The pandemic has been an accelerant in a record era for drug overdose deaths. Between May 2019 and May 2020, according to CDC data, more than 80,000 Americans—the highest number ever—died from drug ODs, a rise of nearly 20%.
The most pronounced jump in deaths during this period occurred between March and May last year, when COVID-19 lockdowns took effect. Unfortunately, those numbers from early in the crisis are almost certainly going to get much worse.
The outbreak, along with the shambolic response to it, is heightening nearly every factor that elevates risk for people with drug addictions. But why exactly is the pandemic proving to be so fatal for people at risk of drug overdose?
One of the biggest risk factors for overdose is injecting potentially lethal drugs, like opioids, by yourself. For obvious reasons, doing so means that help is less likely to arrive in time to save your life should you need it. Just as obviously, the pandemic response dramatically escalates such isolated use: after all, the whole idea of social distancing is to keep people away from each other to prevent contagion.
The people who are most affected are not only those suffering from addiction, but also pain patients, who are struggling to get care as the government and health care providers continue to cut the supply of medical opioids.
While there is as yet little research into exactly why the pandemic has resulted in a jump in drug-related deaths, the story of the Never Use Alone hotline offers important insight.
Callers to NUA’s toll-free number, which started as a way to reduce harm from taking drugs solo, provide their location and phone number, and then operators stay on the line as they take their drugs, contacting emergency services if needed. Founded in September 2019 by Mike Brown, an overdose prevention specialist at Harm Reduction Michigan, at first the hotline only got a few calls.
But when COVID-19 and the attendant lockdowns hit, that changed. “The call volume multiplied,” said Brown, who now has 60 volunteer operators on board. And this gave NUA a window onto a whole world of pain.
“We started getting a lot of calls from people who had been abstinent for a while,” Brown said. Beginning to use again after abstinence is a huge risk factor for overdose: for example, people coming out of jail or prison have at least a three-fold greater risk of dying in their first few weeks of freedom, and similarly elevated risk is seen after abstinence-based rehab.
If someone “falls out," as overdosing is known colloquially, the NUA operator will call the nearest medical emergency service number. (They can’t call 911 because the calls are often long distance and would be routed to the wrong place). Operators typically tell EMS that the victim apparently became unconscious after reporting shortness of breath—aiming to bring medical, but not police attention. If asked directly about overdose, however, they do not lie. They have now received nearly 2,000 calls, they say, and have successfully called EMS to save a life nine times.
The stories NUA keeps hearing are, according to Brown, bleak: loneliness, depression, and anxiety are rampant. Callers can’t get the social support from friends, family or in-person group meetings that they had relied on to maintain their recovery. They feel desolate.
And so they start using bigger doses more frequently and carelessly. Some may actually intend to kill themselves, or simply stop caring whether or not they overdose and die. In fact, suicides by overdose are often misclassified as unintentional deaths, so much so that one researcher argues that states with high levels of gun ownership may have artificially elevated suicide rates because in others, suicides by overdose are undercounted.
Economic loss also figures prominently, Brown said: “Everybody’s kind of hurting right now financially. People are losing their houses, their jobs.” One caller had formerly owned his own business, but the pandemic forced him to shut down the coffee shop he’d put his heart into.
Casey Mulligan, a former Trump administration economist who is a professor of economics at the University of Chicago, has suggested that pandemic relief unemployment checks may have also played a role in the overdose rise by giving people more money at the same time they have fewer healthier options to spend it on.
Brown noted that a few of his callers have indeed mentioned that the checks allowed them to use more. However, he said, there is far more talk about financial and emotional loss, not gains—and no one who was previously abstinent said the checks led to relapse.
Khary Rigg, associate professor of mental health law and policy at the University of South Florida, studies people who use drugs, many of whom have low incomes and are living on the street. “What I’m hearing is a lack of hope,” he said. “There’s no sense of when we’ll get back to normal.” That sort of uncertainty is itself a form of stress.
Jess Blanchard, a volunteer operator for NUA from Southwest Georgia— in her day job, she’s a high school teacher and registered nurse—became involved because her daughter is addicted to heroin.
