COVID-19 and Substance Use Disorders: Recommendations to a Comprehensive Healthcare Response

Ali Farhoudian, Alexander Baldacchino, Nicolas Clark, Gilberto Gerra, Hamed Ekhtiari, Geert Dom, Azarakhsh Mokri, Mandana Sadeghi, Pardis Nematollahi,  Maryanne Demasi, Christian G. Schütz, Seyed Mohammadreza Hashemian, Payam Tabarsi, Susanna Galea-singer, Giuseppe Carrà, Thomas Clausen, Christos Kouimtsidis, Serenella Tolomeo, Seyed Ramin Radfar, Emran Mohammad Razaghi

An International Society of Addiction Medicine (ISAM) Practice and Policy Interest Group Position Paper

29 mars 2020

 

Abstract : Coronavirus disease 2019 (COVID-19) is escalating across the world with higher morbidities and mortalities in certain vulnerable populations. People who use drugs (PWUD) are a marginalized and stigmatized group with lower access to health care services, weaker immunity responses, vulnerability to stress, poor health conditions, and high-risk behaviours that put them at greater risk of COVID-19 infection and its complications. In this paper, an international group of experts on addiction medicine, infectious disease and disaster psychiatry explore the possible concerns raised and provide recommendations to manage the overlaps between COVID-19 and Substance Use Disorder (SUD).

Keywords : Coronavirus; COVID-19; Pandemic ; Public health; Substance use disorder; Addiction medicine; Harm reduction; Policy; Methadone; Opioid substitution therapy;

 

1. Introduction

Coronavirus disease 2019 (COVID-19) is a new member of the family of coronaviruses that infect humans[1] and which first emerged in the Wohan region of China in November 2019 [2]. By March 2020, the World Health Organization (WHO) assessed the global situation of COVID-19 as a pandemic. Cardiovascular disease, chronic respiratory disease, individuals aged 60 or older, and males have a higher risk of mortality than the rest of the population [3-5].

Frequently reported clinical symptoms at onset include pyrexia (83–98%), cough (46%–82%), myalgia or fatigue (11–44%), and shortness of breath (31%) [3-5]. Sore throat and, less commonly, sputum production, headache, hemoptysis, and diarrhea and have also been reported [6]. In more severe cases, COVID-19 can cause pneumonia, severe and acute respiratory syndrome and sometimes (1-3% of all infected cases death [7]. Currently, the medications under investigation for severe cases of COVID-19 include chloroquine phosphate [8] , hydroxychloroquine sulfate [9], lopinavir/ritonavir[10, 11], remdesivir [12], interferon-beta [13], oseltamivir and [11, 14] ribavirin [11] but none have been approved by regulatory authorities for use against COVID-19.

The most common strategies, as advised by WHO, include preventative measures such as quarantine and limitations of movement in infected areas [15, 16], interruption of human-to-human transmission, early identification and isolation, contact tracing of confirmed cases, providing appropriate care for patients, identifying and reducing transmission from the animal source, and minimizing social and economic impact through multispectral partnerships[17]. Bai and colleagues mentioned COVID-19 transmission from asymptomatic patients as a particular challenge for preventive activities [18].

In most countries, people who use drugs (PWUD) are a stigmatized and marginalized population with lower access to healthcare, they suffer from poorer health, weaker immune function, chronic infections, various issues with respiratory, cardiovascular and metabolic systems, as well as a range of psychiatric comorbidities [19, 20]. PWUD are often marginalized, experiencing a high rates of morbidity. Studies show the overall mortality rate is three to five times higher in this marginalized group compared to the general population [21]. Cheung et al estimated that the risk of death among young PWUD homeless women in Toronto is 5 to 30 times higher than their housed counterparts [22, 23] . Substance use imposes different health problems which may complicate superimposed infection with COVID-19. For instance, chronic high alcohol consumption significantly increases the risk of acute respiratory distress syndrome [24]. During the 2009 H1N1 epidemic, a history of opium inhalation was identified as a risk factor for admission to an intensive care unit (ICU) with confirmed H1N1 [25]. Additionally it is important to understand how PWUD have a different perception of risk and risk taking behaviours during an epidemic, making them more risk averse [26, 27]. PWUD has a higher rate of smoking and different studies estimated current smoking rate of more than 70% [28-30]. Several studies found smoking as a significant risk factor for Middle East Respiratory Syndrome (MERS) transmission [31-33]

A literature search did not identify one article focusing around substance use disorder (SUD) and COVID-19. A group of international experts on addiction medicine, infectious disease and disaster management shaped a working group to explore the issues that might emerge when COVID-19 infection effects PWUD and identified the following recommendations for health service providers and policy makers

(…)

LAST VERSION 29 March Submitted