Effect of COVID-19 on the opioid addiction epidemic

A webinar presentation by Dr. Charles Pierce MD, PhD, FCP, CPI

At the Summer HealthTap Doctor Network webinar on June 20, 2021, Dr. Charles Pierce gave a great presentation on "The Effect of COVID-19 on the Opioid Addiction Epidemic." You can watch the video presentation, or review his presentation slides.

In his talk, Dr. Pierce discussed the variety of Substance Abuse Disorder (SUD) patient presentations, described how to approach and manage SUD patients, detailed the use of buprenorphine to manage addiction, and more. Here is a quick summary of key take-aways from his presentation:

Addiction is a physical problem with strong genetic and environmental factors affecting memory, motivation, and inhibition. SUD is a chronic but treatable medical condition.

As physicians, we should not stigmatize SUD patients with labels such as "abuser," "addict," "junkie" or any of the more pejorative descriptors.

Sometimes we forget that tobacco kills far more people each year than do opiates, or that the addictive potential (probability of addiction after first use) is greater for tobacco than heroin, cocaine, alcohol or cannabis! In fact, nicotine addiction is the second-leading cause of death worldwide.

Marijuana is now legal for medical use in many states, and now it's also legal for recreational use in Wash., Ore., Calif., Nev., Colo., Maine and N.Y. We are seeing advertisements for CBD-containing candies in all forms, from gummies to cookies, munchies, and CBD "Kif Kat" and other similarly named chocolate bars. The addictive potential of marijuana means we can expect up to 10% of users may develop dependence.

Methamphetamine is a very addictive stimulant that can be eaten or snorted, or dissolved in liquid and injected. Crystal meth is smoked via pipe. Ongoing use of meth leads to edginess, excitement, anger, fear, plus high body temperature, itching, and emotional problems. Sadly, it may be surreptitiously added to marijuana.

The opioid epidemic has worsened during the pandemic. Last year, deaths from overdose increased by more than 30% to 90,000. Overall, half of drug overdose deaths are attributed to prescription medications, and most heroin users report that they misused prescription opiates before using heroin.

As doctors, we can combat the inappropriate use of prescription opiates with several measures:

1. Too many prescriptions: Prescribe opiates only when benefits are clearly greater than risks. Use non-opioid medications whenever possible.
2. Too many days of treatment: Prescribe fewer days. When possible, taper dosage after just 3 or 4 days of treatment.
3. Too high a dose: Higher dosage ranges (greater than 50 morphine equi-analgesic doses) doubles the risk of overdose. Use the lowest effective dosage, and avoid daily doses of >90 MED.

Fentanyl, and especially carfentanyl, are far more potent than morphine by 100x and 10,000x, so surprisingly small amounts of these drugs can be fatal.

The rate of overdose deaths is higher among whites and Native Americans than among Black, Latino and Asian populations.

Buprenorphine is an opiate that blocks opiate mu receptors and reduces physical craving for opiates. The half-life is 36 hours, so it takes a week of daily treatment to reach maximal effect (or to be eliminated after it's discontinued). It has a low risk of overdose.

Trade name preparations of buprenorphine include

• Subutex (sl tab).
• Sublocade (sc monthly injection).

Preparations that include naloxone:

• Suboxone.
• Bunavail.
• Zubsolv.

The drug abuse treatment act (DATA) governs the use of buprenorphine to manage addiction. Any physician can obtain a "DATA waiver" by taking an 8-hour online course and passing a test. Doctors' ability to prescribe this drug is limited to 30 patients/year in year 1, 100 in year 2, and 275 in year 3. Less than 10% of doctors in practice have achieved this waiver.

Buprenorphine should not be used with benzodiazepines or any CNS depressants (including alcohol) which may result in profound sedation, depression, coma or death. It is contraindicated with pimozide and thioridazine (QT prolongation), and with naltrexone (precipitates withdrawal).