A glass half empty or a glass half full? Addressing the opioid crisis through the lens of COVID-19.

In 2020, the world was struck by the first respiratory disease pandemic in over one hundred years: COVID-19, with the US bearing a disproportionate burden of cases. As a result, attention turned away from the opioid epidemic, which up until that time had been the most pressing public health crisis of the decade. In the US alone, more than 81,000 people died of an overdose between June 2019 and May 2020, a 24 % increase over the previous year and the highest rate ever recorded in the US over a one year period (Ahmad et al., 2021). Despite the worsening of the overdose crisis, US President Biden announced six public health priorities for his administration in his first month of office. Tragically, the opioid crisis was not one of them (Vazquez, 2021).

At the time of writing, four COVID-19 vaccines were developed within a year and over sixty million Americans have received them. By contrast, the proportion of Americans with an opioid addiction who are receiving medications for opioid use disorder (MOUD) remains unchanged, at approximately 20 % (Saloner and Karthikeyan, 2015), and is even lower for indigenous communities (11 %) (Boyd et al., 2021). As documented in this special issue of Drug and Alcohol Dependence, the same socio-structural barriers that have prevented people who use drugs from accessing health care, MOUD and harm reduction services for decades persist.

The fault lines in our society that render communities of color at greatest risk of COVID-19 also place them at risk to addiction and related syndemics, including HIV, viral hepatitis, STIs, endocarditis and overdose (Strathdee et al., 2021). COVID-19 may further widen racial and ethnic health disparities and in some parts of the U.S., has already been associated with higher rates of overdose (Volkow, 2020). Black and indigenous communities have experienced the steepest increases in fatal and non-fatal overdoses (Cano et al., 2020) and are under-represented among those vaccinated against COVID-19 (Ndugga et al., 2021). Women also face additional pressures in the context of COVID-19 and addiction, including their role as mothers and caregivers, and greater exposure to intimate partner violence (El-Bassel and Strathdee, 2015; Sanchez et al., 2020).

Instead of viewing the COVID-19 epidemic and response as a “glass half full”, we should consider it an opportunity to call attention to health disparities and leverage resources to provide integrated health and harm reduction services for people with substance use disorders. For example, testing programs for COVID-19 could be co-located with those for HIV and STIs (Zang et al., 2020). Interventions promoting health literacy in communities of color and in criminal justice settings could address simultaneously disinformation associated with COVID-19, addiction and MOUD. Venues offering COVID-19 vaccines in vulnerable communities could offer referrals for MOUD, syringe exchange and naloxone. The COVID-19 epidemic has also led some MOUD providers to turn to telemedicine consults or to be more willing to offer take-home doses (Tofighi et al., 2021). If these programmatic changes reduce stigma associated with addiction or MOUD, they could be expanded to increase the proportion who initiate and adhere to MOUD regimens.

As this special issue reports, COVID-19 has led many substance users to turn to internet forums such as Reddit to seek drugs, paraphernalia or treatment (Bunting et al., 2021). Researchers should heed these trends and conduct analyses of social media metadata in real time to inform substance use prevention and treatment, and evaluate tailored interventions on social media platforms and apps. This will require public health researchers to engage other disciplines, such as computer science and bioethics, to ensure that the plethora of social media data is mined while protecting privacy and confidentiality. Finally, COVID-19 has led to innovative approaches for disease surveillance, such as detecting SARS-CoV2 RNA in sewage (Crits-Christoph et al., 2021). Similarly, wastewater surveillance of drug metabolites could be used to identify hotspots and gaps in MOUD delivery.

The COVID-19 epidemic is a rude wake-up call to public health leaders and policymakers about the need for pandemic preparedness, but it also offers additional lessons for those of us trying to reduce the health and societal harms associated with the overdose crisis. Necessity is the mother of invention, and in times of crisis, outside the box thinking and unprecedented levels of inter-disciplinary collaboration can lead to breakthroughs. If we address the opioid epidemic as a true public health emergency with the same fervor as we have tackled COVID-19, we may finally remove the age-old barriers to harm reduction and treatment to lessen the detrimental effects of addiction.

This special issue is a call to action to our field to address the pervasive racial/ethnic and socioeconomic inequalities limiting access to MOUD and harm reduction services in lieu of incarceration. If we succeed in addressing the underlying drivers of the opioid epidemic (e.g., structural racism and discrimination, stigma, poverty, homelessness, mental illness and incarceration), we can simultaneously reduce morbidity and mortality associated with substance use disorders and associated syndemics, including COVID-19.

Declaration of Competing Interest

The authors report no declarations of interest.