A new episode of our podcast, “Show Me the Science,” has been posted. In addition to reporting on the state of the COVID-19 pandemic, these episodes feature stories of other groundbreaking research, as well as lifesaving and just plain cool work of faculty, staff and students at the School of Medicine.
In this episode, we discuss issues that were problems long before anyone ever heard of COVID-19: alcohol use disorder and opioid overdose. Both seem to have gotten worse during the pandemic. Alcohol sales rose during the early days of lockdown, and they’ve remained high. Laura J. Bierut, MD, the Alumni Endowed Professor of Psychiatry, says another issue is that with some people losing their jobs while millions more have worked from home, some of the guardrails that have kept people from drinking too much have just gone away. She expects the fallout from the pandemic, in terms of alcohol use, will continue being felt for years to come.
And just as the pandemic has fueled alcohol problems, deaths from drug overdoses have continued to climb, with more than 107,000 overdose deaths reported in the U.S. during a recent 12-month period. One issue, according to Kevin Xu, MD, a resident in psychiatry and Evan S. Schwarz, MD, an associate professor of emergency medicine and director of the Division of Medical Toxicology, is that many who use opioids are not prescribed a drug that can reduce cravings and lower risk of future overdose. That drug, buprenorphine, is prescribed for only about half of the patients treated for opioid use disorder, and it’s used even less frequently in people who use opioids along with other substances, such as cocaine, alcohol or methamphetamine.
The podcast, “Show Me the Science,” is produced by the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis.
Jim Dryden (host): Hello and welcome to “Show Me the Science,” conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri … the Show-Me state. In past episodes, we’ve focused entirely on the way our doctors, researchers and trainees have responded to the COVID-19 pandemic. Now, as the pandemic, we hope, begins to recede, we’re bringing you stories of other groundbreaking research, lifesaving and just plain cool work at the School of Medicine. In this episode, we discuss a couple of things that were problems long before anyone ever heard of COVID-19 but that have only gotten worse during the two years of the pandemic: alcohol abuse and opioid deaths. During the early months of the pandemic, alcohol sales skyrocketed, increasing between 20 and 40% in most places.
Laura J. Bierut, MD: I think alcohol use disorder is likely having a greater impact on the population now, and on our workforce now, than it was in 2019.
Dryden: That’s Washington University psychiatrist Dr. Laura Bierut. She’s the senior author of a recently published study about people with alcohol use disorder and their propensity to miss work. She and psychiatry resident Dr. Ian Parsley found that alcohol use disorder was linked to 232 million missed workdays each year in the United States. And Parsley says the number of people he sees with serious alcohol problems has only increased during the lockdowns and working from home.
Ian Parsley, MD: Working with a lot of people with alcohol use disorder, just anecdotally I’ve seen that just within my patient population, the total amount of use since people have been stuck at home has really gone through the roof. That’s not something that’s just going to resolve itself even as we slowly come out of this pandemic.
Bierut: And I think the other thing is just the type of structure of work. Work has the benefit of giving a structure. You get up in the morning. You get dressed. You go to work. You do all these things. And many people lost their jobs during the pandemic. Others worked at home and lost their structure. So what I think we’re all kind of waiting to see is how this all shakes out. We know the alcohol use increased greatly. And if I had to speculate, I would say that there was probably a lot more drinking during the day, too, as people are home and able to just drink at other times. We’ve also kind of lost our guardrails for certain types of behaviors, with a pattern that is lost. So I think alcohol use disorder is likely having a greater impact on the population now, and on our workforce now, than it was in 2019. We’re kind of holding off on analyzing the data of 2020, 2021, but I’m going to be curious to see what those data look like.
Dryden: And just as the pandemic seems to have fueled problems with alcohol use and abuse, deaths from drug overdose have continued to climb, with the White House recently reporting more than 107,000 overdose deaths in a recent 12-month period. And that doesn’t count those who overdose and don’t die. Dr. Evan Schwarz is an emergency medicine physician and chief of medical toxicology at Washington University.
