“It’s Really, Truly Everywhere”: How the Opioid Crisis Worsened with COVID-19

SHANOOR SEERVAI: More than half a million Americans have died of an overdose from opioids in the past two decades, and the number of people dying has only gone up each year. This public health crisis has gotten worse than the pandemic, and it gets a lot less attention than COVID-19. So, on today’s episode of The Dose, we’re going to talk about why drug overdose deaths are rising and what policymakers can do to fix the problem. I’m your host, Shanoor Seervai, and my guests are Brendan Saloner, a professor of Health Policy at the Johns Hopkins School of Public Health, and Jesse Baumgartner, one of my research colleagues at the Commonwealth Fund.

Brendan, Jesse, welcome to the show.

BRENDAN SALONER: Great to be here.

JESSE BAUMGARTNER: Thanks for having us.

SHANOOR SEERVAI: Jesse, could you start by telling us what we know about drug overdose deaths last year during the pandemic? When did we start seeing the impact and how many people have died?

JESSE BAUMGARTNER: We’re getting more data every month. One thing that’s important to recognize is that during the second half of 2019, before the pandemic hit, drug overdose deaths were trending up. So, after a slight decrease in 2018, we were seeing a rise again. But what the preliminary data that we’ve looked at tells us is that while they were going up right about in March, when the pandemic really started to hit the United States, they really exploded. Monthly totals within a couple of months reached a level that was about 50 percent higher, likely, than they’ve ever been before. And that we know from additional data through the end of the summer and into the fall, that while that started to taper off, those levels were still extremely elevated well into October and likely at least until the end of the year.

So, while we don’t have the final totals yet, and the CDC provides provisional data on a monthly basis, the trend makes it likely that we’re going to see around at least near 90,000 total overdose deaths. And just for some context, that’s about 20,000 higher than we’ve ever seen previously. It would likely be the largest percentage increase in one year that we’ve ever seen.

SHANOOR SEERVAI: And are those drug overdose deaths in total, or is that only overdose deaths from opioids?

JESSE BAUMGARTNER: That’s overdose deaths total. A significant majority of those are related to opioids, probably around 80 percent.

SHANOOR SEERVAI: And if we try to get further into the data, where did deaths go up the highest and how does that map onto the places that were impacted by COVID-19?

JESSE BAUMGARTNER: I think one of the important takeaways is that the overdose death rates have gone up everywhere. The provisional data really shows that between at least January and October, which is where our provisional data takes us right now, most states probably had year over year increases during that stretch of about 30 percent or more. And those geographies really, they range from places like West Virginia that have really been at the heart of the opioid epidemic. And I think, people would be familiar with stories and media around that. But also Western states, Arizona, Colorado, California, states that until a few years ago had really had lower relative burden of overdose deaths. Those states are now seeing some of the largest relative increases. So, we’re really seeing a change in some of the geography that’s really hitting countrywide.

And then, to your last question about the COVID spread, given how wide the outbreaks of COVID have been, I don’t know that they map particularly onto one area or another. We can say that there are a number of Southern Appalachian states that are probably seeing the largest relative increases. But again, when a majority of states are seen over 30 percent increases, it’s hard to say that any state is really singled out, it’s really been across the nation.

BRENDAN SALONER: Well, the numbers that Jesse just took us through are sobering and it’s easy to forget how each of those numbers really relates to a human life, and I think that we have become numb to the impact of that. I think just one thing I’d like to add is that fentanyl, one of the main opioids driving our overdose crisis, is now spreading rapidly into other drug supplies, and many of the overdose deaths that involve cocaine and methamphetamines now also involve fentanyl. So, I think that’s one of the key things to keep in mind with the spread.

SHANOOR SEERVAI: So, who is dying, who are the people behind these numbers?

JESSE BAUMGARTNER: Again, we’re a little limited by the recency of the data. So, provisional data is continuing to come in from the CDC and the limits of what they release are demographic estimates on a quarterly basis that take us through about September of last year of 2020, which is a fairly big chunk of the early pandemic period. And at least initially, it looks like first, every community is getting hit hard. No one has been spared from this. The differences in increases are relative and they’re all starting from a large baseline. So, what they’re showing us though, is that at least initially during the first nine months of 2020, we probably saw greater relative increases among men as opposed to women. But again, large increases across both Black and Latinx communities, which we’re already starting to see higher rates leading into the pandemic through 2019. And then, also a younger age groups that appears, again, a bit of a larger increase, but still large increases across the board. All of these demographics, there’s really no part of the country or any community that’s really being spared.

SHANOOR SEERVAI: Mm-hmm. And there was a time when the opioid epidemic was really talked about this crisis in rural white America. And you mentioned, Jesse, that death rates are now going up in Black and Latinx communities. Tell me more about that. How has that shifted over time?

