The coronavirus pandemic might have several interesting side effects, including a rise in tele-work or distance education, and a noted decrease in greenhouse gas emissions. One that hasn't received much attention so far is its effect on the pre-existing U.S. opioid epidemic. Many possible effects of COVID-19 on patients with opioid use disorders are negative ones. But colleagues in opioid treatment programs have noticed a marked increase in the number of people seeing help for opioid use disorders since the coronavirus pandemic began. There could be several reasons for this shift.
First, it may be more difficult for people to get opioids during social distancing and with stay-at-home orders in effect. The largest single source of opioids in the U.S. is still prescription medication, and non-urgent medical care is limited at the moment. Telehealth visits are often available, but perhaps patients find it more difficult to ask their healthcare providers for opioids when they aren't meeting face-to-face, or perhaps providers find it easier to say no. Non-prescription opioids such as heroin are generally brought into the U.S. from abroad, initially from Columbia and more recently from Mexico. People's access to heroin therefore may have been hindered by the closing of international borders. Opioid withdrawal happens quickly and is severe, so people who can't get opioids from their usual sources might turn to treatment using approved medications to reduce craving and block opioid effects.
A second possible reason for the uptick in treatment seeking might be interpersonal in nature. People who use opioids often have ways of keeping their habits secret from their families or other important social connections. When stay-at-home orders limited mobility, schools and workplaces closed, and non-essential businesses shuttered, most people simply had fewer plausible places to go during the day. This could have limited their ability to acquire opioids without others finding out. And if they did have an adequate supply, they might have found it more difficult to use opioids when other people in their household were home all the time too. Finally, when people spend more time together they might notice more idiosyncrasies in their housemates' behavior, which might lead to clues about a previously concealed habit of drug use. Social pressure to get help might therefore be greater.
Both of these potential explanations for increased opioid treatment are connected to environmental changes and social pressure, external forces that operate at the level of the Intuitive mind. But we shouldn't discount the idea that the strong societal changes produced by COVID-19 simply led people to re-examine their lives, a more Narrative explanation for increased treatment-seeking. In a 2015 book titled The Biology of Desire, neuroscientist Dr. Marc Lewis argues that most people eventually stop using substances as a matter of choice, when the costs of using outweigh the benefits. Dr. Lewis suggests that addictions develop in stages, each with its own distinct neurocognitive features:
- Stage 1 involves planned and intentional pursuit of substances, initiated by the Narrative mind in the prefrontal cortex (PFC, and particularly the ventromedial PFC areas that mentally simulate future actions). Dr. Lewis says that in this stage, "desire focuses attention," and attention is linked to the activity of the Narrative mind.
- In Stage 2, the pursuit of substances transitions to the Intuitive mind. Dr. Lewis cites the well-established neurological principle that "what fires together wires together" to explain the learned associations that develop between drug-related activities and the effects of the drug itself. Eventually, planning activities become linked to rewarding sensations that are generated by lower-brain areas like the nucleus accumbens. At this point, even thinking about drug use or encountering drug-related cues can induce strong cravings and pleasurable feelings in the absence of the actual drug, and drug-seeking behavior is tied to activity in a less-conscious part of the PFC, the orbitofrontal cortex of the brain. Drug use at this stage is "impulsive," and creates a self-sustaining feedback loop that leads to more and more use despite consequences.
- In Stage 3, the absence of substances creates negative emotions, and the purpose of use becomes less about gaining pleasure and more about avoiding pain. Activity in the amygdala and hypothalamus increases when drugs are not used, triggering negative feelings that may resemble those caused by past trauma or negative experiences. Because the rewarding effects of substances quickly fade, a person's use at this stage shifts from "impulsive" to "compulsive" and is focused more and more on avoiding suffering associated with non-use. The reduction of discomfort may provide even stronger motivation than the initial attraction to drugs' effects.
- Finally, in Stage 4, the whole cycle moves outside of consciousness. At this point, drug use is almost entirely initiated by the Intuitive mind. A normal process called "synaptic pruning" deletes some of the prior neural connections between the ventromedial PFC and the midbrain areas that now govern addictive behavior, so it becomes harder and harder to exert conscious control. People may find themselves using without any conscious decision to do so, or even in defiance of a conscious intention. Paradoxically, the harder they try not to use at this stage, the more quickly they may deplete their reservoir of conscious attention or "willpower," and the easier drug use may become. Because "additions are pursued at the expense of other goals," people often experience a decline in interpersonal relationships, lose employment, face legal consequences, or have other hardships at this point. This makes it even harder to experience pleasure in life from other sources, and makes addictive behavior a more and more appealing alternative to the Intuitive system. To the extent that the Narrative mind is involved at all, it is often engaged in silently berating oneself for continued use and its consequences.
What is needed to break this downward cycle? Unfortunately, Dr. Lewis reports, it often takes a serious external event like imprisonment, job loss, divorce, or other consequences to make a person re-examine their behavior. The severity of consequences leads to a re-engagement of the Narrative mind, which begins to construct a different story in which drug use leads to horrible loss instead of drug use leading to pleasure or relief. That opens the door to change. Importantly, this is not about "trying harder," it is about thinking differently -- developing a new narrative about drug use that replaces the old, dysfunctional one. The person essentially needs to stop agreeing with the idea that drugs offer benefits, however much their body might still crave them.
Medication for opioid use disorders (MOUD) can help in this process by making opioids themselves less rewarding. Some of these medications block the pain-relieving effects of opioids, some provide a milder form of relief, and some do both. Treatment can also help to break the cycle of "ego depletion" in which people struggle against using, then relapse, then engage in self-recrimination, until the whole process starts over again. Instead, their conscious attention is freed to pay attention to the negative consequences of use and to develop new narratives about what a substance-free life might look like. The cognitive process takes time, and is separate from the physiological changes produced by treatment; this is why effective MOUD approaches involve counseling as well as medications.
The COVID-19 pandemic has led to valid concerns about whether treatment will be interrupted for people with opioid use disorders who need it, and some people might be at greater risk for relapse as a result. But on the positive side, a great number of new patients seem to be seeking help, and for these people it's entirely possible that the changes will stick even after the immediate crisis has passed. Dr. Lewis argues that once you have experienced the power of an alternate narrative, and begin to get your life back from the hopelessness of long-term addiction, it will be easier to resist temptation in the future. In fact, your brain itself will look different than it did when you were in the depths of the addictive cycle. Further research is needed and people should continue to receive support because addictions are powerful and hard to overcome. But the increase in treatment seeking over recent weeks may be a sign of hope for one epidemic, even as we struggle with a different one.
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