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

This illustration, created at the Centers for Disease Control and Prevention (CDC), reveals ultrastructural morphology exhibited by coronaviruses. Note the spikes that adorn the outer surface of the virus, which impart the look of a corona surrounding the virion, when viewed electron microscopically. A novel coronavirus, named Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), was identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in 2019. The illness caused by this virus has been named coronavirus disease 2019 (COVID-19).

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.

NIH has posted a compilation of updates for applicants and grantees, including a Guide Notice on administrative flexibilities and accompanying FAQs.

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 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.

This content is also available in Spanish - COVID-19: Las posibles implicaciones para las personas con trastornos por consumo de drogas.

Additional Links

For those with questions about how their state justice systems are adjusting operating procedures in response to COVID-19, The Marshall Project is tracking changes as they occur. Also, the Vera Institute of Justice has developed guidance for justice system adjustments to COVID-19. 

Dr. Nora Volkow, Director

Here I highlight important work being done at NIDA and other news related to the science of drug use and addiction.

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 Covid 19 is affecting psychology

seriously covid 19 is affecting people mentally.People with OCD are feeling so much stressed and scared. Therapy sessions of people has stopped which is making them more restless.Many people are facing negative impacts on their psychology due to covid 19 crisis as they are unable to go out or meet family or enjoy their outgoing lifestlye

 buprenorphine abuse

This whole page is what happens when white coated drug dealers overprescribe addictive narcotics to "treat" addiction to overprescribed narcotics. People on Suboxone saying they need it to survive, talking about risking thier lives in MAT clinics to get their fix, demanding months worth of a drug that is sold and traded on the black market, and demanding it without drug testing or evaluation. People ON suboxone saying it doesnt get you high at all and is impossible to overdose on and thinking it just treats the symptoms of withdrawl, It doesnt, the opioid withdrawl stops because suboxone is an opioid. its labeled as a narcotic painkiller not a symptom reducer, by that logic taking heroin "treats" the symptoms of heroin withdawl. Why is there people being prescribed something as dangerous as suboxone without understanding what it is and the risk of abuse and overdose? because MAT is a racket by the same people that caused the opioid epidemic by lying about how safe and non addictive Vicodin was to take long term for chronic pain. NIH knows what they are doing here, its not about health its about $$$

 The evidence is very clear

The evidence is very clear that Suboxone saves lives. It reduces illicit opioid use and thereby reduces overdose risk, reduces the spread of infectious disease, and enables people with opioid use disorder to recover. Even though it acts at the same mu-opioid receptors, its effects in the brain are different from heroin and other misused opioids, so it is not the same thing. The National Academy of Medicine did a comprehensive review and determined that not treating an opioid addicted patient with medication is malpractice.

 my husband is on drugs l

I don't know what to do. we live in our home with my son,daughter, and two grandkids.he stay out all night doing drugs.he tried couple of times to get help.but can not beat it.I am scared for him myself and my two kids and grandkids.I am scared that he could bring the covid-19 home to us.if there is someone that can help? please let me know.I think the drug is cocaine that he use.and he still hold down a job go to work every day.he do not know how to handle it. the drugs.we live in Chicago.can you tell me somebody who can help us.

 What you are experiencing has

What you are experiencing has to be very difficult—I am sorry. There are virtual resources available if your husband is willing to try them. You might contact your state or local public health department to get some guidance about your legal options. The CDC has a website that lists public health departments for the different states and territories:

 Inpatient detox services

To the nurse that claimed inpatient detox is not a medically essential service. I am shocked and disturbed to hear a nurse say this. I don’t know what kind of nurse you are, hopefully not at a hospital. Because if you work at a hospital you should be acutely aware that it is well known that detox from alcohol addiction is not only potentially deadly, but also carries a very high risk of seizures.
And with long term alcohol addicts, it is not uncommon for them to have seizures when trying to stop cold turkey.
Many people being detoxed in hospital wound up there for different reasons like accidents or illness. They cannot be properly treated in a hospital unless the hospital is also detoxing them.
Normal hospitals do not just have inpatient detox for anyone, it’s peole that come in for some reason and need to stay longer in order to safely detox.
You didn’t just sound heartless, you sounded like a very naive and unqualified nurse. Do you realize why the liquor stores are truly still considered essential? No government will publicly acknowledge it, but it’s not because people would be pissed and need booze. Doctors told governors that if they did not leave liquor stores open the hospitals would be overwhelmed by alcohol dependent people having severe withdrawals that require hospitalization to prevent seizure. You sound like you live in a rosy bubble, so you likely don’t really comprehend just how many closeted alcoholics there are.