JESSE BAUMGARTNER: There was for a long time, there was a large gap in age-adjusted death rates between white communities and Black and Latinx communities. Over the past five or six years, maybe even a touch earlier than that, that’s really transformed. As of 2019, Black Americans were dying from overdose deaths at a rate that was almost equivalent to white Americans on an age-adjusted basis, and just five or six years ago, that was not even close. So, it was off the top of my head, I think, about half the rate. So, that has rapidly changed in terms of the demographics. And Latinx communities have also seen larger increases over the past few years, as well as during COVID-19.

BRENDAN SALONER: I think if you were to open up a newspaper about five years ago, a typical story you would see would have been making the point that, whereas the crack epidemic of the 1980s very much hit the African American community hard, the opioid crisis has been a white crisis. And I don’t think that ever was really totally true, but I think that this pervasive idea that this is a white rural crisis and it has therefore a very different kind of response, a less punitive, more compassionate response for that reason, I think has really sunk into the public narrative. The realities, I think, are a lot more complicated. And I think going back to those epidemiological data with fentanyl now spreading into other drugs of use, I think that’s a lot of where we’re seeing the rise in overdose deaths among lack and Latinx populations. And one other group that I would just draw attention to are Native Americans, who have also been incredibly hard hit by the overdose crisis.

SHANOOR SEERVAI: So, everything that you’re describing is concerning, but this opioid crisis was a problem even before COVID-19. Many of our social problems have been exacerbated by the pandemic. And so, could you talk about how the opioid crisis has worsened?

BRENDAN SALONER: There’s a few things going on. So, I think one of the major things has been the pandemic itself creating a lot of stress in people’s lives, a lot of social isolation. We know from the mental health data that depression went through the roof during the pandemic, that a lot of people were just feeling a lot of loneliness. And so, I think those conditions caused a lot of people to use drugs more frequently and to use them in more harmful ways. And another thing that we know, and especially from data that my team has been collecting, is that people are reporting using alone more often. So, I think that’s been a big factor. And one more thing I would add to this has been the change in the drug supply itself. The pandemic disrupted routes where people were obtaining drugs, it became harder for people to obtain drugs. And so, that unreliability, I think, has also created some volatility, some unpredictability for people, which has increased their overdose risk.

SHANOOR SEERVAI: Mm-hmm. And there’s also been the economic toll of the pandemic, so many people have lost jobs.

BRENDAN SALONER: Yeah, absolutely. So, economic stress, I think, is a major precipitator of harmful drug use. Homelessness, which was a crisis before COVID, is a major risk factor for overdose because when people are unhoused, the way that they use drugs is just a lot riskier. So, I think that those things contributed in various ways to people using drugs to cope with stress and also using them in ways that were just more unsafe.

SHANOOR SEERVAI: Mm-hmm. Were there any positive shifts in the pandemic? Was anybody using less or more safely?

BRENDAN SALONER: I think there is a subset of people who did positively change their behaviors. And again, we have seen this in the data that some people said that, you know what, actually, the pandemic changed their social networks. It caused them to use less. It gave them an opportunity to make different decisions in their lives. I think the other silver lining, if you want to call it that, from the pandemic, is that drug treatment, although, for a moment in the spring of 2020, basically shut down. There were really savvy ways in which people figured out how to make it work for people using new technology platforms and new flexibilities created by the federal government. So, I think also, the ability to get treatment more on demand and to get it in different ways has been a benefit to some people who might’ve wanted treatment, but didn’t know how to find it prior to the pandemic.

SHANOOR SEERVAI: Are you talking about telehealth?

BRENDAN SALONER: Telehealth for sure. So, we know that a huge amount of treatment shifted from in-person to telehealth, whether that is visits with a doctor to get a prescription for one of the FDA approved medications to treat opioid use disorder like buprenorphine. Certainly, telehealth being a place where people can meet with a mental health provider, a lot of the self-help groups like Alcoholics Anonymous, Narcotics Anonymous, Smart Recovery, moved to online platforms, which did work for some people, not for everyone. There’s something that gets lost when things get moved into the virtual world.

And then another thing that I would just draw attention to is the medication methadone. If a patient is using it to treat opioid use disorder, then they have to go to a clinic to pick up that methadone. Prior to COVID, most patients had to come into a clinic every day to get their dispensed methadone. With the pandemic, more patients were able to get take-home methadone and that allowed them to basically give medication to themselves at home and created a more convenient environment for treatment.

