COVID-19: Potential Implications for Individuals with Substance Use Disorders

From National Institute on Drug Abuse
March 24, 2020


As people across the U.S. and the rest of the world contend with coronavirus disease 2019 (COVID-19), the research community should be alert to the possibility that it could hit some populations with substance use disorders (SUDs) particularly hard. Because it attacks the lungs, the coronavirus that causes COVID-19 could be an especially serious threat to those who smoke tobacco or marijuana or who vape. People with opioid use disorder (OUD) and methamphetamine use disorder may also be vulnerable due to those drugs’ effects on respiratory and pulmonary health. Additionally, individuals with a substance use disorder are more likely to experience homelessness or incarceration than those in the general population, and these circumstances pose unique challenges regarding transmission of the virus that causes COVID-19. All these possibilities should be a focus of active surveillance as we work to understand this emerging health threat.

SARS-CoV-2, the virus that causes COVID-19 is believed to have jumped species from other mammals (likely bats) to first infect humans in Wuhan, capital of China’s Hubei province, in late 2019. It attacks the respiratory tract and appears to have a higher fatality rate than seasonal influenza. The exact fatality rate is still unknown, since it depends on the number of undiagnosed and asymptomatic cases, and further analyses are needed to determine those figures. Thus far, deaths and serious illness from COVID-19 seem concentrated among those who are older and who have underlying health issues, such as diabetes, cancer, and respiratory conditions. It is therefore reasonable to be concerned that compromised lung function or lung disease related to smoking history, such as chronic obstructive pulmonary disease (COPD), could put people at risk for serious complications of COVID-19.

Co-occurring conditions including COPD, cardiovascular disease, and other respiratory diseases have been found to worsen prognosis in patients with other coronaviruses that affect the respiratory system, such as those that cause SARS and MERS. According to a case series published in JAMA based on data from the Chinese Center for Disease Control and Prevention (China CDC), the case fatality rate (CFR) for COVID-19 was 6.3 percent for those with chronic respiratory disease, compared to a CFR of 2.3 percent overall. In China, 52.9 percent of men smoke, in contrast to just 2.4 percent of women; further analysis of the emerging COVID-19 data from China could help determine if this disparity is contributing to the higher mortality observed in men compared to women, as reported by China CDC. While data thus far are preliminary, they do highlight the need for further research to clarify the role of underlying illness and other factors in susceptibility to COVID-19 and its clinical course.

Vaping, like smoking, may also harm lung health. Whether it can lead to COPD is still unknown, but emerging evidence suggests that exposure to aerosols from e-cigarettes harms the cells of the lung and diminishes the ability to respond to infection. In one NIH-supported study, for instance, influenza virus-infected mice exposed to these aerosols had enhanced tissue damage and inflammation.

People who use opioids at high doses medically or who have Opioid Use Disorder (OUD) face separate challenges to their respiratory health. Since opioids act in the brainstem to slow breathing, their use not only puts the user at risk of life-threatening or fatal overdose, it may also cause a harmful decrease in oxygen in the blood (hypoxemia). Lack of oxygen can be especially damaging to the brain; while brain cells can withstand short periods of low oxygen, they can suffer damage when this state persists. Chronic respiratory disease is already known to increase overdose mortality risk among people taking opioids, and thus diminished lung capacity from COVID-19 could similarly endanger this population.

A history of methamphetamine use may also put people at risk. Methamphetamine constricts the blood vessels, which is one of the properties that contributes to pulmonary damage and pulmonary hypertension in people who use it. Clinicians should be prepared to monitor the possible adverse effects of methamphetamine use, the prevalence of which is increasing in our country, when treating those with COVID-19.

Other risks for people with substance use disorders include decreased access to health care, housing insecurity, and greater likelihood for incarceration. Limited access to health care places people with addiction at greater risk for many illnesses, but if hospitals and clinics are pushed to their capacity, it could be that people with addiction—who are already stigmatized and underserved by the healthcare system—will experience even greater barriers to treatment for COVID-19. Homelessness or incarceration can expose people to environments where they are in close contact with others who might also be at higher risk for infections. The prospect of self-quarantine and other public health measures may also disrupt access to syringe services, medications, and other support needed by people with OUD.

