Francis Collins, MD, PhD, director of the National Institutes of Health (NIH) recently spoke with Nora Volkow, MD, director of NIH’s National Institute on Drug Abuse (NIDA), about the impact of the COVID-19 pandemic on people struggling with substance use disorders and those who are trying to help them.
According to Dr Volkow, there has been an exacerbation of the opioid epidemic with a 24 percent increase in mortality from overdoses in the 12 months ending in July 2020. There was also close to a 50 percent increase in mortality associated with fentanyl, as well as stimulant drugs, like cocaine and methamphetamine. The largest increases, she said, have been very much driven by drug combinations.
Dr Volkow said that this has been the perfect storm. “We have people stressed to their limits by decreases in the economy, the loss of jobs, the death of loved ones. On the other hand, we see dealers taking the opportunity to bring in drugs such as synthetic opioids and synthetic stimulants and distribute them to a much wider extent than previously seen.”
Regarding the risks of coronavirus illness for people who use drugs, it’s been a “double whammy.” “When you look at the electronic health records about the outcomes of people diagnosed with substance use disorders, you consistently see an increased risk for getting infected with COVID-19. And if you look at those who get infected, you observe a significantly increased risk of dying from COVID.”
So, what is driving this vulnerability? One factor, Dr Volkow said, is the pharmacological effects of these drugs. “Basically, all of the drugs of abuse that result in addiction, notably opioids, damage the cardiopulmonary system. Some also damage the immune system. And we know that individuals who have any disruption of cardiovascular health, pulmonary health, immune function, or metabolism are at higher risk of getting infected with COVID-19 and having adverse outcomes.”
However, there is another factor that’s as important. According to Dr Volkow, it’s the way in which our society has dealt with substance use disorders. She said that many people are not actually treating this as a disease that requires intervention and support for recovery. “The stigmatization of individuals with addiction, the lack of access to treatment, the social isolation, have all created havoc by making these individuals so much more vulnerable to get infected with COVID-19.”
Dr Collins then asked about the trends contributing to the current crisis. He said that 3 or 4 years ago, opioid use, especially heroin was rising but then fentanyl started being used more. Now, we are seeing more stimulants and a mixing of different types of drugs.
There has been a shift from the beginning of the opiate pandemic, in which mortality was mainly associated with white Americans, many in rural or semi-suburban areas of the Appalachian states and in New Mexico and Arizona, said Dr Volkow. “Now, the highest increase in mortality from opioids, predominantly driven by fentanyl, is among Black Americans.”
“They’ve had very, very high rates of mortality during the COVID pandemic,” she said. “And when you look at mortality from methamphetamine, it’s chilling to realize that the risk of dying from methamphetamine overdose is 12-fold higher among American Indians and Alaskan Natives than other groups. This should make us pause to think about what’s driving these terrible racial disparities.”
Commenting on drug combinations, Dr Volkow said that many deaths from methamphetamine or cocaine — an estimated 50 percent — are linked to these stimulant drugs being combined with fentanyl or heroin.
“Dealers are lacing these non-opioid drugs with cheaper, yet potent, opioids to make a larger profit. Someone who’s addicted to a stimulant drug like cocaine or methamphetamine is not tolerant to opioids, which means they are going to be at high risk of overdose if they get a stimulant drug that’s laced with an opioid like fentanyl. That’s been contributing to the sharp rise in mortality from non-opioid drugs.”
Dr Collins also asked about treatments for people with stimulant use disorders. Dr Volkow laid out the treatments for opioid addiction and pointed out that an FDA-approved medication for methamphetamine addiction doesn’t exist. She went on to explain about an NIH-funded large clinical trial aimed at investigating the benefits of the combination of 2 medications that were already approved as anti-depressants and for the treatment of smoking cessation and alcoholism. This combination significantly inhibits the urge to take drugs and therefore helps people stay away from use of methamphetamine, Dr Volkow said.
“Now, we want to replicate these findings, and to tie that replication study in with guidelines from the FDA on what is needed to approve our new indication for these medications. Why? Because then insurance can cover it, and that will increase the likelihood that people will get treated.”
Another exciting possibility Dr Volkow mentioned is a monoclonal antibody against methamphetamine that is currently in Phase 2 clinical trials. “If someone comes into the emergency room with an overdose of a combination of opioid and methamphetamine, naloxone often will not work. But this monoclonal antibody with naloxone may offer a greater likelihood of success.”
In addition investigators have been able to modify monoclonal antibodies so they stay in the bloodstream for a longer time. “That means we may someday be able to use this passive immunization approach as a treatment for methamphetamine addiction.
