COVID-19: Potential Implications for Individuals with Substance Use Disorders

This illustration, created at the Centers for Disease Control and Prevention (CDC), reveals ultrastructural morphology exhibited by coronaviruses. Note the spikes that adorn the outer surface of the virus, which impart the look of a corona surrounding the virion, when viewed electron microscopically. A novel coronavirus, named Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), was identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in 2019. The illness caused by this virus has been named coronavirus disease 2019 (COVID-19).

As people across the U.S. and the rest of the world contend with coronavirus disease 2019 (COVID-19), the research community should be alert to the possibility that it could hit some populations with substance use disorders (SUDs) particularly hard. Because it attacks the lungs, the coronavirus that causes COVID-19 could be an especially serious threat to those who smoke tobacco or marijuana or who vape. People with opioid use disorder (OUD) and methamphetamine use disorder may also be vulnerable due to those drugs’ effects on respiratory and pulmonary health. Additionally, individuals with a substance use disorder are more likely to experience homelessness or incarceration than those in the general population, and these circumstances pose unique challenges regarding transmission of the virus that causes COVID-19. All these possibilities should be a focus of active surveillance as we work to understand this emerging health threat.

NIH has posted a compilation of updates for applicants and grantees, including a Guide Notice on administrative flexibilities and accompanying FAQs.

SARS-CoV-2, the virus that causes COVID-19 is believed to have jumped species from other mammals (likely bats) to first infect humans in Wuhan, capital of China’s Hubei province, in late 2019. It attacks the respiratory tract and appears to have a higher fatality rate than seasonal influenza. The exact fatality rate is still unknown, since it depends on the number of undiagnosed and asymptomatic cases, and further analyses are needed to determine those figures. Thus far, deaths and serious illness from COVID-19 seem concentrated among those who are older and who have underlying health issues, such as diabetes, cancer, and respiratory conditions. It is therefore reasonable to be concerned that compromised lung function or lung disease related to smoking history, such as chronic obstructive pulmonary disease (COPD), could put people at risk for serious complications of COVID-19.

Co-occurring conditions including COPD, cardiovascular disease, and other respiratory diseases have been found to worsen prognosis in patients with other coronaviruses that affect the respiratory system, such as those that cause SARS and MERS. According to a case series published in JAMA based on data from the Chinese Center for Disease Control and Prevention (China CDC), the case fatality rate (CFR) for COVID-19 was 6.3 percent for those with chronic respiratory disease, compared to a CFR of 2.3 percent overall. In China, 52.9 percent of men smoke, in contrast to just 2.4 percent of women; further analysis of the emerging COVID-19 data from China could help determine if this disparity is contributing to the higher mortality observed in men compared to women, as reported by China CDC. While data thus far are preliminary, they do highlight the need for further research to clarify the role of underlying illness and other factors in susceptibility to COVID-19 and its clinical course.

Vaping, like smoking, may also harm lung health. Whether it can lead to COPD is still unknown, but emerging evidence suggests that exposure to aerosols from e-cigarettes harms the cells of the lung and diminishes the ability to respond to infection. In one NIH-supported study, for instance, influenza virus-infected mice exposed to these aerosols had enhanced tissue damage and inflammation.

People who use opioids at high doses medically or who have OUD face separate challenges to their respiratory health. Since opioids act in the brainstem to slow breathing, their use not only puts the user at risk of life-threatening or fatal overdose, it may also cause a harmful decrease in oxygen in the blood (hypoxemia). Lack of oxygen can be especially damaging to the brain; while brain cells can withstand short periods of low oxygen, they can suffer damage when this state persists. Chronic respiratory disease is already known to increase overdose mortality risk among people taking opioids, and thus diminished lung capacity from COVID-19 could similarly endanger this population.

A history of methamphetamine use may also put people at risk. Methamphetamine constricts the blood vessels, which is one of the properties that contributes to pulmonary damage and pulmonary hypertension in people who use it. Clinicians should be prepared to monitor the possible adverse effects of methamphetamine use, the prevalence of which is increasing in our country, when treating those with COVID-19.  

Other risks for people with substance use disorders include decreased access to health care, housing insecurity, and greater likelihood for incarceration. Limited access to health care places people with addiction at greater risk for many illnesses, but if hospitals and clinics are pushed to their capacity, it could be that people with addiction—who are already stigmatized and underserved by the healthcare system—will experience even greater barriers to treatment for COVID-19.  Homelessness or incarceration can expose people to environments where they are in close contact with others who might also be at higher risk for infections. The prospect of self-quarantine and other public health measures may also disrupt access to syringe services, medications, and other support needed by people with OUD.  

