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The intersection of COVID-19 and the opioid epidemic put the American healthcare system in a challenging position. Cases surge throughout the country, forcing hospitals to focus on the immediate public health threat of COVID-19 rather than other ongoing public health concerns. Despite declining media coverage of the opioid epidemic, studies show an increase in substance use since late March of 2020 indicating a worsening of the epidemic. The American Medical Association attributes social distancing, a dramatic increase in unemployment, and widespread economic deterioration to the overall increase in feelings of isolation and anxiety, which are common triggers of substance use disorders. Beyond that, COVID-19 presents a unique set of challenges for those in recovery; treatment centers, and outpatient services operate differently if at all due to social distancing guidelines.
Another major cultural shift results from the lack of a unified response to COVID-19 from the US federal government; American citizens continue to lose their jobs. Preliminary research shows that unemployment is one of the largest contributors to the increase in substance use disorders during COVID-19. Daniel Buccino of the Johns Hopkins Broadway Center for Addiction writes, “At first, some of our patients were resilient and resourceful in staying drug-free. As time went on, it started getting harder for them” (Winer 2020).
Unemployment has increased dramatically due to COVID-19, but the issue has been tied to opioid use before COVID-19. Research conducted in 2017 by economists at the National Bureau of Economic Research found that “As the county unemployment rate increases by one percentage point, the opioid death rate per 100,000 rises by 0.19 (3.6%) and the opioid overdose ED visit rate per 100,000 increases by 0.95 (7.0%)” (Hollingsworth, Ruhm and Simon 2017). Macroeconomic shock affects opioid use in “normal” times making the COVID-19 pandemic a perfect storm as it brings economic downturn and mass unemployment coupled with isolation and uncertainty. Coupled with a lack of access to care due to the stress on the health system from the immediate threat of the virus, those in recovery from a substance use disorder find themselves in an exceptionally challenging position.
The solution is twofold. First, healthcare providers need to innovate in order to reach struggling patients. Solutions like Aspenti’s mobile health unit allow healthcare professionals to reach the most vulnerable population without putting themselves or their patients at risk. Second, economic relief provided by the federal government and an expansion of unemployment benefits are crucial resources for the health of the population in these challenging times. Solutions to the pandemic and opioid epidemic are complex and intersected, but until the economic recession due to COVID-19 subsides, it is more difficult than ever for those with a history of substance use to improve their situation.
Hollingsworth, A., Ruhmn, C., and Simon, K. (2017). MACROECONOMIC CONDITIONS AND OPIOID ABUSE. National Bureau of Economic Research. https://www.nber.org/papers/w23192.pdf
Devivo, A. (2020). Aspenti Health™ launches a Mobile Unit for Urine Drug Testing Collections. https://aspenti.com/aspenti-health-launches-a-mobile-unit-for-urine-drug-testing-collections/
Robezieks, A. (2020). COVID-19 may be worsening opioid crisis, but states can take action. https://www.ama-assn.org/delivering-care/opioids/covid-19-may-be-worsening-opioid-crisis-states-can-take-action
Weiner, S. (2020). COVID-19 and the opioid crisis: When a pandemic and an epidemic collide. https://www.aamc.org/news-insights/covid-19-and-opioid-crisis-when-pandemic-and-epidemic-collide
[post_title] => When an Epidemic and Pandemic Collide: Solutions Exist and We Must Act Now
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Health care professionals are on the front lines of an unprecedented global pandemic. Whether caring directly for COVID-19-infected individuals or managing socially-distanced patients, providers are navigating new waters and drawing upon their inner strength to serve others.
On June 10th, Aspenti Health hosted a round table webinar identifying resources and techniques to mitigate provider burnout and support well-being during these challenging times. The webinar was led by Vanessa Clark, Senior VP of Operations at Aspenti Health, Jill Warrington, MD, PhD and Chief Medical Officer at Aspenti Health. Jill is also an Assistant Professor of Pathology at UVMHN. We also hosted special guest speaker, Anya Koutras, MD and Associate Professor of Family Medicine at UVMHN.
During the webinar, the following objectives were explored:
“Burnout is an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.”(I) Up to 50% of all providers are experiencing burnout at any given time. A survey of over 7,000 physicians reported that 1 in 50 planned to leave medicine altogether in the next 2 years, while 1 in 5 planned to reduce clinical hours over the next year(2). In that same survey, 46% of the responders reported at least one burnout symptom. In 2017, volume of medical school applications dropped by 14,000 (AAMC) with predictions of staggering physician shortage by 2030.
