In Kentucky, which just celebrated its first decline in overdose deaths after five years of crisis, many towns are experiencing an abrupt reversal in the numbers.
Nationwide, federal and local officials are reporting alarming spikes in drug overdoses — a hidden epidemic within the coronavirus pandemic. Emerging evidence suggests that the continued isolation, economic devastation and disruptions to the drug trade in recent months are fueling the surge.
Because of how slowly the government collects data, it could be five to six months before definitive numbers exist on the change in overdoses during the pandemic. But data obtained by The Washington Post from a real-time tracker of drug-related emergency calls and interviews with coroners suggest that overdoses have not just increased since the pandemic began but are accelerating as it persists.
Suspected overdoses nationally — not all of them fatal — jumped 18 percent in March compared with last year, 29 percent in April and 42 percent in May, according to the Overdose Detection Mapping Application Program, a federal initiative that collects data from ambulance teams, hospitals and police. In some jurisdictions, such as Milwaukee County, dispatch calls for overdoses have increased more than 50 percent.
When the pandemic hit, some authorities hoped it might lead to a decrease in overdoses by disrupting drug traffic as borders closed and cities shut down. The opposite seems to be happening.
As traditional supply lines are disrupted, people who use drugs appear to be seeking out new suppliers and substances they are less familiar with, increasing the risk of overdose and death. Synthetic drugs and less common substances are increasingly showing up in autopsies and toxicology reports, medical examiners say.
Social distancing has also sequestered people, leaving them to take drugs alone and making it less likely that someone else will be there to call 911 or to administer the lifesaving overdose antidote naloxone, also known as Narcan.
Making matters worse, many treatment centers, drug courts and recovery programs have been forced to close or significantly scale back during shutdowns. With plunging revenue for services and little financial relief from the government, some now teeter on the brink of financial collapse.
Even before the pandemic, experts note, the nation’s infrastructure for helping people with substance use disorders was underfunded and inadequate. Without government intervention, local officials and drug policy experts warn, overdoses and deaths will continue to climb during the pandemic and the existing system will be inundated.
What’s needed, advocates say, is emergency funding to keep afloat treatment programs, recovery centers and needle-exchange programs. Medical associations have also urged federal officials to relax restrictive barriers to opioid treatments such as buprenorphine and called for wider distribution of naloxone.
President Trump and conservatives have repeatedly cited the possible rise of overdoses and suicides when calling for states and businesses to hurry their economic reopening. Yet, of the nearly $2.5 trillion approved for emergency relief, Congress and the Trump administration have designated only $425 million — barely more than a hundredth of 1 percent — for mental health and substance use treatment.
“If it weren’t for covid, these opioid deaths are all we’d be talking about right now,” said Natalia Derevyanny, spokeswoman for the medical examiner’s office in Cook County, Ill., which includes Chicago.
Last year, the Cook County medical examiner recorded 473 overdose deaths from January to June. This year, the total through May reached 656, with more than 400 additional suspected overdoses pending investigation and toxicology reports. The county’s forensic staff — already inundated by the flood of coronavirus deaths — has added shifts and longer hours to deal with the incoming corpses from both crises.
“One epidemic began,” Derevyanny said, “but the other one never stopped.”
The lonely silence
Addiction is a disease of isolation.
“It’s when you feel alone, stigmatized and hopeless that you are most vulnerable and at risk,” said Robert Ashford, who runs a recovery center in Philadelphia and has been in recovery for seven years. “So much of addiction has nothing to do with the substance itself. It has to do with pain or distress or needs that aren’t being met.”
As the pandemic has pushed massive doses of fear, uncertainty, anxiety and depression into people’s lives, it has cut off the human connections that help ease those burdens.
Steven Manzo, 33, lost his job at an Irish pub in Mount Clemens, Mich., after it was forced to close just before St. Patrick’s Day. From the apartment he rented above the bar, he described the disquiet welling up inside of him, with nothing to do but stand on the balcony and watch the empty street below.
“Everything looks normal, but it doesn’t feel normal. I live downtown with bars and restaurants and nobody is here,” he said on March 20. “We have no idea how long it will be.”