Evan S. Schwarz, MD: Clearly, we’re not winning. I can’t say, and I don’t think anybody else could say, looking at the number of people that are dying — and keep in mind that’s only dying, that doesn’t mark all the other morbidity — that we’re winning. We’re clearly not.
Dryden: So what can change that? Schwarz and others believe that, at least in terms of treatments, there is a medication that could help. It’s called buprenorphine. And like heroin and fentanyl, it’s actually an opioid that interacts with the same receptors on brain cells as those dangerous drugs do. But unlike those street drugs, buprenorphine won’t stop a person’s breathing. So it can help with cravings without endangering the life of an opioid user. The problem is that although the drug has been around for two decades or more and although it’s been proven to be effective, a large number of doctors are either reluctant or unable to prescribe it. Psychiatry resident Dr. Kevin Xu has just published an analysis of insurance data from almost 180,000 opioid users. And that data showed that buprenorphine was prescribed for only about half of opioid users, at least among the users who only used opioids. But for people called polysubstance users — in other words, people who also regularly used other substances like alcohol, methamphetamine or cocaine — in that group, some 70% of those folks never got a prescription for buprenorphine.
Kevin Xu, MD: Buprenorphine is a drug that is assigned to treat opioid use disorder and ultimately cut down on cravings and can actually reduce overdoses. It has been demonstrated to really have a substantial impact on decreasing opioid mortality. Like methadone, it is an opioid medication itself. So you are substituting heroin or fentanyl for another opioid. But it’s a safe opioid that is specifically designed that you cannot possibly overdose on buprenorphine or stop breathing, which pretty much every other type of opioid will do. But there’s something special about buprenorphine, which is that it’s a take-home medication. Buprenorphine is something you can take home, and you can go on to do other things with your life. And that’s essential for recovery.
Dryden: Is it considered, though, a bridge to being drug-free? Or is it something that like methadone you would be on?
Xu: It’s something that is flexible, actually, depending on what you yourself are interested in. For some people, they ultimately find that the medication is so helpful for reducing cravings and keeping them in recovery that they end up taking it for a really long period of time. For other people, they find that they only need it for a certain period of time and are ultimately able to really be in sustained recovery without even needing it. So that element of flexibility with take-home doses is another thing that makes it very special.
Dryden: But it’s not used very much. This is what you’re finding in this study, that a lot of patients who would be eligible to get the drug are not getting it.
Xu: There are substantial barriers to people accessing buprenorphine. For a period of time when buprenorphine initially came out in the 2000s, there was some hope that the prescriptions were rising. With every single year, doctors were prescribing more and more. But unfortunately, it’s really plateaued. It’s really concerning because we have seen the opioid overdose crisis really evolve into a different type of monster during COVID, which is escalating overdoses. And we’re not really seeing evidence of buprenorphine scripts going up. That has to do with a lot of barriers to buprenorphine access. That’s a huge problem right now.
Dryden: Barriers such as?
Xu: Well, there’s a lot of — there’s a lack of data about who benefits from buprenorphine. I’ll just start with that. There was a seminal clinical trial that was done in 2017, 2018, right, that was comparing buprenorphine with another medication called naltrexone, which is the other treatment for opioid use disorder. We found over time that it honestly doesn’t do quite as well as buprenorphine. But that was actually a patient population of people with just opioid use disorder by itself, which is becoming increasingly rarer during COVID-19. And that’s actually been a problem in terms of expanding access to buprenorphine. We use the term “polysubstance use disorder” or “co-occurring substance use disorder” to explain the fact that most people these days during COVID are not just struggling with opioid use disorder. They’re struggling with opioid use disorder and many other substance use disorders together. So we call it polysubstance use. And for a very long time, people have had this idea that buprenorphine only benefits people with one substance use disorder, which is opioid use disorder. And if you have polysubstance use, it might not be safe to take buprenorphine or they might not benefit as much. We believe this is a really serious problem these days in terms of a barrier to buprenorphine access.
Dryden: Xu says that as an opioid epidemic has been fueled by a COVID-19 pandemic, he finds it confusing that many people haven’t been able to get a drug that really would help them. Meanwhile, doctors like Evan Schwarz are dealing with the fallout when those users run into trouble and show up at the emergency room.