What are the top causes of burnout?
The practice of clinical medicine. We take care of hurt, sick, scared, dying people and their families, every day. We witness and help with the most difficult and challenging aspects of our communities.
Your specific job. Limited or even lack of resources for patients, third party interference with treatment plans, electronic health record issues, patient population quality measures and other non-direct patient care related stressors in our work weigh us down naturally.
Having a life. We don't live in bubbles and we are accountable to others (and ourselves) outside of our work. We've been trained since medical school to do this "when time allows."
The conditioning of our medical education. “The patient comes first." Many of us have not learned, seen modeled or have practiced how to FIRST take care of ourselves outside and inside of our work to do a better job of putting the patient first.
How can we mitigate burnout?
Begin the day with taking care of yourself.
Get plenty of rest, eat well, be active and engage in activities that fill you with joy.
Be kind and patient with yourself.
Be forgiving and understanding with yourself.
Be the healer to yourself before healing others.
When we learn to lead, listen, learn, let go, and love we are helping ourselves which in turn, helps patients.
“The most basic and powerful way to connect to another person is to listen. Just listen. Perhaps the most important thing we ever give each other is our attention…A loving silence often has far more power to heal and to connect than the most well -intentioned words" said Rachel Naomi Remen.
References:
Content provided by Jill S. Warrington, MD, PhD. Blog edited by Alexa De Vivo.
This is part two of a two part blog series on "Care for Substance Use Disorder Populations during COVID-19". The first portion of this blog covered Digital Health Transformation and Alternative Delivery Models, click here to read part one.
Regulatory requirements and payor reimbursement practices have loosened during COVID-19. As evidenced by the passage of the Coronavirus Aid, Relief, and Economic Security (CARES), some of these changes are likely to be permanent and very impactful for the SUD population (7).
In terms of Population Health Adoption, we see a reinvigorated use of data for public health applications. We have data driving predictive models for hospital capacity (8), disease spread (9) and viral genome mapping to track spread and to identify targets for vaccine and drug development (10).
These points lead us to a recognition of unmet social and behavioral health needs.
With COVID-19, we have seen health disparities by race, socioeconomic status and in access to care. Studies have demonstrated that infection and death rates for COVID-19 have been substantially higher in the African American community (11). With social distancing, there is significant concern about the frequency of depression, anxiety, substance use and domestic abuse (12).
References:
(7) http://www.lincolninternational.com/perspectives/covid-19-pandemic-could-accelerate-recent-u-s-healthcare-growth-trends, [last accessed, 5/6/2020].
(8) Kent, J. 4-6-2020. Tool helps hospitals plan for critical care surges during COVID-19. Health IT Analytics. https://healthitanalytics.com/news/tool-helps-hospitals-plan-for-critical-care-surges-during-covid-19
(9) https://coronavirus.jhu.edu/us-map, [last accessed, 5/6/2020].
(10) https://www.nytimes.com/interactive/2020/04/30/science/coronavirus-mutations.html, [last accessed, 5/6/2020].
(11) Yancy CW. COVID-19 and African Americans. JAMA. Published online April 15, 2020.
(12) https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html, [last accessed, 5/6/2020].
[post_title] => How is COVID-19 Redefining Care Delivery for the SUD Population? Part 2 [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => how-is-covid-19-redefining-care-delivery-for-the-sud-population-part-2 [to_ping] => [pinged] => [post_modified] => 2020-06-08 11:44:18 [post_modified_gmt] => 2020-06-08 15:44:18 [post_content_filtered] => [post_parent] => 0 [guid] => http://aspenti.com/?p=60310 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [3] => WP_Post Object ( [ID] => 60300 [post_author] => 13 [post_date] => 2020-05-14 15:25:27 [post_date_gmt] => 2020-05-14 19:25:27 [post_content] =>Digital Health Transformation and Alternative Delivery Models
Part one of a two part blog series on Care for Substance Use Disorder Populations during COVID-19.
Content provided by Jill S. Warrington, MD, PhD. Blog edited by Alexa De Vivo.
The COVID-19 pandemic has led to unprecedented changes globally, in our communities and in health care. Like a latex balloon that has been stretched and never bounces back to its original form, health care delivery will never be the same as we navigate through and past this emergent crisis.
The silver lining in this challenging global emergency has been the ingenuity and innovation across our country and our world. We have seen remarkable collaborations, accommodations and accelerated transformations.
