We spoke to Brandon Marshall, Associate Professor of Epidemiology, about the opioid epidemic within the pandemic.
Epidemiology is the study of disease from a population perspective. As an epidemiologist, the disease you have focused on most is the opioid epidemic. Is studying a drug epidemic the same as studying, say, a measles epidemic, for example? How is it different?
Many of the tools we use to study drug epidemics are similar to those used to explore other diseases, like measles. Take for example the host-agent-environment framework, which helps us map out what factors cause and exacerbate disease. When it comes to the opioid crisis, we can think of the ‘host’ as patients who take opioid medications and people who use other types of opioids, like heroin. The ‘agent’ is the opioid product. The ‘environment,’ speaking broadly, is the policy, social, or immediate context in which drug use takes place. All three factors come together, often in complex ways, to either increase or mitigate harms, like HIV infection and overdose.
You’re Canadian and received your training at the University of British Columbia. How does your perspective, coming from a country that guarantees hospital access and physician services, impact your approach to studying the opioid epidemic?
Being Canadian has informed my approach to studying the overdose crisis in a number of ways. Take for example the for-profit nature of much of American health care. What we know from decades of research is that any health care system in which a primary goal of some actors is to maximize profit can also have the unintended consequence of maximizing harms to patients. In the United States, highly aggressive marketing by manufacturers of opioids resulted in rapid increases in opioid prescribing, and near exponential growth in overdose deaths over the past two decades.
We published studies last year showing that even small-dollar payments to physicians, like free meals at marketing events, increases opioid prescribing, which in turn is associated with higher overdose deaths at a county-level. As a Canadian, my view is that health is an inherent human right. Even the most marginalized in our society, including people who use drugs, deserve access to high-quality, evidence-based treatment and care, regardless of one’s ability to pay. The overdose crisis is just one example of what happens when profit takes precedence over the health and safety of patients.
Do you think COVID-19 is creating space in the United States for more open-minded consideration of our health care model, especially in the face of the obvious health disparities suffered by Black and Latino Americans during the pandemic?
In the addiction treatment arena, the COVID-19 pandemic has forced federal and state regulators to implement a number of policies that may increase equitable access to treatment. Take for example relaxed federal rules around buprenorphine (an FDA approved medication for opioid use disorder), which can now be initiated over telemedicine versus mandating an in-person assessment. My research team recently demonstrated that buprenorphine is less readily available in segregated minority communities across the U.S. So these innovations in telemedicine and federal policy changes are important, and could help address the massive racial/ethnic disparities we see in access to evidence-based addiction treatment.
Heavily racialized responses to drug-related problems, along with huge racial inequities in access to prevention, treatment, and harm reduction services, are among the biggest challenges to addressing the overdose crisis at a national level. So if the pandemic is finally forcing many of us to have an honest look at racist policies and their detrimental health effects, then that is a good thing.
You serve on Governor Gina Raimondo’s Overdose Prevention Task Force. How was Rhode Island doing combating opioid overdose before the pandemic?
Rhode Island was an early leader in responding to the overdose crisis, implementing a number of policies and programs that helped us bring down the number of overdose deaths from their peak in 2016. But single digit decreases in overdose deaths is not enough. And although overdoses started spiking during the COVID-19 pandemic, they had already started ticking up again late in 2019. We have much more work to do, and need to start taking an honest look at what’s working, what’s not working, and listening to the voices of people who use drugs and those in recovery to take bolder steps to address this massive public health crisis.
What have coronavirus lockdowns been like for people with opioid dependence? What are the added risks?
This is a perilous time for people with opioid use disorder. The pandemic is resulting in massive stressors—like isolation, unemployment, and loss of housing—which we know increase the risk of overdose among those using, and a return to drug use among persons in recovery. But our treatment and recovery communities are rising to the occasion, offering online support groups, doing street outreach, and hosting socially distanced events, like rallies for recovery. If you or someone you know is struggling with alcohol or drug use during COVID-19, know that resources are available. In response to the pandemic, my research team created a new page on PreventOverdoseRI, preventoverdoseri.org/covid-19, with local and state resources available here in Rhode Island.
What has been the overall impact, locally and nationally, of the coronavirus epidemic on the opioid epidemic?
The COVID-19 pandemic is like a series of lightning storms accelerating a national wildfire of overdose and addiction. In many states, overdose deaths are up by more than 30% since the same time last year. However, at a national level, overdoses started increasing before the pandemic, in the summer and fall of 2019. So bold public health action, starting with a massive influx of federal funds, but also serious policy changes, are going to be needed to address the overdose crisis, both during COVID-19 and after the virus has dissipated.