A Dangerous “Cocktail”: The COVID-19 Pandemic and the Youth Opioid Crisis in North America: A Response to Vigo et al. (2020)

Physical distancing measures are a crucial public health strategy in global efforts to combat the novel coronavirus (COVID-19 disease) pandemic. While vital to save lives and slow the spread of the virus, these measures may have significant yet unintended consequences on population mental health. In their editorial, Vigo et al. ¹ aptly observe: “the COVID-19 epidemic adds fire to the simmering opioid epidemic and overdose crisis” in Canada, which has been characterized by high rates of morbidity and mortality due to nonmedical prescription opioid use and illicit opioid use. ² Physical distancing measures are already negatively impacting opioid users, from limiting access to safe supply, supervised injecting sites and outpatient treatments to increasing risks for those that relapse and overdose. ¹

To date, media coverage of the opioid overdose crisis in Canada has primarily focused on the consequences for adults. Recent Canadian media publications have also highlighted how the COVID-19 pandemic has contributed to the worsening of the opioid crisis among adults. This focus on the impacts for adults, and particularly older people, is understandable due to the differential effects of the novel coronavirus. However, there continues to be little to no mention of the experiences of young people during this extraordinary period. Therefore, and elaborating on arguments made by Vigo et al., ¹ we argue that youth and young adults have also been notably impacted by the opioid crisis. In 2019, people aged 29 years and younger represented the age cohort with the second highest rate of opioid-related overdoses (31%) and hospitalizations due to opioid-related poisonings (21%) in Canada. ³ During this same period, 20% of apparent opioid-related deaths occurred among youth and young adults. ³ Nonmedical opioid use (NMOU) during adolescence is particularly problematic as it has been associated with polysubstance use, future opioid use disorders (OUD), and overdose. ^4,5 Therefore, we argue it is plausible that the intersecting COVID-19 pandemic, “parallel mental health epidemic,” ¹ and concurrent opioid epidemic place youth at even greater risk for NMOU, OUD, and overdose at this time.

Vigo et al. ¹ infer that youth may be uniquely impacted during the pandemic as they occupy “critical biopsychosocial development periods,” which may have positive and negative implications for their mental health and propensity to use substances. Additionally, we argue that youth observing physical distancing measures are living in a situation of social instability and shifting social norms. French Sociologist, Emile Durkheim, originally referred to this experience as anomie. Anomie is constituted by human suffering because a coherent system of social regulation is lacking, resulting in transient experience(s) of “normlessness.” For youth, the pandemic may involve numerous changes to everyday engagements including increased interactions with family and time spent within the home, reductions in the pervasive influence of normative school structures as well as fewer extracurricular experiences with peers, mentors, and acquaintances. Youth may also encounter shifts in modes of social interaction with peers, with potential for more online, and less face-to-face engagements. While the social space(s) that youth occupy may be more digitally mediated in comparison to other age groups, we argue that changes in the modes of interaction in combination with other socionormative transitions due to physical distancing may contribute to the experience of normlessness.

This experience is compounded for youth because they already occupy a transitional period of vulnerability, which is in part characterized by the development of identity and autonomy. However, opportunities for this development are currently curtailed, with media coverage reporting that youth are missing important milestones through which maturation and autonomy are consolidated and celebrated (e.g., increased independence from guardians, cancellation, or digitization of graduations).

Youth are also generally more susceptible to increased risk-taking, impulsivity, sensation-seeking, and disregard for negative consequences. In turn, they are more likely to adopt problematic coping behaviors, including substance use. ⁴ Indeed, there are early indications of increased alcohol and cannabis consumption among younger Canadians during the pandemic. ⁶ Boredom, stress, and a lack of structure are cited by as rationale for this behavior. ⁶ Youth are more likely to report NMOU if they use other substances including tobacco, cannabis, and alcohol. ⁵ Moreover, young adults’ consumption of prescription opioids has been shown to be mediated by externalizing and internalizing symptoms including anxiety sensitivity, hopelessness, and implusivity. ⁷ Canadian young people are already demonstrating elevated levels of alcohol and cannabis consumption and are arguably experiencing heightened psychological distress and vulnerability due to the pandemic. Youth may therefore engage in NMOU to cope with the unique and disruptive sociocultural and normative transitions they are facing.