Changes in health care delivery have spanned five domains of medical care. We have seen a transformation of digital health, ingenious alternatives to traditional care delivery models, adjustments in regulatory and payor strategies, an adoption of a population health approach to care and an increasing recognition of our patients’ unmet social and behavioral health needs. If progress continues in each of these domains, long-existing care gaps can be obliterated.
Digital health transformation and alternative delivery models are helping to pave the way for the future of healthcare, post COVID-19. While telehealth was being offered at most healthcare establishments in the pre-COVID-19 world, the spread of mandated stay at home orders prompted telehealth across the globe.
Large health systems such as Geisinger Health System and the Cleveland Clinic have reported a 5-10-fold increase in use of telehealth services (1). We’ve also witnessed adoption of novel strategies in surveillance and triage such as the use of Chat Bots to support patient symptom identification and facial scanners in hospitals to recognize fevers (1,2). Anecdotal reporting for the Substance Use Disorder (SUD) population suggests digital health solutions have reduced numbers of missed appointments (3).
Alternative delivery models were used before the introduction of COVID-19 but many health systems sped up the process of developing take home or remote methods for medical testing.
Prior to and in response to COVID-19, laboratory services were innovating in alternative care delivery models such as at-home blood draws (4), drone use in medical product delivery (5) and at home monitoring programs (6). Further development of these types of innovations will only be aided by COVID-19.
Part two of this blog series, "How is COVID-19 Redefining Care Delivery for the SUD Population?", will discuss regulatory shifts and population health adaption. It will also go over recognition of unmet social and behavioral health needs.
References:
1) Paddy Padmanabhan, 3-27-2020, How the COVID-19 pandemic is reshaping healthcare with technology, CIO. https://www.cio.com/article/3534499/how-the-covid-19-pandemic-is-reshaping-healthcare-with-technology.htm [last accessed, 5/5/2020].
2) Greg Nichols, 3-27-2020, Coronavirus: Business and technology in a Pandemic. Robotics. https://www.zdnet.com/article/overhead-scanners-screen-bystanders-for-signs-of-covid-19/, [last accessed, 5/5/2020].
(3) Mindy Miller, personal communication.
(4) https://www.northwell.edu/northwell-health-labs/labfly, [last accessed, 5/5/2020].
(5) Paavola A. 6 things to know about WakeMed’s drone delivery program. 2-24-2019. Becker’s Hospital Review https://www.beckershospitalreview.com/supply-chain/6-things-to-know-about-wakemed-s-drone-delivery-program.html, [last accessed, 5/5/2020].
(6) American Society of Addiction Medicine, COVID-19 Adjusting drug testing protocols. 4-29-2020. https://www.asam.org/Quality-Science/covid-19-coronavirus/adjusting-drug-testing-protocols, [last accessed, 5/5/2020].
[post_title] => How is COVID-19 Redefining Care Delivery for the SUD Population? [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => how-is-covid-19-redefining-care-delivery-for-the-sud-population [to_ping] => [pinged] => [post_modified] => 2020-05-19 13:45:43 [post_modified_gmt] => 2020-05-19 17:45:43 [post_content_filtered] => [post_parent] => 0 [guid] => http://aspenti.com/?p=60300 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [4] => WP_Post Object ( [ID] => 60244 [post_author] => 5 [post_date] => 2020-01-24 14:01:35 [post_date_gmt] => 2020-01-24 19:01:35 [post_content] =>Medication-Assisted Treatment (MAT; also known as Medications for Opioid Use Disorder; MOUD) is a lifeline for so many in treatment with Opioid Use Disorder. In particular, the combination product of buprenorphine-naloxone (Suboxone) has saved lives by preventing overdoses, reducing IV heroin-associated infectious diseases - such as HIV and Hepatitis C - and by improving patient's chance of staying in treatment.
Given the importance of buprenorphine treatment, patients at times can feel pressure to demonstrate that they are staying on the medications, even if they haven't been able to stick with the treatment plan. This can result in feelings of shame, fear of repercussions, or a desire to not disappoint their provider. As part of the disease process, patients may even be motivated by the desire to divert or sell some of their medications.
Due to these pressures, patients can occasionally engage in a practice where they "spike" the original drug directly into their urine. In this case, buprenorphine will be detected in a patient's urine, but it will not have been actually consumed. This practice will be missed on any common immunoassay-based screening method. However, if confirmation testing is ordered, both the original drug (also known as the parent drug) as well as the drug's metabolite (norbuprenophrine) will be detected.
