Two years ago, I started talking about the likelihood of the pandemic related isolation and turmoil leading to dramatic increases in substance misuse. I termed it an addiction tsunami, others made similar comparisons. The analogy is holding. COVID was the precipitating earthquake. The water is now beginning to rise and envelope a fragile service infrastructure teetering on collapse. It is probable that we are seeing only the initial ripples of this tidal surge.
We have been long vulnerable to the kinds of shocks and traumas we are now experiencing. The COVID-19 pandemic was like an extraordinarily powerful earthquake. Hundreds of thousands have died, and our behavioral health and medical care infrastructure has been severely damaged by the shocks. Our medical care professionals and first responders are particularly vulnerable to substance misuse as they are exposed to long term trauma. We are also ill prepared for this because of deep underlying stigma in these professions. All this before the water started to creep up.
We are woefully ill prepared for what is happening, and what we have focused on has generally been interventions not broadly focused enough to meet the needs of our diverse communities. We have a long-term addiction epidemic decades in the making. Unfortunately, in the last decade it has been narrowly framed as an opioid epidemic. This has had extremely negative and long-term consequences and hobbled our capacity to respond effectively.
We had largely ignored the steady increase in alcohol related deaths (which doubled between 1999 and 2017). A significant facet of the crisis. Instead, we have long focused on overdose deaths. Overdose deaths are a metric that policymakers find appealing because it is easily measurable. It is important to point out that such a narrow focus results in us failing to address the complexity of addiction. We end up ignoring the myriad of ways that addiction kills beyond overdose. We fail to address critical issues such as concomitant benzodiazepine use with opioids which according to NIDA is associated with one in three overdoses. We miss wider solutions by too narrowly conceptualizing the problem.
Consider how street drug use patterns are increasingly complex. As noted above, most persons addicted to opioids are using multiple drugs. This study published in Molecular Psychiatry found that more than 90% of individuals with OUD used more than two other substances within the same year, and over 25% had at least two other substance use disorders along with OUD. Addressing opioid addiction in isolation from other drug use is unhelpful at best, and like the concept of the war on drugs will ultimately be judged as a poor way to frame what actually is occurring. We put on horse blinders and fail to address the full scope of the problem we face, and the water continues to rise.
These complexities include drugs like xylazine, which “gives legs” to a high from any opioid through a synergistic effect. The combination of powerful opioids with this powerful non-opiate sedative is creating a medical and addiction care nightmare. We simply do not have the infrastructure available to effectively address these needs. These patients require intensive medical care provided in close coordination with intensive addiction treatment for extended periods of time. We do not have the capacity in our public service system for these patients. We have been caught flatfooted, dealing with a type of drug use adaptation that was entirely predictable. The water gets deeper.
Some of what we are seeing:
- The Implications of COVID-19 for Mental Health and Substance Use – Drug overdose deaths have sharply increased – largely due to fentanyl – and after a brief period of decline, suicide deaths are once again on the rise. These negative mental health and substance use outcomes have disproportionately affected communities of color and youth.
- Changes in Sewage Sludge Chemical Signatures During a COVID‐19 Community Lockdown, Part 1: Traffic, Drugs, Mental Health, and Disinfectants. Analysis of primary sewage sludge samples from the first wave of the COVID‐19 pandemic shows evidence of changes in chemical use, including increases in several antidepressants and opioids.
- Substance abuse rose in the pandemic. That may explain our slow to return to work. A rise in drug abuse during the COVID-19 pandemic could account for between 9% to 26% of the decline in labor force participation among people aged 25 to 54 between February 2020 and June 2021.
- Alcohol-related deaths, which increased during the first year of the COVID-19 pandemic, continued to rise in 2021.
Alcohol-related deaths soared 25.5% in 2020. During the two decades prior to the pandemic, alcohol-related deaths increased around 2.2% per year. In 2021 alcohol related deaths saw an increase of 9.9% over 2020. Overall, alcohol played a role in 3 out of 100 (3.1%) deaths in the United States in 2021.
