During the COVID-19 pandemic, fatal drug overdoses in the United States hit historic records. These events, coupled with a lack of healthcare support, caused people who use drugs at increased risk of needing substance use treatment. Our research explored the specific ways that the pandemic negatively impacted people who use drugs (PWUD). PWUD and substance use harm reduction workers completed interviews together to identify emergent themes.
1. Increased Risk of Overdose
When COVID-19 first started to upend day-to-day life for Americans, public health officials were sounding the alarm about a possible surge in overdoses and deaths. They worried that economic shock, social isolation, and increased mental health distress would lead to a new wave of opioid overdoses and disrupted access to addiction support and medications that require face-to-face visits.
Overdose rates are on the rise across the United States, with increases of 30 to 40 percent reported by 24 states and the District of Columbia during the first eight months of 2020, and the highest total percentage increase on record in the last 20 years. This was driven largely by the growing use of fentanyl, a powerful synthetic opioid that can be fatal in even small doses.
The CDC estimated that about 90,000 overdose deaths occurred in the first eight months of 2020, with the most fatalities occurring among 25- to 34-year-olds. The number of overdoses was also particularly high in the West, where fentanyl was more prevalent than elsewhere.
CDC estimates that preventable opioid overdoses rose 41 percent in 2020. In the West, the rate of overdoses in states farthest west — Arizona, Colorado, Illinois, and Texas — was more than twice as high as in other regions.
People who use drugs are at higher risk for overdose compared to the general population, as drug abuse is often accompanied by substance misuse and other conditions that increase the risk of developing an overdose. This is especially true for people with underlying medical conditions that predispose them to overdose, such as HIV or Hepatitis C.
We investigated the impact of COVID-19 on people who use drugs by conducting a quantitative survey and semi-structured qualitative interviews with people who used drugs who were also diagnosed with COVID-19 (n=50). The results showed that individuals diagnosed with COVID-19 were more likely to report a nonfatal overdose in the past month. This was also associated with the severity of their COVID-19 infection and previous overdose experiences.
The impact of COVID-19 on people who use drugs suggests that prevention strategies should be adapted to the dual crisis, focusing on community and structural factors. We recommend addressing these factors, including improving access to multi-level interventions that can help prevent overdose and reduce stigma and discrimination related to drug use.
2. Increased Risk of Illness
People with certain medical conditions are more likely to get very sick from COVID-19. These conditions include heart disease and other problems that affect how well your body gets oxygen. They can also make it more difficult for your body to fight off the virus.
One condition that can make your symptoms worse is an inherited blood disorder called sickle cell disease. This condition is caused by your body’s red blood cells not being able to transport oxygen properly. It can cause painful blockages in small blood vessels and may increase your risk of serious COVID-19 symptoms.
Another inherited blood disorder, called thalassemia, can also cause severe COVID-19 symptoms because it causes your body to not produce enough hemoglobin, which helps it carry oxygen. This can lead to a lot of fluid build-up and pain in your lungs, stomach, and legs.
Older people are more likely to get sick from COVID-19 because their bodies ability to fight off germs and infections decreases over time. They also have more long-term health problems like high blood pressure and diabetes.
Other health conditions that can raise your chances of getting very sick from COVID-19 include cancer, chronic obstructive pulmonary disease (COPD), heart failure, and a kidney disease called chronic kidney disease of any stage. Having these medical conditions can make it harder for your body to fight off the virus and make you more likely to have very bad COVID-19 symptoms, including difficulty breathing or a high fever.
If you have any of these conditions, discuss ways to lower your risks with your doctor. You should continue taking your medications as directed by your doctor and keep an eye out for changes in how you feel and how your medical condition affects your overall health.
CDC researchers found that people with these medical conditions were more likely to develop serious illnesses or die from COVID-19. They were more likely to be hospitalized, stay in an intensive care unit, or use a ventilator to help them breathe.
3. Increased Risk of Relapse
During COVID-19, people with drug and alcohol addiction may relapse to use drugs or alcohol. Relapses often occur because individuals begin relaxing their self-imposed rules, express cravings for their abused substances, or romanticize the use of a substance they used in the past.
Relapses are often accompanied by psychiatric symptoms such as depression, fear, and anxiety. Behavioral symptoms such as increased drug or alcohol consumption, social withdrawal, and decreased work productivity are common.
A study published in JAMA Network Open analyzed data from 158 untreated COVID-19 patients and found that more than one-third of those who reported complete symptom resolution subsequently experienced a return of symptoms. Among those who relapsed, most reported mild symptoms, and 15 percent described them as moderate or severe.
According to the CDC, individuals who experience a relapse should isolate themselves for at least five days. This isolation is important to help reduce the risk of re-infecting others with the virus.
In addition, people who have relapsed may be at higher risk of having health problems or developing an illness that can last for a long time. For example, relapsed people can experience permanent heart or lung damage that can affect their quality of life.
Relapsed people can also be at higher risk of re-infecting other patients with the virus because they may not be able to stop coughing or sneezing. This can lead to infections in other people who do not know the person has COVID-19.
These findings are in line with other studies that have found relapses are more likely in individuals who live alone and in those who have lost their jobs or can no longer go to work. Additionally, living alone is known to increase the risk of relapse in individuals with drug or alcohol addiction.
These findings suggest that those who are abstinent or relapsed during the COVID-19 pandemic may have to pay closer attention to the impact of their substance use on their lives. This is especially true for abstinent people who may be at higher risk for relapse due to psychosocial factors, which can be difficult to cope with during an infectious crisis.
4. Increased Risk of Death
For those who have been infected with COVID-19, there is an increased risk of death. The rate of deaths caused by this virus has been remarkably high during the pandemic. It has reached a level where one in eight people who died in 2021 had COVID-19 as a cause of death.
In addition, survivors who are not hospitalized have an increased risk of death within six months of diagnosis with the virus. This is thought to be because these individuals continue to manage a wide range of health problems after the initial infection should have resolved.
We conducted a study of EHR patient data in the US to examine the impact of substance use disorders (SUDs) on COVID-19 mortality. This analysis included alcohol use disorder (AUD), opioid use disorder (OUD), tobacco use disorder (TUD), cannabis use disorder (CUD), and cocaine use disorder (Cocaine-UD).
Of those with SUDs, the risk of COVID-19-related death was significantly greater in African Americans than Caucasians. This was likely due to the increased prevalence of kidney, pulmonary, liver, cardiovascular, metabolic, and immune-related disorders in SUD patients.
Additionally, there were significant associations between the number of pre-existing health conditions and COVID-19-related death. In particular, individuals with uncontrolled diabetes, severe asthma, dementia, and organ transplant were at higher risk of COVID-19-related death.
Moreover, there were significant associations between smoking and COVID-19-related death, although the magnitude of the association was lower. Other comorbidities, such as uncontrolled hypertension and chronic liver disease, were also associated with COVID-19-related death.
Overall, there were 821 COVID-19 deaths among individuals aged 0 to 19 years during the study period, resulting in a crude death rate of 1.0 per 100 000 population overall; 4.3 per 100 000 for those younger than 1 year; 0.6 per 100 000 for those aged 1 to 4 years; 0.4 per 100 000 for those aged 5 to 9 years; and 0.5 per 100 000 for those aged 10 to 14 years; increasing to 1.8 per 100 000 for those aged 15 to 19 years.