Providers have increasingly relied upon the ratio of the metabolite norbuprenorphine to the original drug (buprenorphine), known as the N:B ratio, to identify this practice of spiking urine samples with drug. Since naloxone is also part of the Suboxone combination product, there has been some speculation that naloxone levels can also be used to highlight this practice.
Aspenti conducted a study to determine if elevated naloxone levels can be used to flag possible cases in which patients have spiked their urine with drug. Though only a small case study, this was the largest evaluation of urinary naloxone concentrations to date. We found that naloxone levels (>2000 ng/ml) may be useful clinically to flag cases of possible urine spiking with Suboxone.
To learn more about this recent study, please see the article here: https://ascpjournal.biomedcentral.com/articles/10.1186/s13722-020-0178-9.
[post_title] => Using Naloxone Levels To Detect "Spiked" Urine Tests [post_excerpt] => [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => using-naloxone-levels-to-detect-spiked-urine-tests [to_ping] => [pinged] => [post_modified] => 2020-01-27 13:38:12 [post_modified_gmt] => 2020-01-27 18:38:12 [post_content_filtered] => [post_parent] => 0 [guid] => http://aspenti.com/?p=60244 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [5] => WP_Post Object ( [ID] => 59693 [post_author] => 13 [post_date] => 2019-04-17 16:20:38 [post_date_gmt] => 2019-04-17 20:20:38 [post_content] => On Monday, April 1st China announced it would ban all variants of fentanyl, a powerful opioid. This decision is crucial because it would slow the influx of illegal fentanyl supply coming into the United States. [caption id="attachment_59694" align="alignright" width="194"]
Xi Jinping[/caption]
Chinese leader, Xi Jinping, had made this pledge to President Trump late last year and the fact that it has come to fruition this quickly is an accomplishment for both nations in the war against opioids.
The export of fentanyl from China accounts for a majority of the drugs that end up in the US, and this has caused tension between the nations in the past. There are already some regulations in place that apply to 25 variants of fentanyl but a group of manufacturers have avoided the regulations by slightly changing the molecular structure to gain a legal loophole that allows them to export the drug without government assessment of medical use and safety.
Fentanyl, is a synthetic opioid that is exponentially stronger than morphine and was originally developed to help treat pain for cancer patients. However, the drug can easily be abused and added to heroin to increase it's high effects, or even disguised as heroin. Oftentimes, users will think they are purchasing heroin but are actually purchasing fentanyl, easily resulting in overdose deaths.
The above graph reflects the change in methamphetamine/ice seizures, in terms of amount seized (in kilograms) and the total number of incidents (reported in Kg, dosage units and liter forms) within all HIDTA counties from 2011[/caption]
Individuals usually start with heroin that is being cut with meth, and then move on to straight meth. Meth users don’t feel as sick when they are coming down from the high and meth is cheaper than heroin. However, despite meth being an easier option for it’s users, it is not for treatment options within hospitals and clinics.
Meth overdoses have increased across the United States, and while we may not see the full impact of the influx of meth in Boston right now, it'll show up in a few years. The meth issue is compounding the opioid epidemic, because while patients addicted to fentanyl or heroin are usually prescribed a medication to curb cravings, patients have been trying to use meth while in treatment for their opioid addiction to help cope. It appears the opioid epidemic has set itself on a larger scale, with cocaine and methamphetamines and is becoming more of a drug epidemic.
References:
Martha Bebinger (2018). Meth Use Is Rising In Boston, Intensifying The Opioid Crisis. http://www.wbur.org/commonhealth/2018/11/21/meth-worsening-opioid-epidemic
National Emerging Threats Initiative (2018). Emergening Threats Report 2018: Status and Factors Affecting the United States. https://d279m997dpfwgl.cloudfront.net/wp/2018/11/1120_emerging-threats-report.pdf
[post_title] => Why is Meth Use on the Rise in Boston?
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[post_content] => Aspenti was included in a round table discussion with Governor Phil Scott regarding hiring recovering opioid addicts. “We care tremendously about recovery-friendly workplaces,” said Al Gobeille, Vermont’s Department of Human Services secretary. Gobeille went on to add, "The biggest thing the state does is we provide medically assisted treatment that allows people to get treatment for their addiciton, and then we try to couple that with employment opportunities."
There are about 8,000 people in treatment for opioid use disorder, according to the state’s agency of human services. Watch the news story here to learn about how employers are helping support recovering Vermonters seeking a fresh start.