We know very little right now about COVID-19 and even less about its intersection with substance use disorders. But we can make educated guesses based on past experience that people with compromised health due to smoking or vaping and people with opioid, methamphetamine, cannabis, and other substance use disorders could find themselves at increased risk of COVID-19 and its more serious complications—for multiple physiological and social/environmental reasons. The research community should thus be alert to associations between COVID-19 case severity/mortality and substance use, smoking or vaping history, and smoking- or vaping-related lung disease. We must also ensure that patients with substance use disorders are not discriminated against if a rise in COVID-19 cases places added burden on our healthcare system. 

As we strive to confront the major health challenges of opioid and other drug overdoses—and now the rising infections with COVID-19—NIDA encourages researchers to request supplements that will allow them to obtain data on the risks for COVID-19 in individuals experiencing substance use disorders.

This content is also available in Spanish - COVID-19: Las posibles implicaciones para las personas con trastornos por consumo de drogas.


Additional Links

For those with questions about how their state justice systems are adjusting operating procedures in response to COVID-19, The Marshall Project is tracking changes as they occur. Also, the Vera Institute of Justice has developed guidance for justice system adjustments to COVID-19. 

Dr. Nora Volkow, Director

Here I highlight important work being done at NIDA and other news related to the science of drug use and addiction.

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Comments

COVID-19 information

Thank you for getting this out so quickly. Very helpful.

vulnerable populations

The most vulnerable to Covid-19 among substance abuses is going to be the crack-smoking homeless. The homeless are vulnerable just by being homeless, but add to that the lung damage from smoking crack and the risk is compounded. As Dr. Volkow points out, tobacco and marijuana smoking are also more prevalent among those who are homeless. This is going to be an important area of research.

Other COVID implications on folks with substance abuse disorders

Some 12 step programs are cancelling meetings because of COVID. This means less access to one means of supporting longer term recovery, thus perhaps exacerbating another health issue, substance abuse?.

COVID-19 and substance use

An excellent and informative essay. Missing is whether poor public health among homeless substance users may exacerbate risks of spreading disease. Eg non-hygienic disposal of bodily waste which have been shown to harbor virus, discarded syringes, smoking butts, other paraphernalia. Also smokers and vaperers tend to forcefully expel smoke or vapor, which could spread virus more efficiently than normal exhalation.

Potential for rapid spread in correctional facilities

50% of people behind bars have at least one chronic disease, and these facilities are poorly designed to prevent widespread and rapid transmission, and large boluses of sick individuals may hit the healthcare system when we can least afford it. Prepare now by 1) releasing as many as possible, especially elderly and ill (also least likely to commit crime), 2) urge courts and police to stop sentencing and arresting 3) aggressive screening and isolation both upstream (police and courts) and in the facilities, cohort. Transfer out sick ASAP. Identify those who are infected early and recover who can help with custodial and care efforts as they are likely to be immune and there will be severe staff shortages. Disastrous wide scale rioting in Italy is a somber warning of what to avoid.

Estamos preparados?

It is very interesting to be well informed because the media widely disperses the information.
But are we ready for a pandemic?

Mutual help

Mutual help organizations such as 12 step programs that are be canceled are offering virtual meetings via phone and other virtual software such as zoom and blue jean.

Has Any testing been done?

As preliminary tests show that Influenza type A can actually be slowed by methamphetamine use, has any testing been attempted along the same clinical lines with Methamphetamine? I am prescribed desoxyn for ADHD and I am concerned about any issues this may cause with my use of my prescription and the interaction with the corona virus. Thank you!

More research is needed on

More research is needed on this question. In the meanwhile, talk to your healthcare provider if you are experiencing concerning symptoms, and do not discontinue or change your use of any medications without following their instructions.

This seems like “creating black sheep“

This article did not seem helpful except maybe in helping people find reasons to hate homeless people or drug addicts- I refer you to the comment above saying that smokers expel forcefully (hahahahaha!!) which will only spread the virus further- nothing but nonsense!! These people are NOT at greater risk of passing on the disease (how far does the average person stay from homeless people or drug addicts Or smokers!?!? They’re usually given a wide, wide berth anyway!) They’re only more likely to suffer a more severe form of the disease. But... duh- they’re also more likely to suffer from LIFE more than the average person. No need to single out a group of people. Viruses don’t know the difference!!

