A Requiem
They are found in suburban bedrooms and urban sublets. They are found in college dorms and motel parking lots. They are found in settings that are completely different from each other in every way, save for one depressing similarity: They are found alone. These are the casualties of America’s opioid epidemic, numbering almost half a million since the turn of the century and nearly 50,000 in just 2018. Many succumb in solitude.
Loneliness has long been known to promote the development of substance use disorders, and especially opioid abuse. Like many other substances, opioids act as temporary chemical comrades for those lacking human companionship, their tantalizing reward of brief bliss and euphoria trapping victims in a cruel feedback loop of increasing dependence and isolation. However, unlike alcohol or nicotine, opioids are much more easily consumed in lethal doses, and relapsing individuals whose tolerance to such drugs disappeared as they tried to become “clean” are often the most vulnerable to suffering a fatal overdose.
Though the COVID-19 pandemic has overshadowed the opioid epidemic in recent months, opioids have not disappeared. Instead, with mandatory lockdowns and social distancing measures preventing many struggling with addiction from accessing resources critical to their well-being, the need to tackle the opioid crisis has only become more dire. Indeed, many individuals suffering from substance use disorders now face a distressing Catch-22 in the COVID era. For those who are still employed or defy public health orders to socialize, the constant risk of catching the virus looms, while those who abide by social distancing orders and stay home alone must deal with another menace that can be just as deadly: isolation.
A middle road exists. It is perfectly feasible to provide resources that help reduce the loneliness of those suffering from opioid addiction while respecting social distancing mandates. The solution lies in expanding empirically proven harm reduction strategies that ensure that all individuals who use drugs do so safely and responsibly.
The Backstory
Addiction and loneliness feeding into one another is nothing new, but certain characteristics of the American opioid crisis have brought the relationship to an unprecedented, even more menacing level. The first factor to consider is the distinctive genesis of the opioid epidemic. While drugs such as crack cocaine first emerged in impoverished urban neighborhoods, the communities initially hit hardest by opioids tended to be mid-sized Rust Belt towns experiencing a painful decline from their manufacturing heyday. With a significant portion of male residents in these areas newly unemployed and anxious to stave off boredom and despair, opioid abuse quickly exploded. The resulting deaths of many family breadwinners from overdoses, along with the migration of many others in search of employment elsewhere, soon sparked a pernicious cycle of ever-worsening loneliness and addiction in these declining industrial centers.
However, while former industrial boomtowns and their surrounding rural regions remain hotspots of opioid addiction, the epidemic has become far more than a localized problem. Rather, its explosion across the nation illuminates the second factor behind the unprecedented effects of the opioid crisis: the War on Drugs, a decades-long campaign of punitive enforcement that has only worsened the opioid crisis on multiple levels. For instance, militarized crackdowns on drug trafficking have encouraged smugglers to supply increasingly potent opioids that are smaller and harder to detect. This has resulted in a “wave phenomenon” as deadlier drugs such as heroin and synthetic analogs, most infamously fentanyl, have gradually replaced the prescription opioids that were the most common culprits of addiction in previous decades.
Most critically, the zero tolerance attitude of the War on Drugs has dramatically exacerbated the stigma associated with drug addiction and deepened the relationship between substance use and loneliness. By characterizing victims of addiction as social menaces and encouraging their families to give “tough love” in all cases of addiction instead of only extreme ones, America’s narrow-minded approach in the past half-century has created an underclass of isolated individuals with limited social prospects.
A Two-Epidemic Forte
COVID-19 has helped put the many failures of the War on Drugs on full display. The pandemic has “amplified issues at every level of the addiction spectrum,” Samantha Arsenault, the vice president of national treatment quality initiatives at Shatterproof, an addiction awareness nonprofit, told the HPR. “Whether it’s people engaging in risky behaviors as a coping mechanism, people with substance use disorders trying to seek treatment or maintain treatment regimens,” there is no question that the two crises have fundamentally intersected.
Nationwide, individuals struggling with addiction whose families believed that completely shunning them was the best option for recovery are now truly alone. For those who were in the midst of “rehab” before the pandemic hit, the paucity of remote treatment options is now openly obvious. Faced with safety concerns and receiving little to no support from public authorities in creating emergency accessibility plans, dozens of needle exchange centers have had no choice but to reduce hours, or even close completely, as the virus continues to spread. While some clinics have organized “to-go” bags of clean needles and other supplies for their clients, this Band-Aid solution is not only unable to provide the same quality of care but also cannot reach vulnerable individuals who may have stopped travelling to the clinic altogether due to barriers created by COVID-19.
In any case, individual organizations’ efforts to adjust as best they can to the new global situation are laudable, but only a concentrated national effort can truly slow down the revolving door between addiction and loneliness. Yet across the nation, millions still subscribe to ingrained myths that portray addiction as a “moral failing” instead of the brain disorder that it unquestionably is. And while these widespread misconceptions have marginalized victims of addiction for decades, COVID-19 has further exacerbated the situation. As Dr. Rebecca Baker, executive director of the National Institutes of Health’s Helping to End Addiction Long-Term (NIH HEAL) initiative, puts it in an interview with the HPR, the “most significant barrier” to implementing solutions that are empirically effective in helping victims of addiction survive, recover and reintegrate into society is the deeply rooted stigma associated with addiction in America.
