Confronting the devastating ‘Twindemic’: Drug overdose deaths and the COVID-19

Akhtar Purvez, MD

Interventional Pain Management Practitioner, Researcher, and Author, Pain & Spine Center of Charlottesville, 2335 Seminole Lane, Suite 500, Charlottesville, VA 22901, USA.

Correspondence: Akhtar Purvez,MD, E-mail: mansbal@yahoo.com; Phone: +1 434.328.2774 (P); +1 434.328.2776 (F)

The arrival of a new devastating medical emergency at international level would shove its predecessor into the background, but that won’t make it disappear. SARS and the Ebola virus had no effect on the HIV/AIDS epidemic, and even though the COVID-19 pandemic has been in the focus of the world for the past two years, a previous plague of opioid and other drug overdose has maintained its grip on the mankind.

In the United States alone, there were more than 91,000 drug-related deaths in the year 2020, a jump of 31% from 2019. More than 932,000 people have died since 1999, according to the Centers for Disease Control and Prevention (CDC).[i] That is more than a stunning 9/11 size tragedy happening every month.

In the developing nations, the situation may be even worse. About 700 people die of drug-related complications in Pakistan every day, which translates to 250,000 deaths every year.[ii] Internationally, drug use killed almost half a million people in 2019, while drug use disorders resulted in 18 million years of healthy life lost, mostly due to opioids.[iii]

The fact that these drug-related deaths have been rising substantially every year tells us that the current coping strategies are inadequate and ineffective.

So, what are we doing about it? While this toll is real, national and international governments have shown little interest in confronting and controlling it. The media is largely complicit in its silence. In recent years, the United States and some international governments declared a national emergency, but with very limited resources available and little focus to combat it aggressively. This scarcity of meaningful action means that this epidemic will continue unabated.

When someone dies from COVID-19, they receive an almost unanimous sentiment of “What a shame.” When someone dies of a drug overdose, on the other hand, we are more likely to hear “How could they do that to themselves?”

There are two distinct types of unsafe drug users. Some are pleasure seekers who add drugs such as oxycodone to their shopping list for ‘recreational’ purposes, then become addicted to them and other such substances. Others, are ambushed by the medications they may have taken to abate pain and feel more ‘normal’. Many of these are obtained through legitimate medical prescriptions written by doctors trusted to know what was the best.

Both of these groups present a societal challenge, but the corrective approaches are necessarily different. Those who supply recreational users through the black market, and out of greed, should be initially dealt with by law enforcement agencies, if only because they pose a distinct danger to the public. Operating with little or no medical knowledge, they often stir lethal substances such as fentanyl into what they sell, promising “more bang for the buck.”
As for the other group, we’re more than 20 years into this epidemic and since then the medical knowledge, practice, and technology have considerably improved. While opioids may still have a place for some patients with a terminal illness or in hospice situations, most others can benefit from alternate modalities that may eliminate the need for these highly toxic medications altogether. The prime amongst these is the advances in minimally invasive, interventional pain management procedures. These range from simple muscle injections to relieve spasms to epidural injections, joint injections, nerve blocks, nerve ablation procedures, and neuromodulation techniques that are used to modify pain transmission along the peripheral nerves, in the spinal cord, or in the brain. The later technologies are getting smarter, smaller, and even wireless, and offer convenience and significant relief in selected cases. In many medical practices like that of the author’s, these have greatly minimized or eliminated the need for opioid medications altogether. At government, or private sector institutional levels, these need to be encouraged and incentivized.

Adding even more conservative approaches such as physical therapy and regular exercise programs can also complement pain management procedures to relieve symptoms and improve function and quality of life.

The Centers for Disease Control (CDC) has recommended six guiding principles and five strategic priorities for overdose prevention.[iv] These vary in range from promoting health equity to raising public awareness and reducing stigma, and can be implemented equally on a national and international level.

More research needs to be done to develop new medications that reliably relieve pain without the accompanying risks of respiratory, neurologic, and cardiovascular depression, dependence, and addiction. Monoclonal antibodies, that have revolutionized the management of multiple ailments are now being looked into for relief for chronic pain.[v] The approach the scientists took to research and develop COVID-19 testing, treatment and vaccines shows us the way.

International institutions such as the United Nations Office on Drug Abuse and Crime (UNODC) and national resources like Substance Abuse and Mental Health Administration (SAMHA) and the American Society of Addiction Medicine (ASAM) have been commendably offering logistical support to clinicians to manage those already addicted to opioids and other medications, as well as and offering training, policy, and advocacy. However, extensive new research is desperately needed to figure out whether better and more efficient approaches can be devised rather than just the current office-based opioid treatment which ties people affected to a lifetime of medication replacement programs.

These suggested approaches, guidelines, strategies and research must be designed, and implemented, to help lower the death toll incrementally but effectively — COVID-19 or not.

Conflict of interest

The author reports no professional, commercial or academic conflict of interest.

Author’s contribution

Akhtar Purvez, MD, is the sole author of this editorial.

References

  1. Centers for Disease Control and Prevention. Death Rate Maps & Graphs [accessed on October 27, 2022]. Available at: https://www.cdc.gov/drugoverdose/deaths/index.html
  2. Islam M. State of the art treatment options for Pakistan’s opioid, alcohol and methamphetamine crisis. J Pak Med Assoc. 2020 Jun;70(6):1063-1068. [PubMed] DOI:5455/JPMA.29284
  3. United Nations Office on Drugs and Crime. World Drug Report 2021. Available at https://www.unodc.org/unodc/en/data-and-analysis/wdr2021.html. (Accessed on October 27, 2022)
  4. Centers for Disease Control and Prevention. Overdose Prevention, Preventing Opioid Overdose. Available at: https://www.cdc.gov/opioids/overdoseprevention/index.html (Accessed on October 27, 2022)
  5. Sánchez-Robles EM, Girón R, Paniagua N, Rodríguez-Rivera C, Pascual D, Goicoechea C. Monoclonal Antibodies for Chronic Pain Treatment: Present and Future. Int J Mol Sci. 2021 Sep 25;22(19):10325. [PubMed] PMCID: PMC8508878 DOI: 3390/ijms221910325