This seems like “creating black sheep“

This article did not seem helpful except maybe in helping people find reasons to hate homeless people or drug addicts- I refer you to the comment above saying that smokers expel forcefully (hahahahaha!!) which will only spread the virus further- nothing but nonsense!! These people are NOT at greater risk of passing on the disease (how far does the average person stay from homeless people or drug addicts Or smokers!?!? They’re usually given a wide, wide berth anyway!) They’re only more likely to suffer a more severe form of the disease. But... duh- they’re also more likely to suffer from LIFE more than the average person. No need to single out a group of people. Viruses don’t know the difference!!

COVID19 & POT

No mention of the correlate to cannabis and the immunoresponse, anti-inflamatory, anti-anxiolotic effects in this suggesting a shallow examination, where cannabis being illegal has more of a play in health promotion failure, begging the question? where is the don't share spit message?

I am a 40 year old male

I am a 40 year old male currently prescribed methadone for opioid abuse in the U.S. I am also a smoker. This article was extremely informative and thank you for releasing it in such a timely manner. In my experience it is always better to be well informed then uninformed.

pathogenesis of covid-19

hello misters…
covid-19 different from SARS for targeted receptor. if the covid-19 targeted toward ACE2 why we not observing any oral manifestation for like reaction during incubation periods of the virus? although the oral mucosa enriched by ACE2 !
the targeted receptor represented by the phospholipids / protien links ,,of surfictant ( DPPC) SP-A, SP-B, SP-C, SP-D after breaking of those links the virus having easy pathway for enterance with assistance of Zn ions via thinned cell membranes of alveolar cells .

MMTP

what is being done to loosen take-home restrictions for patients on MAT? Acknowledging that there may be a problem fails to present adequate solutions. they talk, we die.

In reply to by Anonymous

Guidance to opioid treatment programs

On 3/16/20, the Substance Abuse and Mental Health Services Administration issued guidance to opioid treatment programs to provide take-home medication for longer durations for many patients during the pandemic, reducing the need for frequent clinic visits.

Still no answer for us who rely on MAT...

Medication Assisted Treatment (MAT) whether it is methadone, suboxone, vivitol, or subutex...some of us rely on these daily dose medications to survive. It has been proven that cutting someone who is on a Federally funded and prescribed medication for outpatient treatment is DANGEROUS AND DEADLY. I am 31 and relatively healthy, but my mother is 67 yeara old, had battled cancer 5x, and suffers from chronic kidney disease. I am taking safety precautions and proper hand washing, but still it is terrifying the risk I am taking as I am required to go into the methadone clinic daily with questions and concerns....hoping for some take homes, or the ability to not have to put my mother at risk by coming in 6 days a week. The only answer I get is "methadone ia federally funded, it won't stop" that's all well and good...but isn't there something I can do? And being just one of the 4000 patients at my clinic, I know I can't be the only one with a at risk person at home. What steps will be taken to change this everyday risk, and when? I pray day and night that my mother will not have to be the one to die, for an example to be made and a medically necessary need for change to happen, NOW! PLEASE HELP!

Guidance to opioid treatment programs

On 3/16/20, the Substance Abuse and Mental Health Services Administration issued guidance to opioid treatment programs to provide take-home medication for longer durations for many patients during the pandemic, reducing the need for frequent clinic visits.

Substance Abuse

The main issue in regards to substance abuse and use is that by using mind altering chemicals or alcohol, the bodies immune system is weakened. The sharing of any drug related equipment along with a suppressed immune sytem could deff spread quite quickly. Not to mention that it will be hard for any ED dept to determine symptoms due to withdrawal of any mind altering chemical, or while under the influence as addicts do not know their bodies like a sober person would. It will take the Detox facilities and treatment centers by storm if not taken seriously enough, hopefully screening will be utilized and helpful with these facilities as well. Not to mention the importance of hygiene and the lack there of by those who may be using or abusing their bodies. I would hope that these test kits are coming quick so that these certain facilities can properly go about helping people. Thanks all and may you stay healthy!

SUD OP AND RESIDENTIAL TREATMENT GROUPS

I'm a treatment director in Minnesota looking for guidance on facilitating group in a residential and outpatient setting. We have group sizes of often 10 to 16 period it will be a huge burden to try to staff to do smaller groups and provide the same level of care especially in a residential programs is there any specific guidance on this period.