The Opposite of Addiction: Not Sobriety, but Connection
Clearly, the COVID-19 epidemic has highlighted the need for new strategies for tackling the opioid crisis that particularly focus on confronting the toxic stigmatization of its victims. The most promising solutions are the ones that adopt a harm reduction approach and focus on tackling both the physiological and psychological aspects of addiction. While skeptics of harm reduction often point to it as an example of excessive government intervention and the promotion of illicit drug use, it is simply an evidence-based approach that is proven to work. As Monique Tula, executive director of the Harm Reduction Coalition told the HPR, those who use drugs “need positive connections with other people who won’t judge them for their behavior.” For the best chance at recovery, feelings of “purpose and belonging” are essential.
The first step to fighting the stigma of addiction that has left many of its victims helpless in quarantine is “educating the public,” declares Arsenault. Without efforts to dissuade fears that opioid medications such as methadone and buprenorphine perpetuate dependence and promote drug use, social pressure will continue to prompt those struggling with addiction to stay home and use in solitude. To change this status quo, Shatterproof has launched a special education module aiming to reconcile families of those struggling with addiction with the exigencies of the pandemic. Meanwhile, Baker believes that there also needs to be an emphasis on educating primary care physicians on the benefits of medication-based treatment, as many of them are still hesitant on having such conversations with patients who may be struggling with addiction.
The coronavirus-induced national economic crisis, meanwhile, has also affected addiction treatment centers, as many have become financially insolvent. And as many of these rehabilitation facility networks have attracted significant controversy over their practices, a direct bailout to save them is certainly not the only solution on the table. Instead, in order to promote best practices and improve oversight, it may be necessary for regulatory authorities to reconsider the entire business model of a rehabilitation industry that has constantly been criticized for deceptive marketing methods, patient manipulation and even insurance fraud. In addition to exercising their enforcement obligations, governmental authorities should not only continue encouraging the distribution of opioid substitutes and overdose reversal drugs but also lead the charge in launching home delivery services and other experimental programs that act as adaptations to the COVID-19 situation.
However, the most important step to reducing the loneliness of at-risk individuals is ensuring that those who are home aren’t really alone. Telemedicine might offer a chance to do just that. As an opportunity to use innovations in technology to directly connect healthcare providers with individuals struggling with addiction, telemedicine offers not only the lucrative promise of cheaper and more time-efficient physician-patient interactions but also a chance to directly connect with patients in quarantine alone. Dr. Travis Rieder, a professor at Johns Hopkins University, told the HPR that he is “not worried at all” about implementing telemedicine on a larger scale. Though some critics have suggested that reduced physical physician-patient contacts may translate into a repeat of painkiller over-prescriptions like in decades past, Rieder points out that no one is “seeking out methadone to get high” and that telemedicine is the most effective medium to continue harm reduction interventions in a socially distanced world.
Meanwhile, organizations such as Never Use Alone, a nonprofit that connects volunteers with substance users who lack others nearby, are dedicated to ensuring substance users never use alone. In an interview with the HPR, Never Use Alone founder Mike Brown says that their “call volume has doubled at least” since the beginning of the pandemic, as staying home is often “a dangerous place” for at-risk individuals whose few remaining connections to society have now been permanently severed by social distancing measures.
Nevertheless, Brown believes that ultimately changing the widespread belief that families should “kick out of their lives” relatives suffering from addiction would do more good than any harm reduction effort, as family members living in the same residence would be best equipped to immediately contact emergency services after an overdose and administer life-saving reversal drugs. Indeed, as families are still the largest social units allowed to congregate by many states, a campaign to reconnect those estranged by addiction would be incredibly beneficial to mitigating loneliness.
What’s Next?
Although the novel coronavirus has wrought havoc on a global scale, it has also become a real opportunity for Americans to catalyze reform on existing national ills, including the opioid crisis. Dr. Peter Grinspoon, an internist at Massachusetts General Hospital who has written extensively about his past struggles with opioid addiction, agrees. As he points out in a recent Harvard Health Blog article, while the COVID-19 and opioid epidemics have become “additively deadly” together, they have also shined a revealing spotlight on the common “underlying fault lines” exacerbating them both. In an interview with the HPR, Grinspoon contends that “reconnecting is critical” to any odyssey of recovery, meaning that these two national crises are fundamentally interconnected.
This is a both daunting and hopeful insight. Perhaps as we continue to bake bread with family members, organize Zoom calls with friends and search for other activities to alleviate our boredom in quarantine, we should better appreciate how much we take for granted the fact that we still have people in our lives that care for our well-being. While confined, we should also better inform ourselves of the plight of the millions struggling with opioid addiction who lack companionship. If we join the national crusade to reduce their social stigmatization and isolation, we just might be able to prevent yet another lonely OD.
Image Credit: “Drugs” by Brandon Giesbrecht is licensed under CC BY 2.0