Covid-19 offers practical lessons that we can apply to the US’s approach to the overdose crisis, writes Joshua Barocas
With vaccinations becoming broadly available in the US, the shape of the covid-19 pandemic has come into focus. In early 2020, national leaders recognized the start of the crisis, and declared a public health emergency that reorganized biomedicine and public health. This provided new funding and allocation of equipment and services, Medicare and Medicaid requirement waivers, and reassignment of personnel. The Defense Production Act was invoked, which allowed the president to allocate resources and award contracts to promote national defense. The National Institutes of Health (NIH) and the US Food and Drug Administration helped develop vaccines and test therapeutics. The Centers for Disease Control and Prevention (CDC) put staff on the ground in places experiencing surges.
This comprehensive response to covid-19 contrasts with the reaction to another national public health emergency: the overdose crisis. Despite sustained and growing numbers of overdose deaths since the late 1990s, the opioid crisis was not declared a public health emergency until late 2017, after more than 700 000 people had died. Overdose deaths are still climbing in the US, and while some resources have been mobilized, the slow and still inadequate approach to the crisis is nowhere near the scale of the covid-19 response.
The different reactions to these emergencies, which have killed similar numbers of Americans, raise the questions: why have the responses been so different, and what can be learnt from covid-19 to fully and finally tackle the overdose crisis?
Part of the reason for the contrasting responses is the differing nature and public perception of these crises. Covid-19 caused an unprecedented disruption to American life that left no one unaffected, while the economic and societal effects of the overdose crisis are smaller and more localized. Covid-19 arrived suddenly as a novel airborne microbe and every person saw themselves as vulnerable. Conversely, addiction has been in the national consciousness for decades, and while many people know someone with a diagnosis of opioid use disorder (OUD), life for the majority of Americans remains unblighted by overdose. Lastly, covid-19 carried little stigma, while addiction has long been perceived as self-inflicted: adults who are affected are criminalized, considered moral failures, and “othered” by society.
For these reasons, we’re unlikely to ever see a response to overdose that is on the scale of that to covid-19. Yet there are important, practical lessons to apply from covid-19 that can help improve the US’s approach to the overdose crisis.
Lesson one: Treat an emergency like an emergency
At the outset of the pandemic, central command centers were established to monitor the threat, develop protocols, and secure vital resources. At their helms were governors, mayors, and chief medical officers surrounded by experts in infectious diseases and emergency response planning, strategy personnel, and community leaders. Vital also to these central command centers was their ability to communicate rapidly with others. Departments of health were able to communicate needs to the CDC; governors could request resources from the Federal Emergency Management Agency; and new surveillance systems, supported with funding, were established.
Currently, the overdose response is being managed by disparate entities with varying understanding of community needs and generally uncoordinated efforts. There is little coordination between the CDC and local health departments—and even less when it comes to coordination with community based organizations. To accelerate efforts, state and local governments can establish incident command centers that include medical and public health experts, community based organizations, and people with lived experience. Each incident command can work closely with hospitals, first responders, shelters, and community health centers to develop strategies to help people receive lifesaving support and access to treatment. Departments of health should develop community dashboards that provide updated information about the evolving crisis (e.g. a seven day average of overdose deaths). The federal government should support these efforts with bold national goals, new funding, and periodic press conferences.
Lesson two: Mobilize the healthcare system
When hospitals across the country experienced staffing shortages due to covid-19, pediatricians, surgeons, and dermatologists suited up to treat patients. Making this shift possible was the altruism of health professionals, combined with emergency waivers of rules on credentialing. To end the overdose crisis, all clinicians must step up and show that same willingness to help—as should the general medical system. One option is for more clinicians to register to prescribe buprenorphine for OUD, a medication associated with a two thirds reduction in the chance of death. While it is true that there is a complex set of barriers to prescribing medication for OUD, much of it comes down to clinicians’ willingness. Until now, fewer than 10% of primary care physicians have obtained the required federal credentials to offer this treatment; but with President Biden recently reducing the certification requirements for prescribing, it’s become easier to register.
The collective goal should be for patients to have access to life saving medicines at every touchpoint with the healthcare system. For this to happen, the general medical system must see addiction treatment as within its purview—as opposed to leaving it to the fragmented addiction treatment system, which currently lies largely outside the general medical system.
Lesson three: Follow the evidence and invest in rapid innovation
Except for some fringe providers, the scientific community has rallied around evidence based treatments for covid-19. Vaccines and other treatments continue to be studied and providers continue to adapt to changing treatment protocols. This was made possible by the outpouring of funding to rapidly develop and test novel therapeutics and vaccines—$18 billion was invested in Operation Warp Speed. And it worked—vaccines are being administered throughout the US, and mortality rates and hospitalizations are decreasing.
The opioid story is different. Medications for OUD have robust evidence supporting their efficacy, yet they remain underused and access remains limited. For example, despite a lack of supporting evidence, residential treatment and detoxification centers routinely “treat” patients without offering medication. To end the overdose crisis, the scientific community can endorse treatments that work, reject treatments that don’t, and innovate new therapies as the epidemic evolves. Massive funding is needed beyond the NIH Helping to End Addiction Long-Term Initiative, which had a total budget of less than $1 billion dollars in 2019. An “Operation Warp Speed” for overdose can rapidly study and deploy new types of delivery systems for treatment and harm reduction.
Lesson four: Pay attention to equity
Covid-19 has made clear that inequitable access to resources drives disparities in outcomes. The struggle for equity in covid-19 has centered around access to prevention and cure for an acute infectious disease, and providing resources to vulnerable populations so that they can remain safe. People from ethnic minority communities were among the last to have access to covid-19 testing, treatments, and vaccinations. Recognizing these inequities, President Biden has committed $10 billion to ensure that covid-19 vaccines are being equitably distributed, and that testing and treatment are available for vulnerable populations.
Similar disparities exist with addiction: the communities that are disproportionately affected often have inadequate access to medication for OUD and overdose prevention. To end the overdose epidemic, the infrastructure needs to be brought to the communities that are most affected. Just as pop-up testing emerged during the covid-19 pandemic, pop-up harm reduction services can save lives. Syringe service programs could be introduced with the same urgency as vaccination sites. The investment that has been made to combat covid-19 disparities is also needed for overdoses.
The US’s response to covid-19 has been, in many ways, less than ideal, yet it has provided the country with a roadmap of what’s necessary to rise to the challenge of a public health emergency. We must seize this opportunity to build a system that provides lasting solutions to the overdose crisis.
Joshua Barocas is an infectious diseases physician at Boston Medical Center and assistant professor of medicine at Boston University School of Medicine. Twitter @jabarocas
Competing interests: none declared.
Acknowledgements: The author would like to thank Joshua Sharfstein and Michael Stein for their thoughtful review and editing of this piece.