We know very little right now about COVID-19 and even less about its intersection with substance use disorders. But we can make educated guesses based on past experience that people with compromised health due to smoking or vaping and people with opioid, methamphetamine, cannabis, and other substance use disorders could find themselves at increased risk of COVID-19 and its more serious complications—for multiple physiological and social/environmental reasons. The research community should thus be alert to associations between COVID-19 case severity/mortality and substance use, smoking or vaping history, and smoking- or vaping-related lung disease. We must also ensure that patients with substance use disorders are not discriminated against if a rise in COVID-19 cases places added burden on our healthcare system.

As we strive to confront the major health challenges of opioid and other drug overdoses—and now the rising infections with COVID-19—NIDA encourages researchers to request supplements that will allow them to obtain data on the risks for COVID-19 in individuals experiencing substance use disorders.

Vulnerable Populations

The most vulnerable to Covid-19 among substance abuses is going to be the crack-smoking homeless. The homeless are vulnerable just by being homeless, but add to that the lung damage from smoking crack and the risk is compounded. As Dr. Volkow points out, tobacco and marijuana smoking are also more prevalent among those who are homeless. This is going to be an important area of research.


Advocacy Update: CDC Now Claims 2,290 Cases of Vaping-Related EVALI Lung Injury With 49 Deaths!

From the Monthly Blog of Jeremiah Gardner,
Director of Public Affairs
Hazelden Betty Ford Foundation
Initially Posted by Mr. Gardner on November 26, 2019

The American Medical Association is calling for “a ban on all vaping products not approved by the FDA,” and the American Academy of Addiction Psychiatry recommends Americans “cease using all vaping devices until … investigations determine … which, if any, may be considered safe.”

The CDC now has confirmed 2,290 cases of the vaping-related EVALI lung injury, with 49 deaths. And now there are reports of another type of injury which experts are calling “popcorn lung.” In addition, a New York Times report took a deep dive into how electronic-cigarette company Juul is hooking a new, younger generation on nicotine in spite of more states fining lawsuits alleging the company  is aggressively targeting young people with deceptive marketing.  Massachusetts lawmakers voted to ban all flavored tobacco products and tax vaping devices. Some worry public health advocates are overreacting to vaping concerns, pointing to it as a safer alternative than combustible cigarettes.

Granted, the public health concerns over vaping are not convincing across the board. Combustible cigarettes do contain more contaminants. The biggest harm, however, comes from nicotine being quite addictive, leading to years of exposure built upon craving more nicotine. E-cigarettes are even more addictive, packing a far bigger nicotine punch. Because they are so new, we know little about the long-term health impacts of all that nicotine. Moreover, early studies suggest vaping may actually lead young people to begin smoking cigarettes. We must stop assuming that vaping is a healthier strategy for smoking. Although it was initially intended to aid those who wish to quit smoking, it’s safer to stick with evidence-based recommendations and proven smoking cessation programs.

According to the Agency For Healthcare Research and Quality, About 42 million people in the United States (nearly 18 percent of the population) currently smoke. Tobacco use is a leading cause of illness, disability, and death in the United States. Cigarette smoking accounts for one out of every five deaths and is estimated to increase the risk for heart disease and stroke by two to four times. Smoking during pregnancy increases the risk of congenital anomalies, perinatal complications, miscarriage, and stillbirth. Substantial clinical evidence shows that quitting smoking is one of the most important things a person can do for his or her health.

This week’s featured media are from a White House round table on the teen vaping epidemic. Various interest groups offered the President contradictory opinions in an interesting discussion that was robust and, at times, heated. The President’s conclusions remain to be seen. He had previously retreated from his September announcement to ban the sales of flavored e-cigarettes, instead calling it a “suggestion” and warning that a full flavor ban could lead to an increase in illegal sales. He did voice support for legislation to raise the legal age to purchase vaping and tobacco products from 18 to 21. In this NBC report, watch a clip from the meeting plus a clip from pro-vaping demonstrations. CSPAN captured the full round table.

Please feel free to share questions, thoughts and ideas. Plus, follow Recovery Advocacy Update on Twitter for additional information daily.

Jeremy Gardner Dir. Comm. and Public Affairs Haelden Betty Ford.jpgJeremiah Gardner
Director, Communications and Public Affairs