When North Carolina was besieged by Covid-19, Louise Vincent nearly died—but it wasn’t the virus that got almost her. She spent months shuffling in and out of clinics, struggling to get appropriate medical treatment, and eventually was poisoned when she attempted to medicate herself in desperation. The medicine she needed was methadone, which is used to help people manage opioid use disorder. She should have been able to access it easily; Vincent helps run the North Carolina Urban Survivors Union, a drug users’ advocacy and harm reduction group.

But Vincent ran into trouble with her usual methadone clinic, in part because she had missed appointments because of traveling for work.

“They wouldn’t let me come back and said I had failed at their program,” she told me.

She tried to switch to another local methadone provider, but she said it limited her to inadequate doses because of other medications she was taking. During her months-long struggle to get the drug she needed to function, she ended up going back to street heroin.

“I was trying to use as little as possible just to get through the day,” she recalled. But even her limited exposure to the street supply led to frightening side effects. “[The drug] caused skin lesions, all sorts of stuff.… It was horrible. I didn’t know what was wrong with me. And the end result was that I was almost dead with a hemoglobin of 2.9”—a dangerously low level caused by the substance she later discovered had been mixed in: a horse tranquilizer called Xylazine.

The preventable crisis that befell Vincent, which ended with a hospitalization that she described as traumatic, reflects a public health crisis that has quietly metastasized. While much of the attention of public health authorities last year was on the rising infection rates and death toll of Covid-19, another disturbing trend—a spike in overdose deaths during the first months of the pandemic—revealed a health crisis unfolding in the pandemic’s shadow: People are dying at record rates from an epidemic that has claimed about 450,000 lives over the past two decades.

While the pandemic shut down swaths of the economy and put millions out of work, people with opioid use disorder—including both users of prescription painkillers and people who inject street heroin—were bombarded with social stressors from social isolation to barriers to treatment as providers shut their doors. Harm reduction advocates are now asking the Biden administration to overhaul how the government deals with the opioid overdose crisis.

According to the Centers for Disease Control and Prevention, from October 2019 to September 2020 drug overdose deaths nationwide rose 29 percent over the previous year, the vast majority from opioids, which killed an estimated 66,813 people. In the initial months of lockdown, according to the Commonwealth Fund, monthly opioid overdose deaths soared to more than 7,200 last May, up from just over 4,000 deaths a year earlier. Racial disparities have persisted through the pandemic: From 2018 to 2020, overdose deaths rose many times faster for Black and Latinx people than for white users.

The increase is fueled in part by the growing prevalence of fentanyl, a particularly lethal synthetic opioid that is often mixed in with other drugs. The federal government has reported a geographic expansion of the fentanyl market, moving west of the Missouri River, where it was not prevalent prior to 2018.

Some harm reduction organizations provide fentanyl test strips to help screen unregulated drugs—and the Biden administration recently lifted a ban on using federal funds to purchase the testing system. But fentanyl is already spreading much faster than users or service providers can handle. According to a recent study by Stanford researchers, available data for 2020 showed a 63 percent spike in fentanyl mortality over the previous year.

The pandemic did bring some limited improvements in access to medication-assisted treatment (MAT), or treatment drugs prescribed through a regulated program designed to keep people off illicit drugs like heroin, usually in the form of buprenorphine and methadone. Shortly after the onset of the pandemic, the Trump administration lifted a requirement that an in-person doctor’s visit would be needed to prescribe buprenorphine, allowing people to use telehealth appointments instead. It also issued a guidance to methadone providers, advising them to provide up to a month’s supply of MAT doses at a time to stable users, avoiding the usual mandatory daily check-in at the clinic.

Nonetheless, many providers have not followed the new take-home guidelines, according to Urban Survivors Union’s surveys of treatment providers. One respondent in Kentucky said, “They asked me to come in on a day when I was sick with possible COVID-19. They suspended all my 3-weeks COVID-19 take homes and made me come to the clinic daily when I was too sick to come in. They have very little regard for my health. I am [over 60] years old.”

Silvana Mazzella, associate director of the public health and social services nonprofit Prevention Point Philadelphia, said that while the ability to access treatment remotely was a breakthrough, videoconferencing did not work as well for another critical service for vulnerable clients: mental health care. Since many clinics have closed their normal meeting spaces, she said, “for people who are unsheltered or transient, or don’t have [mobile phone access] all the time, this is a real problem. And all of these things contribute to a real change in the landscape and in risk of mortality and disconnection from services.”

Turning a Corner

Though the pandemic has aggravated the opioid overdose epidemic, the Biden administration has signaled a shift in Washington’s approach to the crisis. The massive American Rescue Plan stimulus bill includes a tranche of $30 million dedicated to harm reduction services. That’s a tiny fraction of the $7.6 billion the federal government spent on the opioid overdose crisis in fiscal year 2019. But Beth Connolly, project director of the Substance Use Prevention and Treatment Initiative at Pew Charitable Trusts, said that as the first explicitly targeted federal funding for harm reduction, “it really is a message and a step in the right direction.”

The harm reduction provision in the relief package could boost federal support for syringe service programs (SSPs), which provide clean needles to injection drug users and are highly effective in preventing disease transmission. Amid the rising opioid death toll and associated spread of hepatitis infections, the number of states with legislation directly authorizing needle exchange nearly doubled between 2014 and 2019 to 31 and Washington, D.C. But many state governments have failed to adequately fund the programs, and in some cases, state and local authorities have hampered their work with onerous federal and local restrictions on syringe distribution and policies that criminalize the carrying of unauthorized needles. Meanwhile, the number of SSPs nationwide declined during the pandemic, from an estimated 406 in 2020 to 378 in 2021, and the existing programs serve only a tiny portion of the demand for clean needles.

