Epidemics overlapping: a public health catastrophe

COVID-19 has undoubtedly pushed previous public health concerns to the side, and among them, the decades-long opioid epidemic rages on.

Prior to the outbreak of the coronavirus, the opioid epidemic was on a potentially promising trajectory, with a 4.1% decline in opioid-related deaths between 2017 and 2018 and misuse of prescribed opioids by high school seniors was at an all time low since data started being collected, according to the U.S. Department of Health and Human Services. Contrary to national trends, Missouri peaked at 1,132 deaths in 2018, followed by another concerningly high number of 1,094 in 2019. 

Dr. Rachel Winograd is an associate professor at the University of Missouri-St. Louis and project director for No-MO Deaths, an organization working on multiple projects to address the state’s opioid epidemic response in collaboration with the Missouri Department of Mental Health and localized treatment centers. With data from the first 3 quarters of 2020, she said about 75% of Missouri’s overdose deaths in that time span are opioid related.

“That is a big jump,” Winograd said. “Drilling down, that increase is entirely due to what happened in March, April, and May. That’s when the numbers really soared during the height of the lockdown last year.”

Despite this troubling trend, numbers seemed to stabilize to pre-pandemic levels. However, Winograd saw no reason to celebrate. 

“We were in an overdose crisis before (COVID-19),” she said.

However, based on data predictions by the CDC released in February of this year, Missouri and the other 49 states cadenced similarly disturbing statistics. Through the 12-month period of July 2019 and July 2020, opioid-related deaths rose 24.2% nationally, and 21.1% in Missouri. The same report predicts Missouri may have hit another grim peak for 2020, at 1,916 deaths.

Prevent-Ed, a nonprofit organization based out of St. Louis with a mission to prevent drug misuse through education, intervention and advocacy, has seen COVID-19’s impact on the opioid epidemic first hand.

“People don’t know what they don’t know,” Stacie Zellin, the community education coordinator for Prevent-Ed, said. “A good starting point is working to detangle some of these ideas that people have about what substance use disorder is. There are still people who will view an individual who uses substances as a bad person, they make bad choices and they should go to jail.”

Zellin said various factors caused, in part, by the coronavirus harmed individuals who experience substance use disorder. Among these are the inability to obtain the same substances used pre-pandemic, lack of witnesses in the event of an overdose, and strained public health systems. 

David Stoecker, the executive director and founder of Springfield’s Better Life in Recovery, a 501(c)(3) non-profit, was quick to acknowledge the impact COVID-19 had on the opioid epidemic. 

“I think (COVID-19) isolated people more because it got all of the media’s attention,” Stoecker said. “We were finally starting to get some traction, but took away a little bit of the ground that we gained.”

While Zellin was reluctant to generalize the stigma some citizens feel towards addiction, she felt it necessary to help spread information about the neurobiological aspects of what opioid addiction really means.

She noted that the war on drugs played a significant role in bringing about that mentality, which fails to frame it as exactly what it is: a brain disorder.

“Some of these changes might seem small, but it’s small changes that make big differences,” Zellin said. “There’s a lot of changes around the language that’s used. Prevent-Ed doesn’t use the word ‘abuse’ anymore. If you think about the other contexts we use that word in, like child abuse and spousal abuse, there’s very negative (implication) with that word.”

However optimistic, Dr. Winograd wasn’t shy in noting the difficulty about changing individuals’ views on addiction.

“The stigma piece is really vexing and something the more I know, the more work I do in this area, the tougher it is, I think, to tackle,” Winograd said. “We just don’t know what changes people’s core beliefs.” 

Stoecker understands dealing with disgust and disdain doesn’t encourage rehabilitation. 

“Tough love doesn’t work nearly as well as setting healthy boundaries and treating people with compassion and respect,” Stoecker said.

Stoecker once wore the same shoes; following years of abuse and addiction to accompany multiple mental health diagnoses, he celebrated 12 years of sobriety in January of 2021. Since his life-changing decision, he’s sought to improve the lives of those struggling with similar issues. 

“I like to say that I have gone from dealing dope to dealing hope,” his LinkedIn profile reads.

 Winograd noted that there are different components to handling this issue.

