Tag: pandemic

10/12/21

Unintended Consequences of COVID-19

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On December 17, 2020, while the country’s attention was focused on the just-approved COVID vaccines, the CDC released a health advisory that noted substantial increases in drug overdose deaths across the U.S. Then, the report estimated that there were 81,230 drug overdose deaths in the 12-months ending in May 2020. This represented a worsening of the drug overdose epidemic in the U.S. and was the largest number of drug overdoses ever recorded for a 12-month time period. The CDC report said it appeared that drug overdose deaths accelerated during the COVID-19 pandemic. But then a new CDC report released in July of 2021 reported the number of overdose deaths had increased to 92,183 in December of 2020.

The July 2021 CDC report contains interactive figures showing the month-ending counts of overdose deaths by drug class and by states. From December of 2019 until December of 2020 California overdose deaths increased 45.9%; New York State, 37.3%; New York City, 36.6%. The states with the highest increases of overdose deaths were: Vermont, 57.6%; West Virginia, 55.6%; Kentucky, 53.7%; and South Carolina, 52.8%. The overall increase for the U.S. was 29.6%. See the July 2021 CDC report for more information.

A public health researcher for Brown University said to AP News this was a “staggering loss of human life.” While the nation was already struggling with a serious overdose epidemic, “COVID has greatly exacerbated the crisis.” Lockdowns and other restrictions during the pandemic made treatment harder to get. The increased deaths are most likely from people who were already struggling with addiction. Suspensions of evictions and extended unemployment benefits meant there was more money than usual to spend on drugs.

According to Shannon Monnat, a sociology professor at Syracuse University, what is really driving the surge in overdoses is an increasingly poisoned drug supply. “Nearly all of this increase is fentanyl contamination in some way. Heroin is contaminated. Cocaine is contaminated. Methamphetamine is contaminated.”

Reuters reported that during the pandemic, many drug programs were not able to operate. Restrictions meant therapy sessions were done by Zoom, which are not as impactful as in person face-to-face contact. Indirectly, pandemic lockdowns likely contributed to the increase in overdose deaths. The lockdowns intensified feelings of isolation, which is a factor in anxiety and depression, which leads to drug abuse. A health policy expert at John Hopkins Bloomberg School of Public Health estimated on a day-to-day basis, the U.S. is now seeing more overdose deaths than COVID-19 deaths.

In “Drug overdose deaths accelerating due to the pandemic,” the director of the CDC said the disruption of daily life from COVID-19 hit those with substance use disorder hard. “As we continue the fight to end this pandemic, it’s important to not lose sight of different groups being affected in other ways. We need to take care of people suffering from unintended consequences.” Again, we see the problems from fentanyl contamination. Opioids, primarily illegally manufactured fentanyl, were largely responsible for most of the overdose deaths. Synthetic opioid fatalities rose 38.4% from 2019 to 2020.

Recently, the American Medical Association noted a similar spike in overdose deaths driven by opioid deaths. The past president of the American Medical Association, Patrice Harris, warned of the necessity to continue to pay attention to health issues other than COVID. She said:

It is imperative that we continue to talk about other health issues that are impacting our nation . . . We are appropriately focused on COVID, it is still top of mind for most people, and it’s understandable that we can lose focus on other issues … but we still have to make sure we are focused on the overdose epidemic that we continue to experience in this country.

There was a study in in JAMA Network Open, “Trends in Drug Overdose Mortality in Ohio,” that looked at the overdose deaths in Ohio during the first seven months of the pandemic. Fatal overdoses rose sharply from the declaration of the pandemic on March 11th 2020 to the week of May 31st 2020, an increase of 70.6%. The initial spike in deaths was most pronounced for the youngest adults, those up to and including the age of 24. However, fatal overdoses followed a similar pattern in all age groups, including those 65 years and older. See the follow chart from the JAMA article.

Another study published in the Journal of Drug Issues assessed the relationships between COVID-19 stay-at-home orders and opioid overdoses in Pennsylvania. The authors said in an article for the Fix that Pennsylvania was one of the hardest hit states by the opioid epidemic. They found statistically significant increases in overdoses with heroin, fentanyl, fentanyl analogs or other synthetic opioids, pharmaceutical opioids and carfentanil. The researchers suggested in the Journal of Drug Issues that the observed increases were likely to be underestimates because of undercounts of monthly overdose incidents. They recommended these drug clsses be continuously monitored for changing patterns of use to help guide the most effective treatment interventions.