Harm reduction experts also want to see an expansion of access to Naloxone, an overdose-reversal drug that is delivered easily through a simple nasal pump. While Naloxone is legal to use in all states, some states restrict who can administer it, for example by barring distribution by “lay people” who are not licensed medical personnel.

Congress is weighing legislation to expand MAT access nationwide. Many public health and drug-policy reform organizations have pushed for the Mainstreaming Addiction Treatment (MAT) Act, which would eliminate a requirement that doctors obtain a special credential known as an X-waiver in order to prescribe buprenorphine. Introduced earlier this year by Representative Paul Tonko (D-N.Y.) and Senator Maggie Hassan (D-N.H.), the measure could save an estimated 30,000 lives per year, according to the advocacy group End SUD (Substance Use Disorder).

A parallel bill, the Medicaid Reentry Act, would connect incarcerated people to Medicaid services in the month prior to reentering the community, to avoid a gap in health care coverage that is linked to high overdose rates post-incarceration. The days following release are extremely precarious for people with opioid use disorder, as they often have a reduced tolerance to the drug after being locked up; ensuring that they have medical care post-reentry could stave off fatal overdoses.

“What’s so critical for any disease is early intervention,” said Courtney Hunter of the advocacy network Shatterproof. “And what we’re doing now is we’re treating addiction at stage four—in emergency rooms, after somebody’s overdosed.… Nobody’s treating addiction at stage one, and that’s what we need to be doing to have better outcomes and to save lives.”

Settlements

On top of federal and state funding for opioid treatment and overdose prevention, state lawmakers are anticipating an injection of funds from settlements in lawsuits filed against top pharmaceutical companies and distributors. Dozens of state attorneys general targeted these companies, including Purdue, AmerisourceBergen and Johnson and Johnson, for aggressively and recklessly marketing prescription opioids into communities.

But advocates are concerned that states might divert settlement funds away from their intended purposes, such as compensating the families of overdose victims or funding treatment and prevention. (They point to the state funds yielded from the tobacco industry settlements of the late 1990s, of which only a small percentage was invested in anti-smoking programs.)

Researchers with the Johns Hopkins Bloomberg School of Public Health, in conjunction with a coalition of public health advocacy groups like American Medical Association and AIDS United, has issued a set of principles for spending the settlement money, demanding that state and local authorities establish dedicated funds for evidence-based prevention, treatment, and recovery measures. The coalition also emphasizes the need to use the funds to address racial inequities in the opioid overdose crisis, in light of vastly lower rates of using MAT among Blacks compared to whites and disproportionate criminalization of drug use for Black communities.

Harvard health economist Richard Frank said state governments should avoid plowing new funds into legacy programs that are ineffective, such as inpatient hospital-based detox that is not connected to community-based treatment, which often leaves people even more prone to overdose in the future. “Just like in much of medicine, we pay for things we’ve always paid for, and we don’t incorporate what works into the way we pay as much as we might.” But stigma and political resistance has hampered efforts to expand MAT programs, he added. “There is a philosophy out there that says, ‘Why would you replace one addiction with another addiction?’”

Decriminalization

Only about 29 percent of people with opioid use disorders receive specialty drug treatment. Countless others who never make it to treatment end up behind bars. Tom Smarch recalled how his family was priced out of treatment when his son was thrown into jail at 18. “There was no other place to go,” said Smarch, who has since become an advocate for drug policy reform with Shatterproof. “It was either jail or we would help him with some rehab—but then we didn’t have the financial ability to pay for three months of treatment: $28,000. And so we were stuck between a rock and a hard place.”

While the prevalence of opioid addiction across race and class lines has encouraged public-health-focused approaches to the crisis, drug-war policies have persisted. According to federal data, about 24 to 36 percent of people in prison or jail have a heroin use disorder. Over the past decade, as most states have imposed heavy penalties for fentanyl trafficking, federal convictions on these charges have mostly targeted Black and Latinx people.

During the pandemic, police targeting of people who use opioids has by some accounts intensified. Vincent said that when people were told to shelter at home, the lockdown “was always a reason to be pulled [over], so if you were somebody they wanted to harass, they totally could.”

Lisa Al-Hakim, director of operations of the Seattle-based Peoples Harm Reduction Alliance, is not sure how much will change under the new administration, or with the opioid lawsuit settlements. But her group has always relied on modest private donations and volunteers, not public funds, to distribute syringes and respond to overdoses in the community. Their interventions aim to challenge a drug-policy regime that is based on criminalization rather than healing underlying social problems.

Instead of the War on Drugs, she said, “if we looked into trauma-informed care, if we looked into more mental health services that…were available to people and affordable.… I don’t really think that we would need a giant industry of treatment facilities.… I think that the answer is paying attention to people’s needs in the first place.”

Lisa Wright, director of policy and advocacy with the National Harm Reduction Coalition, which supports decriminalization of opioids, posed the question, “Instead of just locking up people and throwing away the key, what are the ways that we can work together to ensure that we all get to exist, we get our self-determination, we get our autonomy, and we’re not dying in the process?”

For activists like Vincent, the disruption of the pandemic has only affirmed the need for political and medical establishments to listen to people who use drugs—including them in policy discussions, destigmatizing them, and supporting them with life-saving medication. Reflecting on her harrowing experience with tainted opioids, she said, “This is not a story about somebody that wanted to die. This is a story about somebody that didn’t have any desire to get high. I just needed to be well. I needed my opiate use disorder treated. And it was that hard to find anybody to help me treat my opioid use disorder…. It is the medicine that allows me to live and have a normal life. And we deny that to people every single day.”