Written by Sarah Roberts, Emily Leventhal, Dipika Pujara, & Sai Reddy

The Coronavirus pandemic exacerbated a number of pre-existing healthcare crises within the United States, namely the opioid epidemic which has ravaged the country for over two decades. Few places in America have been hit by the opioid epidemic as hard as the state of Ohio—so-called “ground-zero” for this crisis.

On top of troubling trends over the past two decades, the state of Ohio has been tackling a mutating crisis for over a year now: an opioid epidemic combined with a global pandemic. In 2020, Ohio saw record-breaking numbers of overdose deaths; for the year as a whole, Harm Reduction Ohio, a non-profit supporting science-based drug policy in their state, had 4,873 fatal overdoses on record. 

And while the social isolation, economic hardship, and uncertainty of the COVID-19 pandemic clearly worsened mental wellbeing and exacerbated drug use, these explanations do not take into account the unique ways in which the pandemic may have affected Ohioans’ economic accessibility to opiates and the lethality of their state’s drug supply. 

The Stimulus Checks: Coincidence or Causation? 

Dennis Cauchon, president of Harm Reduction Ohio, points to the Economic Impact Payments released by the Internal Revenue Service (IRS) in mid-April 2020 as a significant event behind the data his non-profit analyzes. In the month after the stimulus checks were deposited, 571 people died of drug overdoses in Ohio, the highest number for a single month Harm Reduction Ohio has on record. While the $1,200 stimulus payments meant relief for many people, it may have also provided extra income with which to purchase opiates illegally. Cauchon suspects another spike in overdose deaths is soon to come as the third round of stimulus payments are rolled out as per the American Rescue Plan passed by Congress last month. 

In Franklin County, Ohio, which encompasses Columbus, the state capital, Susan Knoll works as an epidemiologist in the County Coroner’s Office. She, too, points to the stimulus payments as a potential factor in the increase in overdose deaths during the pandemic: 

“We here in Franklin County have what we call a surge… we define that as five or more overdose deaths in a 24-hour period of time. We just started noticing more overdose surges occurring when [the stimulus checks] came out.”

While both anecdotal and statistical data have supported the idea that stimulus checks have negatively impacted the opioid crisis, others question the causal nature of the relationship. Dr. David Driscoll, an Assistant Dean of Research, Director of the Office of Research, and Associate Professor at the University of Virginia School of Medicine, is leading a statewide effort to battle the opioid crisis. While Driscoll acknowledges that many Americans who have received stimulus checks have also suffered from overdoses, he suggests that the claim that stimulus payments have caused spikes in opioid overdoses may be an ecological fallacy, or a failure in reasoning within epidemiology that occurs when an inference is made about an individual based on aggregate, group-level data. Because the conclusion about stimulus payments is being drawn from aggregate data, rather than individual data, the impact of stimulus checks cannot be removed from the “overarching contextual factors associated with the pandemic, including loss of jobs, financial stability, and social isolation.” The aggregation of data results in the concealment of certain factors, so the strength of the correlation tends to be larger when an association is made at a group level.

Regardless of the impact of stimulus checks on opioid overdoses, one does not have to choose between providing necessary stimulus payments to Americans and controlling the opioid crisis. Driscoll suggests that the government should provide more comprehensive services beyond just payments for those affected by the pandemic, such as “job training and placement, counseling, and if necessary, management of substance use disorders.” The government has missed the mark in terms of substance-abuse prevention and treatment; by ignoring the complexity of the pandemic’s impact on mental as well as physical health and assuming that simple monetary relief will help all individuals impacted by the pandemic, the government is neglecting its most vulnerable populations. 

Though correlation cannot prove causation in terms of the connection between opioid overdoses and stimulus payments and the stimulus checks are most likely not the immediate cause for opioid overdoses in the state, they have become the means by which people are obtaining these drugs. Ms. Knoll says that when the coroner’s office begins to conduct interviews with overdose victims’ next-of-kin, they will be able to start to draw causal links. These causal links may then inform policy for the specific services and support needed for these vulnerable individuals. 

Ms. Knoll’s job involves examining and collecting toxicological data on deaths in Franklin County; in particular, tracking the use of opioids and figuring out why overdose rates are so high in the area. However, Ms. Knoll and her coworkers have been doing much more than data analysis during the pandemic: they go out into the field themselves. In areas of Columbus with high rates of overdose, they hand out Naloxone (“Narcan”), the life-saving FDA-approved overdose antidote. A woman Ms. Knoll works with visits the homeless camps once per week to hand out Narcan as well. “We need to take the resources to them,” says Ms. Knoll. 