SHANOOR SEERVAI: Brendan, you mentioned when we spoke the last time that you’re working on a survey of people who are enrolled in harm-reduction programs. So, tell me a little bit first about what harm reduction programs are, and then what you’re hearing from these people.

BRENDAN SALONER: Harm reduction, it’s a strategy and it’s also a philosophy. So, the philosophy is that we are committed to the empowerment of people who use drugs and allowing them to use drugs in ways that are maximally safe for them. The strategies include giving people access to supplies that make drug use safer, more hygienic, like sterile syringes, naloxone, the medication that reverses a drug overdose, fentanyl test strips. And in terms of what we’re learning from harm-reduction clients, I think a big challenge has been keeping supplies going to people who need them during the pandemic. So, as I had mentioned earlier, drug use has become a lot more unpredictable and a lot of concerns have come to the surface about people’s safety in the pandemic.

People who might’ve used with partners before, early in the pandemic, not wanting to congregate with other people, not wanting to go into public places, that affected drug use too. So, a lot of the harm-reduction treatment providers had to come up with new strategies to work with their clients, to check in with them, to make sure that they were safe, to send peers out for different kinds of outreach. And I think that clearly those efforts have helped. Have they been enough to meet the demand that’s out there? I really don’t think so. I think that that’s an unmet challenge.

SHANOOR SEERVAI: You’ve also both mentioned that the drug supply is becoming increasingly dangerous. Can you tell me what you mean by that?

BRENDAN SALONER: Yeah. So, take cocaine. So, cocaine, I think, in most cities, if you were going to go out and buy cocaine in the street a few years ago, you would have been relatively confident that the drug that you were going to take home would be, if not pure cocaine, at least cocaine cut with other things that your body was used to. Now, it’s much more of an unpredictable game out there. So, the drug supply fentanyl has basically traveled everywhere. And I think many doctors are advising their patients and harm-reduction programs are telling people, no matter what you think you’re using, fentanyl can be out there.

The other thing that has happened, there has been fentanyl traveling to parts of the country where people had previously been using mainly heroin in the illicit drug market. So, fentanyl-involved deaths really traveling in a remarkable way to states west of the Mississippi, where previously fentanyl had been more of a phenomenon in the Midwest, the Northeast, and the Mid-Atlantic.

SHANOOR SEERVAI: Mm-hmm. Could we just back up and can you tell us why fentanyl is so dangerous?

JESSE BAUMGARTNER: Yeah. This is actually a bit of a personal point for me. I had a cousin in 2019 who passed away from a fentanyl-laced pill in Seattle. I mean, back in 2016, when overdose deaths were at a pretty high rate, we were probably seeing about 30 percent of them have a relation to a synthetic opioid of some type, with fentanyl being the one that is most notable. And that’s exploded over the last four years, up to the point where in 2019 that was up in the realm of 50 percent of overdose deaths were associated with some type of synthetic opioid. And for the preliminary data we have during COVID, we think that’s probably somewhere closer to 60 percent. So, it just speaks to how quickly this has happened and obviously not overnight. But in terms of the way we look at data, it sure feels like the makeup of these overdose deaths, what’s causing them, has really just flipped upside down. And this issue is now, to Brendan’s point, no longer regionally focused. It’s really, truly everywhere.

BRENDAN SALONER: Jesse, I’m sorry for your loss. That’s a really tragic story. Just for people to know what fentanyl is, fentanyl is a synthetic opioid, meaning that it’s actually not derived from the opium poppy, but it has a potency that’s much higher than heroin, for example. So, fentanyl can be on a per weight basis more than a hundred times more potent than heroin. And so, it’s a really slippery and difficult to wrangle opioid. And I think that, that has really frustrated a lot of efforts to try to tamp down on the overdose death numbers.

SHANOOR SEERVAI: I want to spend a little bit of time talking about the criminal justice system. One in five people who is incarcerated is incarcerated for a drug offense. And so, I have a couple of questions. One is, are there ways in which people who use drugs and are incarcerated have had treatment made available to them during the pandemic?

BRENDAN SALONER: The most therapeutic place to get treatment is not in a jail or a prison. But having said that, I think good news is that more jails and prisons are starting to provide the evidence-based medications to treat opioid addiction. So, more people who are incarcerated have the ability to get methadone and buprenorphine in their jails and prisons, and I think that this has actually continued through the pandemic. We had a worry that programs might shut down, but from what we can hear and from surveys that we’ve done of jails and prisons, we’re hearing that they are staying the course and keeping these programs running.

So, I think that’s really great thing. That solution has to be embedded in a larger strategy that includes providing access to medications for people when they’re reentering the community. So, it’s very important not to just start them on treatment during incarceration, but to make sure that during that critical period of reentry when overdose risk is so high, that they continue to access medication treatment.