“People are lonely. Social isolation is killing people,” said Blanchard. “COVID’s killing people too. But social isolation is, is really, really hurting people.” Many of her callers just want someone to talk to, and the topics range from heartbreaking stories about being rejected by family to just bonding over mutual love of cats. (NUA now has a second hotline that people at risk can call even if they aren’t using, just to talk.)
Blanchard tells callers to put her on speakerphone so that she can rouse them if they nod out, but are not actually overdosing. “I can be really loud,” she said, describing a voice she’s had to use many times as a teacher. Several times, she said, she’s had to call EMS after she heard her caller fall to the floor. Often, she hears back from them later.
“The last guy, he said, ‘Jess you're an angel. You saved my life,” she said, adding, “This one always gets me—‘My mama didn't have to go to the funeral home and pick out my casket because of you.’”
Changes in the drug supply have also made matters worse. Shutdowns related to the pandemic have led to fluctuations in purity and availability. Such changes put users at higher risk because they make finding the right dose more difficult by changing tolerance. And all of this is exacerbated by the fact that the fentanyl and other synthetic opioids that now contaminate most of the heroin market already tend to vary greatly in potency.
“Nearly all of the increase in overdoses involves fentanyl,” said Shannon Monnat, associate professor of sociology at Syracuse University. She also noted a rise in methamphetamine use, which carries less overdose risk but is associated with more troubling behavior that tends to bring law enforcement attention. “The pill problem has basically disappeared in most places, and now they’re dealing with the joint problems of fentanyl and meth,” she says.
The end of the era of widespread availability of medical opioids like oxycodone, however, has been the beginning of a new crisis for pain patients. The supply of medical opioids has fallen by 60% since 2011, with much of the decrease driven by doctors tapering or cutting off existing patients who were taking high doses. Theoretically, this should have reduced their overdose risk—but in reality, studies show that this risk triples when people’s medications are stopped.
“The situation has been so dire that it has led to reports of patient suicide,” said Travis Rieder, a bioethicist at Johns Hopkins University and the author of the book In Pain, which describes his own struggle with pain and opioid treatment. One study of veterans found that losing access to opioid medication led to suicidal thoughts in 9% of patients and actual action in 2%.
While the media focus has been on people with addictions, hidden among the overdose and suicide statistics are the deaths of pain patients who have also lost hope for relief, often after having their medications cut off. Until recently, only activists tracked these deaths—but Stefan Kertesz, professor of medicine at the University of Alabama at Birmingham, is now conducting a study to look more closely.
During the pandemic, some of the government requirements for in-person visits to get opioid treatment for pain or addiction have been lifted, but many people with both conditions continue to report difficulty in getting the care they need. For many, having to make fewer visits to the doctor or clinic has been liberating, but others miss the social connection they get from seeing counselors or physicians in person.
“At its core, I think addiction is about a need for connection,” said Monnat. “My research shows that work, family, and community are the three most important factors for understanding why drug overdose rates are higher in some places than others. Work, family, and community are the three arenas where we derive meaning and purpose from our lives. If we don’t have those connections, we might seek it out elsewhere, for example with drugs.”
COVID, of course, has made connecting with work, family and community far harder, and since social contact is a fundamental biological need for human stress relief, it is not surprising that more are seeking relief through opioids. Indeed, these drugs work in the brain in part by replicating the sense of warmth, comfort and safety we feel when loved.
In Brown’s case, he’s found meaning and purpose through his work with NUA. “This has been the best thing for my recovery,” he said. “I've always been the type that loves to help people. But this has given me a huge sense of purpose and pride.” The actual calls can be stressful because he can’t be sure help will arrive in time if someone does OD. However, he says that “99.999% of the time,” the call ends without incident.
And in those rare cases where someone does overdose, he often hears back from victims later. “I get calls from people who say that they are alive because ‘You were there to listen to me,’ because of Never Use Alone," he said. "And there’s no drug in the world that can make you feel as good as that.”