Sharing this with my clients

Thank you for sharing this so quickly, great information, sharing this with my smoking clients.

Outpatient Substance Abuse Treatment

I am a counselor at an outpatient substance abuse treatment center in a state that has over 30 cases and 1 death. As of now, we have no access or plans in place for telehealth / telecounseling services at our center and are continuing to operate "business as usual." It seems like an enormous risk to continue our outpatient counseling groups as much of our clients fall into this vulnerable category (pre-existing conditions, low income, limited access to healthcare, etc). I wonder, now, if outpatient alcohol and drug counseling should be considered "medically necessary" as our director described it, or if we should be protecting the health of our clients by postponing group services. I want to support my clients in their recovery journey without putting them at what seems to be substantial risk.

COVID-19 & LUNG DAMAGE

I am 73, with a back history of bronchitis. I want to know if covid-19 causes permanent lung damage?

Since this is a novel virus,

Since this is a novel virus, long term outcomes are not currently known.  Please check with your healthcare provider and the CDC for the latest information.

HIV Undetected / AIDS

Great Information Thanks

Suboxone

I read things about methadone programs But what about someone like me who is in need of a suboxone refill but the doctor requires patients to come in every few weeks to prescribe. I also live in Florida where there is a state of emergency

article on corona19

In regards to methamphetamine use.i got clean9 years ago after the better part of 27 years of IV use.is the increased risk of getting infected determined to be that of if i still used

At this time, many critical

At this time, many critical questions about vulnerability to COVID-19 remain unanswered, including those related to risk to someone who has stopped smoking or using drugs.  

Counseling Services

You should not be doing any individual/group sessions at this time. We shut down all groups as of last Friday march 13th. We along with everyone else at University of Md Hospitals and clinics are preparing for telemedicine and hopefully set up some type of skype/FaceTime sessions

What about withdrawal?

With social distancing, will we see people like college students and other populations with addictions suddenly not having access to drug and therefore a spike in withdrawal issues?

Suboxone (follow up)

Do you think these people care about patients being treated with buprenorphine (suboxone)?
THESE are the same people who inexplicably insist that people treated with suboxone (a drug that DOESN’T get the user high and is nearly impossible to overdose on) visit their Dr every 30 days!

DRUG POLICY in the USA is a perfect guide on “how to CREATE an opioid epidemic”, Driven by maximizing pharma MONEY at every turn, rather than focusing on what’s best for Americans.

EVEN THE NIDA will admit that plant therapy, such as Ibogaine, COULD BE successfully used to treat opioid abuse, as they funded a successful trial of the plant in the 90’s!
They (NIDA) also admit that forcing patients to visit their Dr once a month (as if we have nothing better to do with our lives than sit in packed Dr offices) is prohibitive.

Prison lobbying and pharma lobbying succeeds, and American citizens suffer.
Here we sit, STILL, in the year 2020, once a month, in Dr offices (in perfect health), filled with sick people spreading viruses.
OR slip back to black market opioid abuse.
“HOW TO CREATE an opioid epidemic”: Just look at US drug policy...

Group therapy and social distancing

Please comment how this can be accomplished?

Methadone Clinics

PLEASE I'm begging that all methadone clinics have a mandatory 2 week, minimum, take home doses. I am very high risk with kidney disease, asthma, diabetes. At any given time there are 20-50 people in the clinic. There us absolutely no possible way of social distancing! Information was put out on the 16th but our governors and CDC, department of health need to put out media to let the providers know. These take home medications need to be mandatory and the word needs to be put out to all the clinics. Please dont let us be forgotten! Right now that's how I feel, we are forgotten and left behind.

Supplements for COVID-19 research

You mention that "NIDA encourages researchers to request supplements that will allow them to obtain data on the risks for COVID-19 in individuals experiencing substance use disorders." Can you please clarify how researchers should request supplements?

pseudo science

There are no studies supporting an actual elevated risk among smokers. Your conjecture is hypothetical. The majority of smokers do not have COPD and will have exactly the same immune response. I accept it is worse for critical occurrences to be a smoker, but you would have to fall into that category. Post hoc ergo propter hoc

Anxiety

Thank you for supporting our families and individual s who have difficulty in our past healthcare delivery, add Covid19 and we must all advocate. Easy to criticize, take positive action to help this population

Inpatient Detox facilities

I have mixed emotions working with such a high risk/vulnerable population as a nurse...my question is this..not to sound heartless but during this crisis inpatient detox is not a medically necessAry service...I am praying they shut our unit down as I am being potentially being exposed to this virus daily and this is a voluntary unit many more leave than stay and are successfully discharged...not to mention the only thing at this moment we are doing is dosing the patients ...other than that all group therapy on the unit is cancelled ...any thoughts on this?