- Recent Trends in Mental Health and Substance Use Concerns Among Adolescents – Deaths due to drug overdose among adolescents nearly doubled from 2019. With the largest increases in these deaths were among adolescent males (deaths more than doubled), as well as Black (deaths more than tripled) and Hispanic (deaths more than doubled) adolescents.
Like a tsunami, the longer we wait to respond, the more devastating the consequences will be and the harder it will become to get people into recovery. Like a tsunami, increases in drug and alcohol use across society will lead to a long-term surge in addiction. It will result in an increase in addiction for those most vulnerable to it as a result of things like genetics and exposure to trauma. Boredom, lack of purpose and loneliness may also be significant contributing issues. These upstream causative factors need to be addressed even as we try and pull people out of the water.
Surging water in a tsunami overruns the low ground and weak spots. Our public care SUD workforce and infrastructure is that low ground that is being inundated. It is particularly vulnerable because the type of long-term investment it requires to remain viable is not where resources have historically been invested. We have had a workforce crisis over the course of my decades in the field and we kept pushing off the solutions. Crisis fails to describe what we now face.
This will play out in time as measured in decades. It comes at a time when our service infrastructure and workforce were already in bad shape. It is highly probable that addiction related deaths over time will eclipse the direct loss of life from the pandemic by several multitudes. We are losing treatment and recovery support centers and care infrastructure at the very moment we need to be fortifying them and preparing for the increases in demand.
While significant amounts of new dollars from the opioid settlements will go to needed pharmaceutical treatments for opioids, people require comprehensive care and support beyond medication only remedies. Money had not flowed to the rest of the care infrastructure in similar ways as it has to MAT. Federal opioid crisis initiatives focused on infusing short term dollars to the states targeted on opioids that did little to address the long-term needs of the care system. These were “spend quickly or lose” dollars, not long-term investment. Money went to where it could be spent fast and far too often not to where it was needed most. In defense of our allocation systems, they are not really designed or resourced to do what we need done, so quick money was better than no money, which was the other door.
Single drug focused interventions and short-term harm reduction efforts that do not lead to comprehensive treatment and recovery will not get us to the safety of high ground. If we were serious as a nation in addressing SUDs, we would need to conceptualize addiction needs in America much like we do cancer, with a myriad of interventions, services and supports over the long term that can be individualized to the needs of the individuals, families and communities served. Long term remission is the standard of care for cancer. We do not think in those terms about addiction. We should.
This would need to include:
- Building an SUD service infrastructure that is on the scale of the need for these services in America. The one we have typically does not even provide people with the minimum dose of effective care for patients with average needs.
- Developing a sustainable and properly resourced SUD service system workforce.
- Establishing a recovery-oriented system of care that meets the long-term needs of the diverse communities served. This would require the authentic representation of communities of recovery in the design, implementation, facilitation, and evaluation of programming at all strata, from federal, state, regional to the local community levels.
Recently, the Governor of California deployed the National Guard in the tenderloin district of San Francisco to address open air drug dealing. It is driving away business and making living in the city untenable. Those who can afford to leave it are heading for the hills. This is one major city in one major state, yet these dynamics are playing out across America. The truth is that “those people” are quite often “our people.” Our neighbors, our friends, our family members. We are not even close to taking this emerging crisis as seriously as we should. Considering just opioids and not the impact of other illegal drugs or alcohol, in 2022, the U.S. Congress Joint Economic Committee (JEC) found that the opioid epidemic cost the United States nearly $1.5 trillion in 2020, or 7 percent of gross domestic product (GDP), an increase of about one-third since the cost was last measured in 2017.
This is our leading domestic challenge in the United States, and conditions are worsening. What would we do if this was any other issue beyond the highly stigmatized condition that it is? When will we start doing those things?
The water is rising around us while we consider these questions.