Increased time spent within familial contexts may further amplify the vulnerabilities (e.g., domestic violence) to which some youth are already exposed and could potentially place youth at increased risk for NMOU. Research has shown increased risk of pharmaceutical opioid overdose for youth who are exposed to family members with opioid prescriptions. ⁸ Increased risk of opioid use could result from enhanced access to opioids through familial networks and the impact of interactional effects via family members regarding NMOU norms. Current medical guidelines recommend using codeine to treat symptoms of COVID-19, which could also increase youth exposure to opioids in the home if service providers prescribe codeine and families adhere to the directives. Young females also report accessing opioids more often through family members than young males, ⁹ and thus, it is also possible that the increased interaction with family and associated potential exposure to opioids may have a more pronounced impact on the consumption behaviors of female youth.

For youth who do commence or continue NMOU during this time, social isolation may directly increase the risk of mortality. In an effort to adhere to physical distancing requirements, youth may be forced to use opioids alone without “buddying-up”; ¹ however, no one will be present to call emergency services if overdose occurs. Additionally, reduction in potential help-seeking behaviors by youth and family members to avoid hospital exposure (and increased risk of contracting COVID-19) may contribute to increased risk of death due to overdose.

It is important to highlight the possibility that youth may experience beneficial and protective effects due to physical distancing measures. Increased time at home with family may elicit increased emotional support and mitigate potential substance use risks that may ordinarily occur due to the influence of peers. Time spent with family may also cultivate cognitive reflection about the impact of peer values and behaviors on one’s own perceptions and behaviors concerning substance use and in turn may have salutary effects on young people’s current and future propensity to use substances.

Relatedly, research indicates that many youth, particularly young males, report obtaining opioids through their classmates. ⁹ It follows that reduced face-to-face interaction with peers could hypothetically result in reduced opioid access and usage (i.e., through less face-to-face peer pressure). However, this could exacerbate the risks to youth as they seek opioids through less familiar/alternative sources.

As youth are normally more “connected” via social networking, the deleterious effects of lessened face-to-face interactions with peers may be softened. In these instances, youth may be able to leverage their online social networks and resources to counteract the impacts of social isolation as they seek out social and emotional support online. It remains to be understood how youth will cope in response to sociocultural and normative changes they are facing and how modified forms of activities and interactions, as well as major life events will influence their developmental trajectories.

In addition to recommendations put forth by Vigo et al, ¹ we argue that research and mental health services related to opioid use are urgently needed to address the multifaceted nature of NMOU risk for young people during the pandemic. The rapid dissemination of public health messaging to encourage family members to safely store and dispose of prescription medications is required. Additionally, research identifying, characterizing, and monitoring the influence of physical distancing measures on the lived experiences of youth will be vital to develop a nuanced understanding of positive and negative impacts on their social environments, cognitions, and behaviors related to mental health and substance use.

This data will inform development of targeted, online interventions for youth who may be in exploratory or early phases of NMOU and other high-risk substance use. We concur with Vigo et al. ¹ that psychoeducation, peer-, and specialist-supported therapies be “scaled up” and delivered online. We recognize that some schools and universities have transitioned to online education. Mental health services may be able to harness these online educational systems to reach youth and provide crucial preventative and early intervention mental health support. Recent research indicates that youth who are at risk of NMOU identify digital technologies as a meaningful and appropriate format through which to receive mental health and substance use supports. ¹⁰ This suggests an opportunity to adapt interventions ordinarily delivered in-person in educational and community settings and mobilize them to online formats. These combined efforts may prove crucial in supporting youth and young adults who are in early or exploratory phases of NMOU or who have OUD and, in turn, reduce the risk of opioid overdoses during the COVID-19 pandemic.