This analysis suggests that the onset of COVID-19 in the state of Pennsylvania, and resulting policy responses to mitigate infection, created unintended consequences for opioid overdose. These unforeseen outcomes obligate attention to how economic effects of the pandemic, coupled with mental health stress and other triggers for addiction, complicate and undermine patterns of opioid use and misuse, and emphasize the need for opioid use to be addressed alongside efforts to mitigate and manage COVID-19 infection.

It was pointed out how the economic recession associated with the pandemic undermined housing policy and access, “which will have lingering effects for social cohesion, access to medical care, and consistent routines critical for addiction management.” Percentages of fatal versus nonfatal overdoses remained relatively constant throughout the study at 16-17%. Heroin accounted for the largest percent (65%) of the total reported opioid-related overdose cases, followed by fentanyl (14%) and the unknown drug class (14%). “Increased mental health stress, social isolation, and economic uncertainty will likely continue to affect those most vulnerable to addiction and relapse.”

The double impact of COVID-19 and drug overdoses induced a drop in life expectancy for 2020. The CDC reported that life expectancy at birth for 2020 was 77.3 years, a decrease of 1.5 years from 78.8 in 2019. This was the lowest it has been since 2003. The decline in life expectancy was primarily due to COVID-19 (73.8% of the negative effect), unintentional injuries (11.2%), and homicide (3.1%). “Increases in unintentional injury deaths in 2020 were largely driven by drug overdose deaths.”

“The Leading Causes of Death in the US for 2020,” published in JAMA, found that COVID-19 was the third leading cause-of-death after heart disease and cancer. There were substantial increases from 2019 to 2020 for several leading causes. Heart disease deaths increased by 4.8%; unintentional injury by 11.1%; Alzheimer disease by 9.8%; and diabetes by 15.4%. Early estimates of life expectancy at birth for January 2020 to June 2020 showed declines not seen since World War II. See the following table taken from “The Leading Causes of Death in the US for 2020.”

The influence of the pandemic on the opioid epidemic has not gone unnoticed by the White House. In March of 2021, President Biden released a Statement of Drug Policy Priorities that said illicitly manufactured fentanyl and synthetic opioids other than methadone (SOOTM) have been the main influence behind the increase. However, overdose deaths from cocaine and other psychostimulants like methamphetamine have also risen. “New data suggest that COVID-19 has exacerbated the epidemic.” The American Rescue Plan, signed into law in March of 2021, set the following drug policy priorities for the administration:

  • Expanding access to evidence-based treatment;
  • Advancing racial equity issues in our approach to drug policy;
  • Enhancing evidence-based harm reduction efforts;
  • Supporting evidence-based prevention efforts to reduce youth substance use;
  • Reducing the supply of illicit substances; Advancing recovery-ready workplaces and expanding the addiction workforce; and
  • Expanding access to recovery support services.

Concern over the entwined consequences of the COVID-19 pandemic and the opioid epidemic exist beyond the US. In an opinion article for the BMJ, Ian Hamilton noted how the COVID-19 pandemic has amplified inequalities such as poverty, unemployment, poor housing and homelessness in the UK. He said these inequalities have been felt most acutely felt by those from the lowest socioeconomic groups. “Until effective ways of reducing social inequality are implemented, the best that we can hope for is timely specialist support for those developing drug related problems, such as dependency.” He concluded that problem drug use is an issue that will be with us for years and we need to build a workforce to meet the demand and ensure that these avoidable fatalities “are just that—avoided.”

08/24/21

Homelessness and COVID-19

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The findings for the 2020 Annual Homeless Assessment Report (AHAR) to Congress were published in January of 2021 and it contained some disturbing information. In a single night in 2020, approximately 580,000 people experienced homelessness in the U.S. Sixty-one percent stayed in sheltered locations, while 39% were “living rough” on the street, in abandoned buildings, or wherever they could pitch a tent. For the fourth year in a row, homelessness increased nationwide. The number of people who were homeless increased by 2% between 2019 and 2020. Almost 60% experienced homelessness in an urban area and 53% of all unsheltered people were counted in the nation’s 50 largest cities.

The 2020 AHAR count reflects a 7% increase of individuals staying outdoors with the number of sheltered individuals remained largely unchanged, with a 0.6% decline. “Increases in the unsheltered population occurred across all geographic categories.” The key factor was a sizeable increase (21%) in the number of unsheltered people with chronic patterns of homelessness. This means being homeless for more four times in the past 3 years, or continuously homeless for at least one year.

Unsheltered families with children also increased for the first time since data collection began.  In 2020, just under 172,000 people in families with children were homeless. While most of these homeless families (90%) were in sheltered locations, there was an increase of unsheltered families by 13%.