 Person In Recovery

Most people see me and they would never know I had a substance use problem that I battled on and off for 25 years. I have lost my dad and uncle to this disease. I work my butt off in 12 step programs, bible study, helping others and I work in the field with woman who are incarcerated for opioid use. When someone finds out I am an ex heroin addict or I smoked crack at 17 years old their mouth drops, but then all of a sudden they start treating me like I can't do things they can and that I must break easily. The deal is, I am a human being with a disease just like anyone else with a disease. I have to take care of myself and it is not up to the government to take care of me like I am a child. I bet everyone has gone out to buy smokes or food daily, gas.... something. It might kill you to go to the clinic every couple days, but so will shopping. The government didn't invite us to the clinic in the first place... we may be looked at differently if we stopped acting so entitled all the time and complaining and blaming everyone else for our decisions we made. Yes we suffer, let's stop making everyone else suffer too.

 no relationship between active smoking and severe COVID-19

Unfortunately, quite a few articles appear in literature that deny the correlation between active smoking and severe COVlD-19 lung disease. In many countries in Europe, such as Italy, among the "essential" stores kept open by the government there are the tobacconists. There is a need for a strong stance from NIDA on this subject. Thank you Daniel L. Amram

 Some of this information is right on, however...

It was been proven for more than 20 years that inhalation of methamphetamine smoke actually stops the reproduction of airborne pathogens such as influenza and even the common cold. In some cases test results show that it is also the only drug ever to be proven to kill or completely rid the body of any infection including gang green and a build up of mucus membrains in the asophogus and nasal passages. It has also been proven to reverse the affects of COPD provided the subject has quit smoking all other substances aside from meth. I happen to know this one personally for I've watched the positive affects on my father who's as of 6 months ago could not breath well enough to walk ten feet without collapsing. Now having used meth amphetamine in a very controlled manner he is able to walk as far as he pleases, he does not weeze the way he did so badly, his mental additude far exceeds my expectations and he's even talking about going back to work. He is 72, was a heavy drinker and smoker of marijuana and tobacco and crack cocaine for more than 30 years. So in my opinion we need to be doing more testing and see what all thehelth benefits from this drug really are.

 There is no evidence that

There is no evidence that methamphetamine could be protective against COVID-19. One preclinical study (a study using cell cultures) suggested that methamphetamine could protect cells against Influenza A; although it is an interesting finding worth further research, it falls far short of evidence that the drug protects users from airborne viruses or rid the body of infections. The bulk of existing evidence suggests methamphetamine use has adverse effects on immunity and susceptibility to infection.

 I know a drug addict body matabolites thing differently

I want to know when not using drugs a addict still has a very different brain and body chemistry I want to know if maybe that might have a different effect for us in contact with covid-19 our bodies on drugs always not good but in recovery I wonder if we might make the difference that they can't figure out some people r not getting symptoms and wonder has anyone looked into the abnormal mind and body of a addict instead of our situations and reactions to the drugs but what about when we r a recovering alcoholic or addict I always hear about what drugs do in ur body but not about our bodies in recovery our problem isn't drugs it's our chemistry and or digestive system I want to know could this be what y'all have missed in your studies it took for ever for y'all to learn addiction was a disease because everyone thought we chose to use maybe u missed the science part once again...........????

 Real facts on marijuana

Marijuana is a miracle drug. I can not understand how you can put marijuana in the same article as meth, opiates, and tobacco. I think you should open your negativity and look at the facts of the benefits of marijuana. I am an edible cannabis don't smoke.