SHANOOR SEERVAI: And do you think that some of this that has been changing during the COVID-19 pandemic will impact the ways in which we think about criminal justice reform, think about really treating drug use as a substance use disorder, as a social and health issue, rather than a criminal issue?

BRENDAN SALONER: We are right on the precipice of a big national decision. So, right now, jails are 25 percent emptier than they were prior to COVID. That is a stunning thing to think about. So, the idea of making this kind of change permanent, I think is very tangible, it’s within reach. It’s something that advocates have wanted for a long time: decarceration as a strategy to push treatment into more therapeutic environments. But we’re also at a moment of unprecedented, not unprecedented, but certainly high, high, high crime, higher than it has been in the last couple decades.

So, it’s also a dangerous situation where there may be a public backlash against some of these decarceral strategies. So, it’s really important to provide access to services for people who are at risk of incarceration when they’re in the community, because that is the best way to keep people from returning to jail or to go to prison is to basically make sure that they get what they need in a more therapeutic community setting.

SHANOOR SEERVAI: What steps can the Biden administration take to address the public health crisis that drug overdose has created?

BRENDAN SALONER: I think that they’re starting to do a lot of the right things. I’ve been really impressed with the comprehensive approach that they’ve been taking to this issue, centering harm reduction, and really talking about it as a strategy that is important for the administration to lead with, trying to get more states to expand Medicaid, which I think would be a really critical lever to pull. So, I do think that there is an appetite that there has not been in the past to try to take a more wide-ranging strategy to this issue. In my opinion, a lot of the key action in the months and years to come are going to be in states and local governments.

JESSE BAUMGARTNER: I would just piggyback on Brendan’s point about Medicaid expansion though, and why it’s so critical. The remaining nonexpansion states are incredibly well-represented in the analysis we’ve done on some of the hardest-hit states with increases in these types of deaths, relatively speaking.

SHANOOR SEERVAI: Mm-hmm. And which are these hard-hit states that have not expanded?

JESSE BAUMGARTNER: Not to generalize, but if you look at the South, most of them are there. Florida and Louisiana, South Carolina, those are some of the largest recent increases, but really, that whole region has been increasing as has the rest of the country.

SHANOOR SEERVAI: And as we’re wrapping up, if we think about states that maybe have done a good job, Brendan, you said that this crisis really has to be addressed on the state and local level. So, are there any states we can look to for leadership on this?

BRENDAN SALONER: One state that comes to mind is Rhode Island. So, Rhode Island, I think really the strategy started with the governor owning this issue. Governor Raimondo decided that she was going to make this a cornerstone of her state policy, committed resources to it, created a lot of transparency and accountability about what the state was doing. Made sure that the Rhode Island Department of Corrections was providing all the medications to treat opioid use disorder. Created a centers of excellence model to basically allow for multiple entry points into treatment in the community, and got the hospitals on board too, which I think was really important. So, that’s a small state, it’s hard to know whether a Rhode Island–type strategy is going to scale to a big state, but I think that it does provide a proof of concept of what could happen.

I think there have been other interesting models that have been pursued in some of the states that you might not expect. One state that I’m really excited about is Missouri, which has a medication-first approach to treatment. So, in Missouri, the state drug and alcohol programs have created a whole system where they will support people in recovery, even if they’re not ready to start counseling, they can still get medication. I think that was a really big shift in that state. Louisiana has used its power of credentialing and licensure oversight to require residential treatment programs to provide access to medications. So, all of these models are interesting, small. We really need to do these things to scale, to see the changes that will ultimately help to reverse the tide of this epidemic.

SHANOOR SEERVAI: Mm-hmm. And we started this conversation by talking about the urgency of this epidemic. And so, are there any final thoughts you can leave us with on really what a big crisis we have on our hands still?

BRENDAN SALONER: We have a huge, monumental crisis on our hands, but we can do something about it. I think that’s the thing that I want to leave people with is a sense of hopefulness, because if we succumb to despair, then this will become normalized. And this is a country where we have normalized a lot of death and loss, and these tragedies don’t need to happen. I really think about this a lot. People who have died from the opioid crisis did not need to die and there are things that can be done. So, I want people to feel, not a sense of hopelessness. We don’t need to be paralyzed around this. There is a better future.

SHANOOR SEERVAI: All right. Thank you both so much for joining me today.

BRENDAN SALONER: Thanks for having me.

JESSE BAUMGARTNER: Yeah. Thank you.

SHANOOR SEERVAI: The Dose is hosted by me, Shanoor Seervai. I produce this show for the Commonwealth Fund, along with Andrea Muraskin, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions, with additional music from Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. Thanks for listening.