Manzo spent much of his early 20s struggling with a heroin addiction. It took huge effort — and the help of family members, co-workers and two treatment programs — for him to turn his life around. He secured a job as a cook and bartender and discovered a gift for making customers laugh.
The pandemic took it all away, he said.
Two weeks after Manzo talked to a Washington Post reporter about his sudden unemployment, he was found dead in his apartment of an apparent overdose.
His mother, JoAnne Manzo, fought back tears as she described the rainy night she drove to her son’s apartment just after his body was discovered.
Talking to his friends, she tried to piece together his last moments. He and a younger friend — also in recovery — had been drinking that weekend and got bored. They bought $40 worth of cocaine and heroin, telling themselves they would use just that one time. Shortly after midnight, Manzo saw his friend out the door. Manzo’s body was discovered two days later, sprawled out on the kitchen floor not far from his five guitars and drum set.
“He was clean for eight years. He would always tell me, ‘My trigger is depression. That is my trigger,’ ” his mother said.
The virus, she believes, took away one of the strongest forces in Manzo’s life — the presence of people who loved him. “If he had still been working, he would have been able to fight that urge, because he was busy. He loved that job. He loved people.”
Reasons for the rise
Michigan — where Manzo died — now ranks third in the United States for the highest unemployment rate, with 1 in 5 workers out of a job. Nationwide, more than 20 million are unemployed as the nation faces its worst economic crisis since the Great Depression.
Research has established strong links between stagnating economies and increases in suicides, drug use and overdoses. In recent years, economists Anne Case and Nobel Prize-winner Angus Deaton have dubbed such increasing fatalities in declining blue-collar communities “deaths of despair.”
For months, the Trump administration and several governors have seized on such research as their central argument for reopening states and businesses at any cost.
“We have to reopen — for our health,” Health and Human Services Secretary Alex Azar wrote recently in a Post op-ed. “The economic crisis brought on by the virus is a silent killer.” As evidence, Azar cited a study suggesting that for every one percentage point increase in the unemployment rate in past recessions, the opioid death rate appears to increase by more than 3 percent.
But in an interview, the lead researcher behind that study rejected Azar’s premise as a misuse and an oversimplification of his data.
Many factors — not just job loss — trigger opioid use, said Alex Hollingsworth, a health economist at Indiana University. “Don’t use opioid deaths as a reason to reopen.”
Hollingsworth and other economists, including Case, who spearheaded much of the research on “deaths of despair,” point out that their findings are based on previous recessions that were wildly different from this one.
One big difference is how suddenly this downturn occurred — causing tens of millions of Americans to lose their jobs almost overnight. Deaths of despair normally occur after years of hardship. The pandemic has also introduced unprecedented disruptions into individual habits and society, making it difficult to foresee the exact effect.
But the biggest objection to such arguments — that tie the declining economy to an inevitable increase in overdoses — is the implied assumption that nothing can be done to avert it.
The focus, many economists and health experts agree, should be on finding safe and sustainable ways to reopen the economy, while increasing access and funding for mental health and substance use care.
“We need to multitask as a society,” said Nora Volkow, director of the National Institute on Drug Abuse, a federal research agency.
The problem is a lack of political will, said Alex H. Kral, an epidemiologist at the nonprofit research institute RTI International.
“We may not have a vaccine for covid, but we actually have very effective treatments for opioid use disorder,” Kral said. “We have medication and proven interventions. It doesn’t have to play out the way we fear it will.”
‘Cries for help’
Before the pandemic hit, national efforts to stem the opioid crisis were just starting to show progress.
In January, the Centers for Disease Control and Prevention released 2018 data showing a slight decline in fatal overdoses for the first time in 28 years. But decades into the opioid epidemic, federal and state agencies still lack a system to collect overdose data in real or near-real time.
The closest thing that exists comes from the Overdose Detection Mapping Application Program, which receives county-level data from emergency agencies. Since it began in 2017, ODMAP has forged agreements with a patchwork of about 3,300 agencies in 49 states that voluntarily provide data.
Of the counties participating, 62 percent have reported increased overdoses since March. And among counties that took part in the program last year and this year, data provided to The Post by ODMAP show a 42 percent increase in May.