“There is the science and evidence prong,” she said. “We just need to keep showing people the data, like this is treatable, medications work, they don’t get people high, it’s not replacing one addiction for another and harm reduction isn’t enabling.”

Another prong, she said, is pulling at heartstrings. Finding examples of former individuals who experienced drug addiction and recovered can help put a face on some routes (harm reduction, methadone, etc.) that people feel uneasy about.

Kathryn Wall, the public health information administrator for the Springfield-Greene County Health Department, said they hope that substance use becomes better understood as a disease, not a choice.

“Stigma is one of the most dangerous things a person struggling with a mental health issue or substance use can encounter, and all of us play a part in battling it,” she said.

While COVID-19 has certainly played a significant role in accelerating this drug crisis across the state, it’s only a contributing factor. Despite former Governor Eric Greitens executive order in 2017 to establish a statewide Prescription drug monitoring program, Missouri remains the sole jurisdiction in the union without an active PDMP. 

Before his resignation, Greitens created what Zellin described as an “irregular” PDMP. While a regular program often consists of a system where physicians and pharmacists were provided access to patient information, Greitens’ plan, in partnership with Express Scripts, a pharmacy benefit management organization, focused primarily on prescribing trends of physicians. 

Despite the lack of a statewide program, Zellin noted that local PDMPs cover large swaths of the state, leaving only small pockets left without coverage. However, Zellin and Prevent-Ed, are in favor of elevating that to a statewide level.

“It has consistently come up in the Missouri legislature,” Zellin said. “In the most recent version, it’s the same argument we hear that it violates people’s privacy. We’re hopeful every year but something just always seems to happen.”

In 2017, Springfield joined the list of municipalities and counties across Missouri that adopted localized PDMPs, according to Wall. Despite being dated before the coronavirus pandemic, a 2019 report by the Community Mental Health and Substance Abuse Assessment pointed towards a sharp increase in alcohol and drug-related disorder diagnosis between 2014 and 2016 across Greene county.  

Be that as it may, the county defied state and national opioid-related death trends in 2020. According to data from the Greene County Medical Examiner’s Office, overdose deaths decreased from 89 in 2019, to 77 last year.

“Our community stepped up to address the crisis, including passing a local prescription drug monitoring program, initiating programs from agencies like Burrell Behavioral Health and Jordan Valley Community Health Center, widening the use, awareness and accessibility of opioid overdose reversal medications like Narcan, and other efforts,” Wall said.

Winograd, however, has her doubts about PDMPs and is wary to cast or withhold support.

“At the end of the day, it’s a database,” she said. “The effectiveness of them is entirely contingent on how they are used. The evidence is really mixed.”

An theoretical example she provided was the unintended consequences of a PDMP. Data may suggest a decrease in opioid prescriptions, which initially may seem like a positive trend. However, that information could be used to “catch people” that are pharmacy or doctor hopping. Instead of connecting them to the help they need they are cut off from their doctor or medication and are inevitably forced to illegally obtain those substances from other sources, which are often laced with deadly amounts of fentanyl.

Despite facing an uphill battle on multiple fronts, Zellin and Winograd are both optimistic about what the future holds. 

“This epidemic has been going on for so long and it has changed so much,” Zellin said. “We started out paying attention to a prescription pain pill problem, which transitioned to a heroin epidemic, which has now transitioned to a fentanyl epidemic.”

As the epidemic changed, the public health response has had to follow suit, she said. 

“There’s really good, thoughtful, evidence-based work being done in the state of Missouri and elsewhere.”

Winograd is also impressed by the progress that has been made in recent history, but said she hopes to look past COVID-19 

“We have fit a lot of change into a short amount of time, and if we can keep that pace up, I’m really excited to see where our mindsets are 4 years from now,” Winograd said.

From robust addiction treatment out of primary care programs, to mobile vehicles providing treatment access for hard-to-reach neighborhoods, to syringe exchange programs, to addressing racial inequalities of substance use disorders, to abandoning the old-school dogmatic attitudes about these issues, Winograd, Zellin, and their colleagues across the country have a lot of goals for the future.

“Will people have access to housing, transportation, childcare, and employment in addition to what we think of as treatment?” Winograd said. “Because people are well-rounded individuals with multi-faceted priorities and we need to address them as such. If we keep this momentum up, I think we can do a ton of good and save and improve a lot of lives.”

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