 Response: Other COVID implications on folks with substance abuse

"Some 12 step programs are cancelling meetings because of COVID-19. This means less access to one means of supporting longer term recovery, thus perhaps exacerbating another health issue, substance abuse?." RESP: Most structured 12 step programs for and with people who want it, have adapted to Churches and Schools being closed by utilizing on-line tools such as Zoom, gotomeeting, webex, etc. These tools, although they lack in eye-to-eye, hand-to-hand, and hug-to-hug interactions, allow the 12-step programs to continue uninterrupted. As the Big Book states in the 4th edition from 2000, we adapt to get what we need "Modem to modem", yes the modem has been replaced, but its the same concept.

 Range of Symptoms for COVID-19

I understand that there is not much information on the novel virus and its effects on the body. People's reported symptoms have ranged from asymptomatic to less severe than the seasonal flu to fatal. Although respiratory issues can seem and most likely will have an effect on people experiencing COVID symptoms, with the variety of cases reported, could it possibly be the different treatments used for each individual that is affecting them more than their medical history. For example, recently there have been reports that advil was a common medicine taken by patients who had experiences fatal symptoms of COVID-19. Important to not assume corona fault

 Although concerns had been

Although concerns had been raised about non-steroidal anti-inflammatory drugs like Advil, thus far there is no evidence they lead to worse outcomes in patients with COVID-19.

 To comment further about "creating black sheep"

A group of homeless (known to use all sorts of intoxicant) in Fort Collins, CO has had only 1 person test positive. She stayed 1 night at the end of March, diagnosed 4 days later at the hospital, recovered & was cleared to return to the mission within a week. They're (at least in Fort Collins) at no more risk than anyone else, I have theories as to why it hasn't hit that particular group like many would suspect/expect...but for another time. (In part: average age & social status)

 overeating serious problem

overeating serious problem can't go out to get help I don't think

 Above referral

One of the smartest men I’ve known invited me to lunch where those at table were Doctors and a EBR Coroner , their discussion was on how alcohol and drugs affected the brain causing depression, anxiety, bi polar disorders and many other disorders. Weakening the immune system as well . Of course their discussion was way over my educational level and today Wish like hell I had had a recorder. Was enough to convince me I did not need to add to the depression and other mental issues I was having. Been sober since and that was 30 years ago . OFTEN relate this meeting to newcomers with alcohol and drug problems

 Shame on NIDA

Relapse was predicted and predictable

This was predictable and predicted, and should come as no surprise, especially to those of us who study it. Despite NIDA's budget, drug and alcohol abuse has not been curtailed. Recovery occurs when alternative behaviors are established and maintained by feedback and rewarding consequences for non-use. When those novel rewards are terminated too quickly, behavior regresses to a previous state - resurgence... relapse... Sad but true... NIDA has done nothing during this pandemic because their sole focus is on drug development to treat addiction (phamacotherapeutics). There are too many biochemists and pharmacologists and too few psychologists and behavioral biologists working on the drug abuse pandemic at NIDA. Shame on you, Nora Volkow, shame on you!!

 NIDA has always and continues

NIDA has always and continues to support a broad range of research to understand the complexities of addiction related to its biology, including genetic and developmental influences on vulnerability; the role of social and socio-economic factors in its etiology and treatment; and the development and use of behavioral and pharmacological approaches to its treatment (alone and combined).  These remain scientific priorities for the institute.

 Smoking meth cures ?!!!?

Regrettably been a meth smoker for 22yrs. Meth has been known to cure the flu,fact. Covid is just that, a flu. I've been in contact with the virus now twice and wouldn't you know a day later after a few measly coughs it ran for the hills. But the truth is that dying from a virus, sometimes feels like a better alternative than meth addiction. STAY AWAY FROM DRUGS!!!!

 Although we do not yet have

Although we do not yet have any direct data on the implications of methamphetamine use for COVID-19 illness, it is worth noting that methamphetamine constricts the blood vessels, which contributes to pulmonary damage and pulmonary hypertension. This may put methamphetamine users at increased risk.