People identifying as black or African American accounted for 39 percent of all people experiencing homelessness and 53 percent of people experiencing homelessness as members of families with children but are 12 percent of the total U.S. population. Together, American Indian, Alaska Native, Pacific Islander and Native Hawaiian populations account for one percent of the U.S. population, but five percent of the homeless population and seven percent of the unsheltered population. In contrast, 48 percent of all people experiencing homelessness were white compared with 74 percent of the U.S. population. People identifying as Hispanic or Latino (who can be of any race) are about 23 percent of the homeless population but only 16 percent of the population overall. [See the following graphic]

Psychological Services published a special issue on homelessness in 2017, “Homelessness as a Public Mental Health and Social Problem.” The authors said after deinstitutionalization in the 1960s, thousands of patients moved out of mental institutions into community-based care became homeless. Under the Bush administration, the federal government began requiring communities to conduct and report annual point-in-time counts of homeless individuals to track the scope of the problem. An epidemiological study found that 4.2% of Americans have experienced homelessness for over one month sometime in their lives and 1.5% experienced homelessness in the past year. “From both epidemiological studies and PIT counts, it is clear that homelessness remains a major problem in the country.”

Risk factors that are strongly associated with homelessness include adverse childhood experiences, mental illness and substance abuse. Most research on homelessness has focused on homeless, single, middle-aged men. “But there is increasing study on the growing number of homeless women and families who may have different needs.”

While there have been efforts to provide housing for the homeless or those at risk of homelessness, such as the HUD Exchange, many people who enter supported housing return to homelessness. Comprehensive primary care and behavioral health services have been intentionally integrated into many homeless organizations. Unfortunately, there continues to be limited access to mental health and substance use services available for many in supportive housing.

Nan Roman, the President and CEO of the National Alliance to End Homelessness, said the 2020 report gave a deeply troubling picture of homelessness in the U.S. on the eve of the COVID-19 pandemic. She said these results show an under-resourced system supposed to meet the needs of people at risk of and experiencing homelessness. While the Alliance was encouraged by the investments federal leaders have made in homelessness and housing resources during the pandemic, “the numbers make it clear that these investments are tragically overdue.”

COVID-19 and Homelessness

The pandemic was a major disruption for homeless system operations. The yearly Point-in-Time (PIT) survey for 2021 of persons who are homeless received new guidance that allowed for flexibility when counting people who were unsheltered. There were allowances made for observation-only counts, samplings, abbreviated surveys, and longer times permitted for the process. There was even a report published to guide those conducting a street-based PIT count that maintained the health and safety of those performing the count as well as those individuals who were homeless during the COVID-19 pandemic. See the National Alliance to End Homelessness for a webinar on “Conducting the 2021 PIT in the Age of COVID-19” and other resources.

In “COVID-19 and the State of Homelessness,” the National Alliance to End Homelessness reported how the pandemic significantly complicated efforts to end homelessness. One expert predicted there would be an increase of 250,000 new people homeless over the course of the year. Consider that before the pandemic, systems were not able to serve everyone experiencing homelessness. “Providers only had capacity to offer an emergency shelter bed to 1 in 2 individuals experiencing homelessness in 2019.” Limited resources resulted in overcrowded shelters and social distancing was difficult, if not impossible. “Unsheltered people lack consistent access to water, soap, and hand sanitizers that help prevent the spread of the virus.”

In “People experiencing homelessness: Their potential exposure to COVID-19,” Lima et al noted how many homeless people already have a diminished health condition, higher rates of chronic illnesses or compromised immune systems, “all of which are risk factors for developing a more serious manifestation of the coronavirus infection.” Those suffering from mental illness potentially struggle recognizing and responding to threats of infection. They also have less access to health care providers who could order diagnostic testing, and if confirmed, isolate them from others in coordination with local. Health departments.

In “Data for: People experiencing homelessness: Their potential exposure to COVID-19,” Neto et al said homeless organizations warned the coronavirus could cause catastrophic harm to unhoused communities. People who sleep in shelters or on the streets already have a lower life expectancy, as well as struggles with addiction and underlying health conditions that put them at greater risk should they develop the virus. Experts say the chronically ill homeless have a unique vulnerability to the coronavirus. “If exposed, people experiencing homelessness might be more susceptible to illness or death due to the prevalence of underlying physical and mental medical conditions and a lack of reliable and affordable health care.”

People experiencing homelessness are increasingly older and sicker. Many have underlying health conditions but lack access to primary-care physicians or preventive health screenings. They struggle to find public bathrooms to maintain their basic hygiene. Those who live in tent encampments or crowded shelters might be unable to keep their distance from others or self-isolate if they show symptoms.

