.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Manchikanti L, Vanaparthy R, Atluri S, Sachdeva H, Kaye AD, Hirsch JA. COVID-19 and the opioid epidemic: two public health emergencies that intersect with chronic pain. Pain Ther. 2021;1-18. doi:10.1007/s40122-021-00243-2