Schwarz: So I think the pandemic has shown where there are problems and made them worse. Patients are more isolated in some ways, and it disrupted some of their regular treatment and some of their regular therapy, which was very hard on them. Patients were using alone and in isolation, which increased overdoses and increased death. Now, there were a few things that came out of this that have helped. A lot of them center on telemedicine and loosening of restrictions, which have helped increase access in some ways. But overall, we’re still seeing an increase in the amount of deaths since the pandemic started.
Dryden: We know alcohol sales spiked early in the pandemic and then they stayed high. I guess it’s harder to track opioid sales because there’s not an official market for that sort of thing. Are more people using? Are the same people using more? Do you know?
Schwarz: So that’s a good question. I think we need to separate this into medicines that are prescribed that are diverted to the illicit products on the streets. So this isn’t a problem so much with doctors overprescribing at this point. What we have is a problem with the illicit opioids in particular that are coming in. And to your question, I think it’s a little of both. We know the fentanyl and the fentanyl analogs that are being made illicitly. So again, not fentanyl used in medicine that’s being diverted, but fentanyl and analogs that are made on the street are coming in very easily and are very cheap and easy to produce. And they’re just very potent. So all those things are contributing to the current death rates that we’re seeing.
Dryden: The question sort of is, “Who’s winning?”
Schwarz: I think the short answer is clearly we’re not winning. I can’t say, and I don’t think anybody else could say, looking at the number of people that are dying — and keep in mind that’s only dying, that doesn’t mark all the other morbidity — that we’re winning. We’re clearly not. Now, to your point, things like naloxone distribution has been great, and I can’t even think of where it would be without that. The problem, of course, with that is if you want to buy it at a pharmacy — you can now get it without a prescription — it’s still very expensive. And many of our patients can’t afford that. And of course, if you’re using alone, it doesn’t matter how much Narcan or naloxone you have because there’s no one else there to administer it to you. And I know the U.S. government just placed a huge emphasis on things like harm reduction — so, keeping patients safe until we can get them into treatment or until they’re ready for more formal treatment.
Dryden: So what is the standard way to treat a person who shows up in the emergency department due to an overdose or a serious drug-related issue? Or is there at this point a standard way that you go about referring or prescribing? How does that work?
Schwarz: So I don’t know that there’s necessarily a standard. I want to say that the big emergency physician organizations, and I think many emergency physicians, see a need to change how we’ve been treating patients in the past. I think, unfortunately, still the majority of places, the standard of what would happen is the patient would come in, and once they’re proven safe for discharge — so you know that they’re not going to stop breathing suddenly — it would be discharging the patient to hopefully follow up somewhere. I think the organizations and physicians, in general, are moving toward more and more emergency departments being able to at least offer buprenorphine in the emergency department. And I think that’s going to help some. There also are changes to some of the laws and regulations that are hopefully going to allow the emergency medicine physician to hopefully give patients up to 72 hours’ worth of medications for opioid use disorder so the patient can walk out the door with them in hand and start using them. But we still know we need to do a better job and increase access because that’s still a barrier for some patients.
Dryden: Buprenorphine actually is a narcotic. I mean, it can be used as a treatment for opioid disorder. My understanding is that it’s a good way to prevent future overdose as well.
Schwarz: It’s safe for an opioid. So for someone who’s never had an opioid before, like a little child, could still get opioid toxic from it. But when you’re talking about patients that are opioid-tolerant, so patients with opioid use disorder — these are the patients that are using heroin or whatever else — it’s a very safe medication for them and can be started pretty easily in the emergency department and through other avenues. So it’s a great treatment option for these patients. And literature shows that it decreases mortality from opioid overdoses.
Dryden: Now, you’re part of a new trial that tried to figure out more effective ways to use buprenorphine, correct? Can you tell us about that?
Schwarz: Sure. So this is a trial. And what the study is looking at is a traditional sublingual buprenorphine versus injectable —
Dryden: Sublingual means you hold the pill under your tongue while it dissolves.
