The ripple effect created around the world by the COVID-19 pandemic is still being felt even 3 years after the initial outbreak and declaration of the pandemic status back in March of 2020. Although this pandemic has not left any single person or group of people’s lives untouched, there is some disproportion in who it has impacted the most, and one of these groups are people with opioid use disorders in Canada. In 2018 12.6 % of Canadians reported their use of opioids, and 9.6% reported having am opioid use disorder (Carrière, 2021). There are many distinct factors that play a role in the development of an opioid use disorder; however, the pandemic amplified these factors, and facilitated the spread of this disorder as the pandemic spread across the globe. Using the social-ecological model we will examine how the COVID-19 pandemic impacted people with opioid use disorders.
The social-ecological model is a framework that helps to identify the many social and environmental factors that lead to various modern day social issues. The social-ecological model is based on four factors that play major roles in the issues. These are individual factors, behavioral and biological factors, the second is relationship factors, these refer to relationships, or smaller social networks. The third is community factors, this level examines larger networks outside of an individual's personal space that have implications in the issues. And the final is the societal factor, this looks at how structural factors of a larger community may be playing a role in the issue at hand.
Figure 1. this graph shows the number of deaths related to opioid overdose over the years. note the significant increase in deaths starting from the beginning of the COVID-19 pandemic.
When looking only at opioid abuse, the most vulnerable population to opioid use disorders are young males, 20-24 years of age, with poor mental health, low emotional or mental support, and who are isolated, or who live alone and spend prolonged periods of time alone (Carrière, 2021). One of the measures taken during the pandemic to avoid the spread of COVID-19 is self-isolation, and keeping a small circle, for someone who is already struggling with mental illness and is having trouble to find emotional support, the pandemic has only amplified that struggle.
The relationship between COVID-19 and people with opioid use disorders at the individual level can be defined under two categories: behavioral and biological factors (Cowan, 2021). At the behavioral level, this theory suggests that an individual's behaviors can impact their risk of infection, by increasing risk of exposure by putting them in areas where safety measures are not enforced. An example of this is for people who are trying to recover from an opioid use disorder and must present themselves at a clinic every day for a methadone shot, they are now increasing their risk of COVID-19 exposure by going to the clinic every day in a time where most people are isolating themselves at home, and avoiding any kind of health care facility where symptomatic people will be. On the other hand of this example, we have people who are still struggling with their addictions, and they must still get their opioids some way, and so they must go to their dealers (Galea, 2002). People battling with opioid use disorders also tend to struggle with home security, and so tend to live in shelters, group homes or have unstable living conditions, this is another behavioral factor that increases their risk of COVID-19 exposure as they tend to be in more crowded spaces where safety measures are not as strictly enforced (Galea, 2002). When we look at the biological factors, we see that People with opioid use disorders tend to have an increased risk of infection due to substance abuse related immunosuppression, and opioid respiratory depression, this can lead to more severe COVID-19 infections in this group of people. Overall, due to these individual factors we see more COVID-19 infections in people with opioid use disorders as well as more hospitalizations and deaths (Galea, 2002).
A more unexpected side effect of the COVID –19 pandemic on opioid abuse is the loss of social networks for people in recovery and attempting to get better. Those struggling with substance abuse rely heavily on social networks, friends, and support group to keep them straight, and motivated (Galea, 2002). With the pandemic reducing this social aspect many recovering addicts are left with little choice but to turn to their old habits. The pandemic has also created this new double-edged sword where people with opioid use disorders who continue to gather and ignore the regulations are increasing their risk of COVID-19 exposure, however those who continue to use alone are at higher risk of overdose as they have no one around to administer naloxone in the case of an accidental overdose (Galea, 2002).
In addition to the loss of networks for support, Canadians overall have experienced a dramatic increase in depression and anxiety during the pandemic (Dozois, 2021) and so this increase in depression and decrease in support networks come together to create the perfect storm for a recovering addict.
At the community level it is the treatment centers and harm reduction efforts in place for people with opioid use disorders that have taken the largest hit by the pandemic. Despite their efforts to continue providing care to users, through delivery services and PPE being provided, there were still major limitations. One being delivery services were limited by the lack of permanent address for people with opioid use disorders and inadequate PPE in the clinics.
Another factor at the community level that increases the risk of COVID-19 infection for individuals with opioid use disorders is their exposure to areas that have high rates of COVID-19 such as shelters, clinics, and group homes.
The COVID-19 pandemic has even impacted people with opioid use disorders at the structural level as the restrictions created to prevent the spread of the virus required easing up on other restriction such as making methadone treatment more available to those in recovery (Leppla, 2020). This restriction may have reduced the person's risk of infection but has increased the risk for overdose or unsafe use, as patient were able to take the methadone home or have it delivered to their home, where there is no monitoring of the patient during administration.
With the help of the social-ecological model here we were able to examine the deep effects that the COVID-19 pandemic has had on the vulnerable population of individuals with opioid use disorders in Canada. From the examples that we looked at above we see that many factors have played a role at multiple level, for example we see how the social isolation that the pandemic has created has impacted people with opioid use disorders at an individual, social, and communal level. Social Isolation impacts the risk of substance abuse, risk of infection and risk of mortality among this vulnerable population due to personal behaviors, community disruption and social support decrease.
In conclusion, the social-ecological model has exposed the COVID-19 pandemic's deep effects on people with opioid use disorders by reaching deep within the various layers of the contributing factors of this issue.
References:
Carrière, G., Garner, R., & Sanmartin, C. (2021). Significant factors associated with problematic use of opioid pain relief medications among the household population, Canada, 2018. Health Reports, Vol. 32, No. 12, December 2021, 32(12), 13–26. https://doi.org/https://www.doi.org/10.25318/82-003-x202101200002-eng
Cowan, E., Khan, M.R., Shastry, S. et al. Conceptualizing the effects of the COVID-19 pandemic on people with opioid use disorder: an application of the social ecological model. Addict Sci Clin Pract 16, 4 (2021). https://doi.org/10.1186/s13722-020-00210-w
Dozois, D. J. A., & Mental Health Research Canada. (2021). Anxiety and depression in Canada during the COVID-19 pandemic: A national survey. Canadian Psychology / Psychologie canadienne, 62(1), 136–142. https://doi.org/10.1037/cap0000251
Galea S, Vlahov D. Social determinants and the health of drug users: socioeconomic status, homelessness, and incarceration. Public Health Rep. 2002;117 Suppl 1(Suppl 1):S135-45. PMID: 12435837; PMCID: PMC1913691.
Leppla, I. E., & Gross, M. S. (2020). Optimizing medication treatment of opioid use disorder during COVID-19 (SARS-COV-2). Journal of Addiction Medicine, 14(4). https://doi.org/10.1097/adm.0000000000000678