Dr Collins also asked about medication development and Dr Volkow responded by saying that the NIH is interested in developing antidotes that will be more effective in reversing overdose deaths from fentanyl. “We’re also interested in providing longer lasting medications for treatment of opioid use disorders, which would improve the likelihood of patients being protected from overdoses,” she said.
Dr Volkow also spoke about research from the Helping to End Addiction Long-termSM Initiative, or NIH HEAL InitiativeSM, which includes over 20 programs led by 12 NIH Institutes and Centers.
One of these programs, the Justice Community Opioid Innovation Network (JCOIN) involves a network of researchers that is working with judges and with the workers in jail and prison systems responsible for taking care of individuals with substance use disorders. One thing, she said, that’s been transformative in the jail and prison system has been the embracing of telehealth. “In the past, telehealth was not much of a reality in jails and prisons because of the fear of it could lead to communications that could perhaps be considered dangerous. That’s changed due to COVID-19. Now, telehealth is providing access to treatment for individuals in jail and prison, many of them with substance use disorders.”
Dr Volkow continued. “…because of COVID, many nonviolent individuals in jails and prisons were released. This gives us an opportunity to evaluate how best to help such individuals achieve recovery from substance use disorders. Hopefully we can generate data to show that there are much more effective strategies than incarceration for dealing with substance use disorders.”
Then there is the HEALing Communities Study, which focuses on Massachusetts, New York, Ohio, and Kentucky. These 4 states have the highest rates of mortality from overdoses from the beginning of the opioid epidemic.
Dr Volkow explained that by implementing a battery of interventions for which there is evidence of benefit, this ambitious study set out to decrease overdose mortality by 40 percent in 2 years. However, COVID came along and “turned everything upside down.”
“Still, because we consolidated interactions between agencies, we’ve been able to apply support systems more efficiently in those communities in ways that have been very, very reinforcing. Obviously, there’ve been delays in implementation of interventions that require in-person interactions or that involve hospital emergency departments, which have been saturated with COVID patients.”
Dr Collins then transitioned to answering questions from people who subscribe to the HEAL website. The first question was: “What is NIH doing through HEAL to address the stigma that prevents people who need opioid medications for treatment from getting them?”
Dr Volkow answered, “As we look at the issue of stigma, we need to recognize that there are structural issues in how our society is prioritizing the importance of substance use disorders and the investments devoted to them. And we need to recognize that substance use disorder doesn’t exist in isolation; it is frequently comorbid with mental illness.”
According to Dr Volkow, some of the issues that we believe are the most problematic are not. “We need to empower these communities to speak up and help them do so. This is probably one of the most important things that we can do in terms of addressing stigma for addiction.”
The next question was: “In small communities, how can we provide more access to medications for opioid use disorder?”
Dr Volkow spoke about one project that was funded through HEAL to evaluate the effectiveness of community pharmacies for delivering buprenorphine to individuals with opioid use disorder. “The results show that patients receiving buprenorphine through community pharmacies in rural areas had as good outcomes as patients being treated by specialized clinicians on site.”
She also commented on the March 2020 DEA relaxation of its rules on how a physician can prescribe buprenorphine. “In the past, you needed to go physically to see a doctor. Now, the DEA allows a patient to be initiated on buprenorphine through telehealth, and that’s opened the possibility of greater access to treatment in rural communities.”
The last question asked was:“What is the HEAL initiative doing to promote prevention of opioid use?”
Dr Volkow answered that this is where the HEAL initiative is aiming to provide alternative treatments for the management of pain that reduce the risk of addiction.
There’s also the issue of prevention in people who start to take opioids because they either want to “get high or escape.” “With the COVID pandemic, we’ve seen increases in anxiety and in depression. Those are factors that can put a teenager or young adult on a trajectory for higher risk of substance use disorders.”
Dr Volkow said that there is prevention research specifically targeted at the transition from adolescence to young adulthood. “That is the period of greatest vulnerability of uptake of opioids, or drugs of misuse. We’re also targeting minority groups that may be at very, very high risk. We want to be able to understand the factors that make them more vulnerable to tailor prevention interventions more effectively.”
Dr Collins ended by saying, “These developments give me hope in the wake of a very difficult year. Clearly, we still have the capacity to work together, we are resilient, and we are determined to put an end to our nation’s opioid crisis.”
Lessons learned about substance use disorders during the COVID-19 pandemic. NIH. Published online April 8, 2021. Accessed April 11, 2021. https://directorsblog.nih.gov/2021/04/08/lessons-learned-about-substance-use-disorders-during-the-covid-19-pandemic/