Schwarz: — versus injectable buprenorphine. And the thought being that if we can just inject you in the emergency department, it lasts for about seven days. So if the physician can’t prescribe buprenorphine for you to go home with or if it’s going to take a little bit longer for you to get into follow-up or, as the patient, if you’re concerned, “If I take this home, someone may steal it or I may not be able to get access to a pharmacy,” this takes all that concern away, because we can just give you the medication in an injectable version in the emergency department. It can control your withdrawals. It can control your cravings and gives you seven days to follow up. So we’re trying to see if there’s a difference between just the normal induction with sublingual buprenorphine versus injectable product and if patients follow up and continue with care.
Dryden: And is the idea that buprenorphine would be a bridge to not using at all? Or is it just that these patients are in crisis, and we don’t want them going through withdrawal in the hospital so we’re going to give them something to keep them safe for a few days? What’s the goal here?
Schwarz: So the easy and complex answer is yes. All of the above. For patients that get on this and want to stay on it and want to be abstinent, fantastic. For patients that just want to get themselves out of withdrawal and then aren’t sure what they want to do, it’s a way to get them out of withdrawal. Hopefully, once they’re out of withdrawal, they can start thinking more clearly about things and say, “I actually feel really good right now. I’m not worried about withdrawal. I’m not worried about cravings.” And maybe then they go on to say, “This is something I want to be on for a longer period of time.” We do realize that for some patients, they start on buprenorphine, and they never use again. Other patients, it does take a little while, it takes multiple times sometimes, before they stop using.
Dryden: Back to opioids within the pandemic. We’ve had waves of the pandemic. Is there any evidence that opioid use and opioid problems are following along or reacting in any way when the virus goes up or down? Or is it just up here and that’s where it’s been the whole time and that’s where it’s staying? Or how does that work?
Schwarz: So I think that works in general, just like alcohol and other drugs. When people are going through a bad time and when it’s in a pandemic, so everybody’s having a rough time and a difficult time, we see use of drugs and use of alcohol and things like that go up.
Dryden: And are there risks associated with opioid use that would make a user more vulnerable perhaps to SARS-CoV-2?
Schwarz: I don’t know that there are any specific risks because of the opioids. What we do know is when people are intoxicated, they tend to make poor decisions and so may not be making decisions that keep them safe as well as far as things that would decrease the risk of them getting the virus or transmitting the virus.
Dryden: Emergency rooms were being overrun by people with the virus. And I wonder if folks who might have had opioid use disorder got pushed to the back rooms for a while there because there was so much COVID in the emergency department. Or what about drug users?
Schwarz: Yeah, that’s a great question. Unfortunately, I think the reality is that their care got even more limited. I think first, many were afraid to go to the emergency department because they heard about all of the horrible things happening at the hospital with patients that were coming in that had COVID and that they were afraid that they were going to get exposed to that, which was a very real and understandable fear. I think they were using by themselves again. And their normal support of how they would get to the hospital or get to the emergency department became more and more limited. And for those that showed up, they got put into a waiting room with, instead of 10 people, all of a sudden there’s 30 or 40 people in the waiting room. And they’re getting triage to a lower priority and maybe starting to go through withdrawal, and so they left because they just couldn’t wait to be seen anymore. I think one thing that we really need to keep an eye on is a lot of these regulations that have increased access were all done under emergency declarations. And so we need to see what we can do to make a lot of those things permanent so we don’t lose them once we feel that the pandemic is at a place that a lot of those emergency temporary acts all go away and anything that’s established underneath them would then go away, too.
Dryden: Something that’s not going away anytime soon is drug and alcohol abuse. The pandemic didn’t create those problems. And when it’s finally over, opioids and alcohol will still be around and available. And they’ll cause problems for people. All of the guests we featured in this episode say it’s important to keep looking for and then prescribing effective treatments and strategies to help patients get and remain clean and sober. “Show Me the Science” is a production of the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis. The goal of this project is to introduce you to the groundbreaking research, lifesaving and just plain cool work being done by faculty staff and students at the School of Medicine. If you’ve enjoyed what you’ve heard, please remember to subscribe and tell your friends. Thanks for tuning in. I’m Jim Dryden. Stay safe.