COVID-19 and SUD: FAQs for Clinicians

Learn more about COVID-19 and its effects on people with substance use disorder (SUD) with the answers to these frequently asked questions from the National Institute on Drug Abuse (NIDA).

Vulnerable Populations

How do substance use disorders (SUDs) make people vulnerable to COVID-19?

People who smoke or vape, use opioids, or have a SUD may be especially susceptible to infection by the virus that causes COVID-19 and associated complications because of its direct challenge to respiratory health.

Risk for severe COVID-19 and death escalates with older age, but is also concentrated among those who are immunocompromised or have underlying health conditions, including diabetes, cancer, and heart and respiratory diseases. Many of the latter arise from smoking and COVID-19 may further increase risk for death and illness among people who smoke.

Because of impediments to delivering care to this population, people with SUD who develop COVID-19 may also find it more difficult to receive care. Individuals with SUD 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 1,2.

Are people with opioid use disorder (OUD), methamphetamine use disorder, or other psychostimulant use disorders at particularly high risk if they contract COVID-19?

Yes, because opioids and methamphetamines negatively impact respiratory and pulmonary health. 

At least 2 million people in the United States have an OUD, and more than 10 million people misuse opioids. These individuals may be at increased risk for the most adverse consequences of COVID-19. People who use opioids at high doses medically, or who have OUD face separate challenges to their respiratory health. Because 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) which can lead to cardiac, pulmonary, and brain complications. If severe, hypoxemia can result in overdose and death. Chronic respiratory disease is already known to increase overdose mortality. risk among people taking opioids, so diminished lung capacity from COVID-19 could further endanger this population.

Methamphetamine is a highly toxic drug that causes pulmonary damage, pulmonary hypertension, and cardiomyopathy; its use has markedly increased in the United States as of late. Methamphetamine constricts the blood vessels, contributing to pulmonary damage and pulmonary hypertension in people who use it. Clinicians should be prepared to monitor the possible adverse effects of methamphetamine use when treating people with COVID-19 1,2.

Are there other risks for people with SUDs who have COVID-19?

Yes. People with SUDs are at risk of decreased access to health care and 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, people with addiction—who are already stigmatized and underserved by the healthcare system—may 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 contracting COVID-19. In addition, self-quarantine and other public health measures may disrupt access to syringe services, medications, and other support needed by people with SUDs. 1.

Treatment Delivery

Has COVID-19 created additional barriers to obtaining OUD treatment medications or to accessing syringe services programs?

Yes. Social distancing will increase the likelihood of opioid overdoses occurring when there are no observers who can administer naloxone to reverse them. This will likely result in fatalities. Emergency department physicians with increased caseloads may be less likely to initiate buprenorphine therapy for patients with OUD, which is an important component of mitigating the effects of the opioid crisis 2.

How has treatment delivery for people with SUD been changed due to the pandemic?

We are hearing from multiple sources that it has become harder for patients to be able to access treatment. This includes our most effective strategy to prevent opioid-related overdose deaths—access to medications for OUD, including naloxone and buprenorphine. Some clinics are also forced to limit the number of patients they can take care of 3.

Are there any new regulations related to addressing the challenges of accessing medications?

Yes. In response to the social distancing challenges, the Substance Abuse and Mental Health Services Administration has advised opioid treatment programs to provide take-home medication more flexibly during the pandemic, and the Drug Enforcement Administration has issued guidance to facilitate controlled substance prescribing 2.

Social Supports and Recovery

How is COVID-19 impacting those in recovery? 

Social support is crucial for people in recovery from SUD; further, social isolation is a risk factor for relapse. Although the social distancing measures being implemented nationwide are important for reducing COVID-19 transmission, they may be especially difficult for people in recovery because they limit access to peer-support groups or other sources of social connection. While face-to-face interaction is a key feature of recovery support, virtual meetings may be useful for those with access to the internet.

In addition, people who are feeling isolated and stressed—as much of the population is during a pandemic—frequently turn to substances to alleviate their negative feelings. People in recovery may face heightened urges to use substances that put them at risk for relapse. Peers, family members, and addiction treatment providers should be alert to this possibility. Clinicians should monitor patients for signs of substance misuse or use disorders, given the unprecedented stresses, fears, or even grief they may be facing 2.

How do we provide social support for people at risk for increased substance use and SUDs during the COVID-19 pandemic?

The first step we can take to provide better support to people at risk for substance use and SUDs is removing the stigma of addiction. People with SUD are already marginalized and underserved by health care services, largely because of stigma. Much of this discrimination is based on the erroneous but persistent, widespread belief—even among health care workers—that addiction is the result of weak character and poor choices, despite the science that has clearly shown it to be a disorder arising from alterations in brain circuitry. When hospitals are pushed to their capacity, there is added danger of people with SUD being deprioritized for care if they present with COVID-19 symptoms. It is incumbent on all health care workers not to discriminate against patients with SUD and to treat these individuals with compassion and dignity as they would any others 2,3.

SUD Research

How has the COVID-19 pandemic affected research plans put in place as a part of the NIH vision to address the SUD crisis?

Currently, the majority of the $900 million that NIDA has deployed for research has been put on hold in order for researchers and clinicians to meet the needs of the healthcare system[3].

Has research related to bringing medication-assisted treatments to prison inmates stopped?

Yes. Prisons are high-risk locations for the spread of COVID-19, and have closed their doors to outsiders. Prisons are not allowing researchers onsite in an attempt to reduce exposure risk. Furthermore, some institutional review boards (IRBs) are closing, making it impossible to recruit patients for clinical trials. We are currently exploring the possibility of using virtual technologies to advance some of the goals that we aim to achieve with the HEAL initiative [3].

References

  1. Volkow N. COVID-19: Potential Implications for Individuals with Substance Use Disorders. National Institute on Drug Abuse website. https://www.drugabuse.gov/about-nida/noras-blog/2020/04/covid-19-potential-implications-individuals-substance-use-disorders.
  2. Volkow, N., 2020. Collision of the COVID-19 and Addiction Epidemics. Annals of Internal Medicine, 173(1), pp.61-62. https://www.acpjournals.org/doi/10.7326/M20-1212
  3. Collins F, Volkow N. Coping with the Collision of Public Health Crises: COVID-19 and Substance Use Disorders. NIH Director's Blog. https://directorsblog.nih.gov/2020/04/21/coping-with-the-collision-of-public-health-crises-covid-19-and-substance-use-disorders.