Substance use disorders (SUD), and particularly opioid use disorder (OUD), substantially increase the risk for COVID-19, according to an analysis of electronic health records (EHR).
Among over 73 million patients, the risk of COVID-19 was far higher among patients diagnosed with an SUD in the past year compared with the general population after adjusting for age, gender, race, and insurance type (adjusted odds ratio 8.7, 95% CI 8.4-9.0, P<10−30), reported Nora D. Volkow, MD, director of the National Institute on Drug Abuse (NIDA), and colleagues, in Molecular Psychiatry.
Patients with OUD had the highest risk (aOR 10.2, 95% CI 9.1-11.5, P<10−30), followed by patients with:
- Tobacco use disorder: aOR 8.2 (95% CI 7.9-8.5)
- Alcohol use disorder: aOR 7.8 (95% CI 7.0-8.5)
- Cocaine use disorder: aOR 6.5 (95% CI 5.2-8.1)
- Cannabis use disorder: aOR 5.3 (95% CI 4.4-6.4)
Overall, patients with SUD also had significantly higher hospitalization and death rates due to COVID-19 versus the general population, Volkow’s group stated.
“Newspapers are reporting an increased risk of relapsing and an increased rate of people overdosing and dying, but there is very limited data in terms of how [patients with SUD] are faring in terms of the risk of getting COVID-19, and if they do, what happens to them,” Volkow told MedPage Today.
Patients with SUD have a higher risk for other conditions that are associated with COVID-19, such as respiratory or cardiovascular problems, commented Allison Lin, MD, of the Veterans Affairs Ann Arbor Healthcare System in Michigan.
Early data suggested respiratory conditions tied to smoking, like chronic obstructive pulmonary disease (COPD), were linked with a higher case-fatality rate among COVID-19 patients. Obesity, diabetes, and hypertension, are all established risk factors for COVID-19.
In this study, patients with a recent SUD diagnosis had a higher prevalence of many conditions compared with the general population, including asthma (22.11% vs 6.89%), COPD (18.86% vs 4.64%), cardiovascular disease (72.67% vs 23.34%), and obesity (30.12% vs 7.23%), Volkow and colleagues reported. Many of these conditions were even more prevalent in African-American patients than white patients, they added.
In line with research from the general population, seniors and African Americans in this study were at an elevated risk for COVID-19 among the SUD population versus younger adults (aOR 1.3, 95% CI 1.2–1.4) and white people (aOR 2.2, 95% CI 2.0–2.3), respectively. Hospitalization and mortality were also significantly higher among African Americans versus whites, they noted.
“Even among the most vulnerable populations, you still see evidence of racial disparities,” Volkow said.
Lin added that the increased risk among patients with SUD could also be in part attributable to behavioral factors or access to healthcare.
“There are parallel epidemics,” Lin told MedPage Today. “For this particular population, not only are we thinking about COVID-19, but we also need to be thinking about getting them into SUD treatment.”
In a July 2020 editorial in the Annals of Internal Medicine, Volkow noted that many risks patients with SUD face due to COVID-19 are indirect, and result from a reduced access to healthcare. Housing instability, for example, has soared amid the pandemic. Patients with SUD are more likely to be homeless, and vice versa, she noted.
Unemployment and social isolation may be particularly difficult for patients with SUD, as pathways to recovery may be disrupted by the pandemic, Volkow stated.
“To sustain recovery, you have to be integrated into social systems in ways that are meaningful and productive,” she said. “To the extent that we are removing that ability is making them very vulnerable.”
The IBM Watson Health Explorys EHR database used for this study included 360 hospitals across all 50 states. Data was collected in June, at which point COVID-19 was identified as the “Coronavirus infection (disorder)” code.
Of 73,099,850 in the database, 7,510,380 were diagnosed with a lifetime SUD (10.3%), 722,370 (0.99%) were diagnosed with an SUD in the past year, and 12,030 patients were diagnosed with COVID-19. Lifetime SUD patients likely represent active and recovered patients, whereas patients with a recent SUD diagnosis represent active users, the authors noted.
Among COVID-19 patients, 1,880 patients were diagnosed with a lifetime SUD and 1,050 were diagnosed with a recent SUD, researchers reported.
There was no significant difference in the risk of COVID-19 among patients that were prescribed OUD treatments, such as methadone, buprenorphine, or naltrexone versus patients not on these medications (aOR 1.1, 95% CI 0.9–1.3, P=0.58). However, methadone doses administered through methadone clinics were not captured in this data, which was a limitation, the authors noted.
The EHR data in the study likely underrepresents patients in rural communities, and the diagnosis of “COVID-19” was not added until after the study was conducted, the authors noted. A lack of available testing and potential ascertainment bias for illicit SUD are also limitations, they noted. Finally, the authors could not adjust the data for social adversity or the influence of medical conditions on COVID-19 risk.
Volkow disclosed no relevant relationships with industry. A co-author disclosed support from the Eunice Kennedy Shriver National Institute of Child Health & Human Development, the National Institute on Aging, the American Cancer Society, and the Clinical and Translational Science Collaborative.