We understand your concerns

We understand your concerns in these especially trying time.  And it is critical to balance patient need for ongoing addiction care with necessary safety precautions for those providing it.  It is also important to treat SUD patients with compassion, and to recognize that in addition to being in potentially life threatening circumstances, patients with SUD are sensitive to how they are treated and it may determine whether they choose to get care or not.  There are resources to help support recovery in these difficult circumstances; for example, virtual meetings of mutual support groups (e.g. SMART Recovery, AA, and NA) are available to those with access to the internet.  Also, on 3/16/20, the Substance Abuse and Mental Health Services Administration issued guidance to opioid treatment programs to provide take-home medication for longer durations for many patients during the pandemic, reducing the need for frequent clinic visits.  They also recently released Virtual Recovery Resources for Substance Use and  Mental Illness. 

Risk of alcohol hand sanitizers

I appreciate your article highlighting these high risks. Can you also address the alcohol ingestion and/or poisoning risks of the use of alcohol based (70 proof) hand sanitizers with the SUD population and with children and pregnant or breastfeeding mothers. At the time of SARS we had children and teens abusing the substance by licking their hands.

Alcohol-based hand sanitizers

Alcohol-based hand sanitizers were not designed to be ingested, and can result in adverse health consequences. This would apply to all populations

Suboxone and Covid19 Symptoms

When you take Suboxone it helps with withdrawal symptoms, right? So, will it also reduce Covid19 symptoms?
As we know, Suboxone significantly reduces withdrawal symptoms, which also closely mimics Covid19 symptoms. Vomiting, diarrhea, headaches, muscle aches, confusion, and breathing issues (rapid breathing or shallow breathing that accompanies opioid overuse, stopping opioids, or overdosing) are all symptoms Suboxone helps with. If Suboxone does tamp down Covid19 symptoms, could users of the drug be carrying the virus without symptoms and not know it?

While there is some overlap

While there is some overlap in symptoms of opioid withdrawal and COVID-19, these symptoms have entirely different causes and there is no evidence that Suboxone can ameliorate symptoms of COVID-19.

Drug Testing

I would like to hear from other substance abuse facilities that also have labs or conduct observed drug testing for court ordered programs. Have you suspeneded the drug testing?

Buprenorphine

I have my once a month appt coming next week. I work at Dept oSocial Services. I Am considered “essential” personnel. If our state or the US go on lockdown I will be working from home. If everyone is on lockdown including pharmacies how will I get my script. And if I am still somehow given one what if they are out due to shortages etc. The receptionist at my dr won’t answer these questions. Many essential workers and first responders take buprenorphone. Without it we will be very Ill. It seems to me we should be prepared before the lockdown occurs. Also I’ve heard it’s coming won’t be long. Very scared and worried. I can’t do my job and help others if I’m put in this predicament.

We certainly understand your

We certainly understand your anxiety in this difficult time, and recommend you look at the resources that SAMHSA has posted for patients and providers. Also, please note that states and countries that have implemented “lockdown” procedures still allow pharmacies and grocery stores to operate, as they provide essential functions.   Hopefully, you will not experience a disruption in your treatment. 

Probation urine testing exposure

Will the heath and well being of probationers (clean test for 2yrs) who are required to report to unsanitary bodily fluids depositories under threat of arrest for violating the terms, and by extension every person (incl. children) living in their entire apartment building, ever be important enough to consider addressing?

We have been explicitly excluded from *all* of the safety measures and emergency benefits being afforded to the general public, government &court employees.

A lot of people concerned about alcohol/addiction relapse and getting their Suboxone/opioid drugs and expansive safety nets and resources are being continually extended to meet their needs.

I have breast cancer/radiation (weakened immune system) plus negative drug tests for 18 months and a warrant for my arrest will immediately be issued when I know my health and safety is perpetually compromised by contact with any surface in that facility.
My life was already destroyed and my health is being forcefully jeopardized.
I’m so scared, I have no options that are free from negative consequences, no contact over my heath and safety.

People in situations like mine just don’t matter. Even dogs have higher priority.
My neighbors aren’t comfortable knowing they don’t matter, either.