Ortiz, the coroner in Columbus and surrounding Franklin County, said that she and her staff just moved this year into a facility three times the size of its old office so they could handle exactly this kind of added volume. They’re already out of space.
“There’s just so many. And the bodies absolutely can’t go on the floor, out of respect for the decedents,” she said. “We’re trying to borrow carts that emergency management was saving for hospitals and the possible covid surge.”
Ortiz and more than half a dozen other coroners nationwide described a dangerous trend from recent years that has accelerated during the pandemic: dealers mixing long-standing narcotics such as heroin and cocaine with much more powerful synthetic drugs, including fentanyl and carfentanil.
The American Medical Association recently issued a warning, citing reports from officials in 34 states about the increased spread of such synthetic drugs and rising overdoses.
Sandy Rivera, an emergency medical technician in Union City, N.J., said she saw an abrupt change in May in the types of cases to which her ambulance was responding.
For weeks, it had been almost all respiratory illnesses and cardiac arrests related to the coronavirus. Then, suddenly, nearly half her cases became overdoses and suicide attempts, a ratio she has never encountered in 15 years working on ambulances.
“One night, that’s all I had,” Rivera said. One patient took a bottle of Tylenol. Another took medication that belonged to her children. An elderly patient had been drinking and swallowed 10 pills of Benadryl.
“They were cries for help,” she said.
At a time when they are needed most, some treatment centers and addiction clinics are struggling to stay solvent and have begun closing programs.
In May, Austin Recovery Network, the oldest addiction treatment provider in Texas, shuttered its clinics. “It is only a matter of time until we run out of money,” the board of the nonprofit organization told staff members.
Lynn Sherman, chairman of the treatment provider’s board, said the decision to close the clinics was “hard as hell.”
The organization is still holding online support groups and running a shelter for parents and children, Sherman said, but, she added, “I don’t think our area will have enough capacity in the future to provide the help that’s needed.”
Even as Austin Recovery Network shut down its residential treatment programs for adults, it has seen an increase in people walking into its offices, begging for detox treatment and a place to stay amid the pandemic.
In normal times, most nonprofit behavioral health centers operate on extremely thin margins and rely on reimbursements from major government health programs such as Medicaid and Medicare and grants from local government.
During the pandemic, they have struggled to treat patients, leading to severe drops in reimbursement, said Chuck Ingoglia, president of the National Council for Behavioral Health, which represents 3,326 treatment organizations. In a recent survey, 44 percent of the council’s members said they will run out of money in the next six months.
Many are bracing for deeper cuts in the coming year, as states grapple with budget crunches.
“Mental health and substance use programs are often the first thing cut,” said Tami Mark, a drug policy researcher at RTI International. “The last recession decimated behavioral health funding so badly it took them 10 years just to get back to previous levels.”
‘Failures of the system’
When the Democratic-controlled House passed a $3 trillion coronavirus relief bill in May, the legislation, dubbed the Heroes Act, designated $3 billion for mental health and substance use disorders programs — seven times more than the amount Congress approved in March.
But the White House and Republicans have declared the bill dead on arrival, leaving it unclear whether any additional funding will go toward programs for mental health and substance use disorders.
“We as a society often have a tendency to stigmatize and blame those who use drugs,” said Ashford, the recovery center director in Philadelphia. “But if overdoses really increase during this pandemic, it will be because of failures of the system.”
Since her son’s death, JoAnne Manzo has asked herself the same question over and over: What exactly happened? “I know in my heart he did not want to take his life,” she said.
On Friday, she finally received the official death certificate. Under cause of death, it said: “acute fentanyl and cocaine.”
The autopsy took nearly three months because county officials were overwhelmed with covid-19 cases. The pandemic also made it impossible to hold a funeral, so she had her son’s body cremated.
JoAnne Manzo took the ashes and put a small portion into a heart necklace she now wears every day.
She knows how lonely her son felt during the last days of his life. Since his death, she has tried to keep him as close as possible.
If you or someone you know is struggling with addiction, the Substance Abuse and Mental Health Services Administration can help you locate treatment at www.findtreatment.gov or at this free helpline: 1-800-662-HELP (4357).
Alyssa Fowers and Ariana Eunjung Cha contributed to this report.