“Prior to the pandemic… sure, we were having overdose deaths, and the numbers were going up, but not like they have with COVID,” says Ms. Knoll. “I think the CDC put it this way: the opioid crisis… is actually the epidemic within the pandemic. Everybody has been so focused on COVID and the fallout from COVID…unfortunately, that caused a lot of resources for those that were in recovery to be lost.” 

Increased Lethality 

The nature of the Coronavirus lockdown may also have created a more lethal supply of drugs in Ohio. Contrary to popular belief, it is not the volume of drug users in Ohio which puts the state at the top in terms of overdose deaths—the number of drug users in Ohio is, in fact, average when compared to the rest of the country. Instead, Ohio’s drug supply is composed of a higher amount of more dangerous drugs than in other areas—the amount of fentanyl, a highly lethal synthetic opioid, in Ohio’s drug supply directly correlates with the number of overdose deaths the state sees. Synthetic opioids like fentanyl (and carfentanil, its more potent counterpart) are small, lightweight, and thus easier to smuggle through a transportation system made hyper-vigilant amidst the pandemic. In June 2020, just a few months after the COVID-19 pandemic reached Ohio, fentanyl as a percent of all drugs seized in Ohio reached an all-time high of 31.7%.

Chief Tom Synan, the chief of police of Newtown, Ohio, and co-founder of the Hamilton County Heroin Coalition, believes China’s lockdown in the first few months of 2020 set the conditions for addicts to face a greater risk of drug overdose. “China has historically been one of the biggest distributors of fentanyl and fentanyl precursors,” says Chief Synan. “It seems like it would be a good thing to have fentanyl cut off, but it actually ends up being a bad thing, because if you are a heavy user of fentanyl, and then all of sudden the supply is disrupted, your tolerances go down.” The effect Chief Synan references is reduced drug tolerance caused by a disruption to routine use of a drug. Drug tolerance is built up over time—as a person begins to use drugs on a regular basis, their bodies start to require larger and larger amounts of the drug to produce the same effect a smaller dose once had. Once they stop using the drug altogether or significantly reduce the amount they use, their tolerance decreases again. This phenomenon becomes dangerous once a person whose tolerance has since decreased uses the drug at the heightened amount that they were once able to tolerate. Their body’s tolerance lowered, this person faces increased risk of overdose because their body is unprepared for the amount of drug that has been ingested. 

The slight changes made during the pandemic have led to “users (being) subject to a wide variety of other dangerous substances being substituted without their knowledge,” explained Dr. Thomas Gilson. The alterations in day to day life contributes to this overall increase in overdose rates. As CDC Director Robert Redfield, M.D explains, “The disruption to daily life due to the COVID-19 pandemic has hit those with substance use disorder hard.” This significant change in lifestyle acted as a new stressor on those already suffering. This, in addition to the increase of synthetic opioids contribute to the overall increase in overdoses.

Hope for the Post-Pandemic Future

There is some hope that the pandemic brought to the addiction community, however. According to Driscoll, those who live in rural areas remain the most affected by the opioid crisis, encapsulated by the idea of a rural mortality penalty, or the large disparities in mortality in rural communities compared to metro areas. Lack of access to opioid therapy and mental health services have contributed to this rural mortality penalty, but the pandemic’s effect on expanding telehealth brings hope to rural residents with Opioid Use Disorder (OUD). Evidence suggests that telehealth-based opioid therapy is just as effective as in-person treatment, and these programs would allow rural patients to engage with clinicians and mental health professionals from their remote homes. 

Additionally, online meetings of Ohio’s Narcotics Anonymous (NA) chapters mean people who live in rural areas without the means to travel can attend, an option which will hopefully extend beyond when in-person meetings become routine again. In the Cleveland area, over 250 Alcoholics Anonymous (AA) chapters meet each week, and on top of local meetings, some members tell Dr. David Streem of the Cleveland Clinic that they frequent AA meetings hosted in Ireland over Zoom. Those who have watched this crisis unfold first-hand can offer us knowledge about what will really work for struggling people—Ms. Knoll suggests pop-up recovery resources, a one-stop website where people can get all the information they need about addiction recovery in a single place, as well as mail-order naloxone and test strips. These signs of hope, the unrelenting search for answers by Harm Reduction Ohio, Susan Knolls, and the Cleveland Clinic, and new insights into what the addiction community truly needs in such a hard-hit state hopefully stand as a model for other communities in America facing the same crisis. In the future, Ohio’s research on the pandemic’s intersection with the opioid epidemic should serve as a framework for protocols on maintaining addiction recovery during emergency situations. 

Edited by Greta Campbell

---

NOTICE: For training in administering naloxone (“Narcan”), the lifesaving FDA-approved overdose antidote, or to purchase this medication, visit https://www.naloxoneexchange.com/ .