A CDC Morbidity and Mortality Weekly Report (MMWR) for May 1, 2020 assessed the infection prevalence of COVID in five homeless shelters for residents and staff members in four U.S. cities—Boston, San Francisco, Seattle and Atlanta. They found that when COVID clusters (two or more cases in the preceding two weeks) occurred, “high proportions of residents and staff members had positive test results for SARS-CoV-2.” Community incidence (the average number of reported cases in the count per 100,000 persons per day during the testing period) varied, with Boston having the highest incidence and San Francisco the lowest.

To protect homeless shelter residents and staff members, CDC recommends that homeless service providers implement recommended infection control practices, apply social distancing measures including ensuring residents’ heads are at least 6 feet (2 meters) apart while sleeping, and promote use of cloth face coverings among all residents. These measures become especially important once ongoing COVID-19 transmission is identified within communities where shelters are located. Given the high proportion of positive tests in the shelters with identified clusters and evidence for presymptomatic and asymptomatic transmission of SARS-CoV-2, testing of all residents and staff members regardless of symptoms at shelters where clusters have been detected should be considered. If testing is easily accessible, regular testing in shelters before identifying clusters should also be considered. Testing all persons can facilitate isolation of those who are infected to minimize ongoing transmission in these settings.

In the Journal of Internal Medicine, “Addressing the COVID-19 Pandemic Among Persons Experiencing Homelessness,” Barocas et al noted that at least 1 in 5 of 13.8 million adults in rental housing say they are behind in rent. Coupled with an end to the federal eviction moratorium, this could mean an increase of more than 2.7 million newly homeless or unstably housed people in the U.S. Medical conditions such as heart and lung disease disproportionately effect the unsheltered and place them at risk for high morbidity and mortality from COVID-19. “A sudden increase in the number of people without housing or infections in the existing homeless population combined with COVID-19’s current strain on our health care system will greatly reduce our ability to care for this vulnerable population.”

Barocas et al recommended four changes. First, immediate improvements to and expansion of the national shelter system are needed. They believe the situation will become more dire if the federal eviction moratorium is not extended. Federal and state relief plans need to allocate funds for more shelters that are properly staffed and resourced.

Second, there needs to be an improvement with ongoing surveillance to prevent outbreaks among homeless individuals. One of the suggestions was to increase the use of waste water-based epidemiology, the practice measuring biomarkers in wastewater. “Active surveillance of municipal wastewater mapped to homeless shelters could be used to identify insipient outbreaks.” This seems to be a potentially low-cost COVID-19 surveillance method that could be used in low-resource settings such as shelters.

The third recommendation is to develop a universal approach to testing and contact tracing. A lack of testing supplies has led to a disproportionate allocation of tests across society, with more socially disadvantaged individuals encountering challenges when accessing tests. New methods of contact tracing rely on the assumption of stable housing, secure internet, or cell phones with application abilities. While most homeless people own or have access to a mobile phone, they often do not have smartphones that support app-based programs. “We need a dedicated investment in contact tracing in this population; otherwise, expanded testing will be for naught.”

The fourth and final recommendation is to provide places for persons with inadequate housing and without a permanent home to isolate once they are diagnosed with COVID-19 and do not meet criteria for skilled nursing care. Shelters are usually not equipped to convert entire floors into quarantine units. Innovative approaches to help this vulnerable population attain a space to recuperate and limit the spread of COVID-19, such as using hotels or college dormitories for temporary housing, were suggested.

As a nation, we have, thus far, done little to protect persons experiencing homelessness from COVID-19 disease. In the short term, we need funding for the expansion and improvement of our shelter systems, development and implementation of innovative strategies for active surveillance of outbreaks, rapid deployment of more COVID-19 tests coupled with a comprehensive contact tracing strategy, and expanded space for recuperation for this population. For a long-term effect, we need to extend the eviction moratoria and to use the pandemic as an opportunity to expand affordable and low-income housing and establish pathways to regain housing. Continued neglect of this vulnerable population will most certainly lead to considerable strain on the already stretched healthcare system during times of SARS-CoV-2 surge, increased transmission and mortality from SARS-CoV-2, and a widening health disparity gap.

The 2021 Annual Homeless Assessment Report will not be completed and published until 2022. The 2020 AHAR was published in March of 2021 and already showed a 2% increase from 2019 to 2020. What will the 2021 AHAR reveal?

04/7/20

Serving Others During the Pandemic

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Traditionally Christians celebrate Easter together in local church services, sometimes with pageantry composed specially for the occasion, but not this year. Following the recommendations of health officials against social gatherings, the COVID-19 pandemic has led to silent, empty buildings or a skeleton crew of individuals presenting a worship service to an empty church that congregants watch live on YouTube or some other media streaming service. There are some who are resistant to social distancing and stay at home orders, like the pastor of a megachurch in Tampa Florida who was arrested for holding public worship services. But is this really the best way to demonstrate your faith in the face of the COVID-19 pandemic? We can look to the past and gain insight from how the followers of Christ acted in times of plague.

In 166 AD triumphant Roman legions returned from their victory over the Parthians in Armenia, bringing with them an epidemic that would ravage the Roman Empire for the next twenty years. Known as the Antonine Plague, it would alter the landscape of the Roman world and kill at least 7 to 10 percent of the population. Lyman Stone said in “Christianity Has Been Handling Epidemics for 2000 Years,” some historians have also suggested it contributed to the spread of Christianity, as “Christians cared for the sick and offered a spiritual model whereby plagues were not the work of angry and capricious deities but the product of a broken Creation in revolt against a loving God.” But it was the Plague of Cyprian (250-270) that really triggered an explosive growth of Christianity.

That plague caused political, military, economic and religious upheaval within the Roman Empire. At its height, it claimed an estimated 5,000 deaths per day in Rome. The outbreak claimed the lives of two emperors: Hostilian (251 AD) and Claudius II Gothicus (270 AD). It also decimated the ranks of the military. Populations in the countryside fled to the cities. “The abandonment of the fields along with the deaths of farmers who remained caused the collapse of agriculture production.”

The illness claimed the lives of emperors and pagans who could offer no explanation for the cause of the plague or suggestions for how to prevent further illness much less actions for curing the sick and dying. Christians played an active role in caring for the ill as well as actively providing care in the burial of the dead. Those Christians who themselves perished from the illness claimed martyrdom while offering non-believers who would convert the possibility of rewards in the Christian afterlife.

Pagans believing the plague had a supernatural origin, believed the gods were punishing them. Dionysius, the bishop of Alexandria, said “the heathen” deserted those who began to be sick, and fled from their close friends. Not so the Christians:

Most of our brother Christians showed unbounded love and loyalty, never sparing themselves and thinking only of one another. Heedless of danger, they took charge of the sick, attending to their every need and ministering to them in Christ, and with them departed this life serenely happy; for they were infected by others with the disease, drawing on themselves the sickness of their neighbors and cheerfully accepting their pains. Many, in nursing and curing others, transferred their death to themselves and died in their stead.

Writing for The Gospel Coalition, Glen Scrivner said Christian death rates during the Plague of Cyprian were significantly lower than the general population. The mutual love and care meant those who provided care were at a higher risk of infection, but those who were infected had better survival rates. When the plague had swept through the Empire, Christians were stronger as a proportion of society since proportionally more of them survived. “They also had more resilience because they had a robust hope in the face of death.”

In 1527, Martin Luther refused calls to leave Wittenberg during an outbreak of the bubonic plague, staying rather to care for the sick. This refusal cost him the life of his daughter, Elizabeth. He wrote a tract reflecting on what a Christian should do, “Whether Christians Should Flee the Plague.” He called for Christian doctors to remain at their hospitals; Christians who hold public office should continue in their service. “Preachers and pastors should likewise remain steadfast before the peril of death.”

Where no such emergency exists and where enough people are available for nursing and taking care of the sick, and where, voluntarily or by orders, those who are weak in faith make provision so that there is no need for additional helpers, or where the sick do not want them and have refused their services, I judge that they have an equal choice either to flee or to remain.

Applying this stance to the current situation, Lyman Stone said it is better for Christians to die serving our neighbor than surrounded by a pile of masks we never had a chance to use. If we care for each other, if we share masks and hand soap and canned foods, if we truly are our brother’s keeper, we may actually help flatten the COVID-19 surge. “The Christian motive for hygiene and sanitation does not arise in self-preservation but in an ethic of service to our neighbor. We wish to care for the afflicted, which first and foremost means not infecting the healthy.”

And there are ways Christians can care, and are caring for the sick and loving their neighbor in this time. Christianity Today noted where churches are dropping off groceries or supplies to those in need. Another church in a farming community provides fresh eggs, fruit and vegetables for those in need. An unemployed young woman was given toilet paper purchased by a store employee when she discovered the store was out. Others provide care and meals for the medical workers and first responders. Another church recruited childcare workers for healthcare workers.

The concluding words of Ed Stetzer for Christianity Today exemplify the heart of those Christians who ministered during the Antoine Plague and the Plague of Cyprian. Martin Luther cries, “Amen!” to these words: “We don’t know a lot about the future. But we know the Lord does, and he cares. And in the meantime, we are called to glorify him by serving others.” So, what can you do during the COVID-19 pandemic?