[post_title] => Local Vermont Businesses Helping Recovering Addicts Find Employment
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[post_content] => Our kids are getting the message!
Like you, my readers, I find myself simultaneously worrying and hoping much of the time. With constant exposure to essential information regarding opioid use in America, it can be difficult to feel optimistic. Well here is some good news to start off the New Year!
There is ample reason for our country to celebrate this New Year, as one reviews the recent findings of the 2017 Monitoring The Future Study, https://www.drugabuse.gov/news-events/news-releases/2017/12/vaping-popular-among-teens-opioid-misuse-historic-lows. This study clearly reflects the ability of our youth to make healthy decisions when they are guided by the attention of adults in leadership positions, providing them with accurate information regarding drugs and decision-making skills.
Our Prevention Programs are working.
At a recent teleconference I attended led by Dr. Nora Volkow, NIDA Director, I learned adolescent tobacco use is at an all-time low since 1979.
Dr. Johnson of the University of Michigan, the Principal Investigator of this study for 42 years, stated that there has been a “tremendous decline in cigarette smoking since the mid-90s, the most prevalent cause of preventable death and disease in America.” Dr. Volkow also noted significant decreases in alcohol and pain-medication use.
Reasons For Celebration
I tuned in to the President’s Commission on Combating Drug Addiction and the Opioid Crisis’ announcement of its Final Report on November 1, with the hope that the Commission had independently done its homework and arrived at meaningful recommendations for our country’s health.
I was not disappointed.
While the broadcast itself lasted much longer than I had planned, (over two hours), I found myself thoroughly engaged from the opening comments to the unanimous vote to adopt the committee’s recommendations.
What was striking about the broadcast was the human emotion expressed by the committee, the empathy in the chamber, and the scientific data and decades of experience in this field available to the leadership. If the Administration chooses to fully utilize the potential at its disposal, as recommended by the Commission, we will be looking back at this era someday as history, rather than wondering why “history repeats itself”.
Dr. Bertha Madras, well-noted chair of the Division of Neurochemistry at Harvard Medical School, was the lead author of the 131-page final report. Dr. Madras advised “If we don’t stop the pipeline into substance use, if we don’t promote prevention, we are going to have an open-ended catastrophe that goes on for generations.”
The human tragedy and immeasurable anguish associated with this crisis was poignantly and powerfully communicated by Doug Griffin.
Mr. Griffin, a father from Newton, NH, talked about how his daughter, Courtney, struggled with opioids. Courtney died at age 20, from an overdose. Mr. Griffin, sobbing, ended his testimony with, “I pray your children are spared from this plague, and that you never know what it’s like to be me.”
As unimaginable as it may seem, to really understand the depth and magnitude of America’s drug crisis, we need to multiply Mr. Griffin’s pain by 64,000 in 2016; this is the estimated number of drug overdose deaths for that year according to preliminary data from the Centers for Disease Control and Prevention. One death every seven minutes.
The Commission’s Final Report was issued November 1, 2017…
This Blog was written on November 20, 2017…
One death every seven minutes equals 3,908 overdose deaths since the Commission’s Report. Yet there have been 0 words from the Administration regarding funding intentions or planning in response to the Report.
A link to the Commission’s Full report, and a link to a PBS analysis of the Commission’s formal announcement, including the video, are noted below. These are both worth a very close look when time permits.
Only a well-informed public can influence its leaders in meaningful and appropriate ways.
Commission’s Final Report
https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Meeting%20Draft%20of%20Final%20Report%20-%20November%201%2C%202017.pdf
PBS NEWSHOUR Summary and Video of the Commission’s announcement (Please note there is a 44 ½ minute delay in the video’s beginning. Viewers can easily advance to the starting point)
https://www.pbs.org/newshour/health/watch-live-trumps-opioid-commission-slated-to-release-final-report
[post_title] => Opportunity Knocks: The President’s Commission On Combatting Drug Addiction And The Opioid Crisis’ Final Report
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The intersection of COVID-19 and the opioid epidemic put the American healthcare system in a challenging position. Cases surge throughout the country, forcing hospitals to focus on the immediate public health threat of COVID-19 rather than other ongoing public health concerns. Despite declining media coverage of the opioid epidemic, studies show an increase in substance use since late March of 2020 indicating a worsening of the epidemic. The American Medical Association attributes social distancing, a dramatic increase in unemployment, and widespread economic deterioration to the overall increase in feelings of isolation and anxiety, which are common triggers of substance use disorders. Beyond that, COVID-19 presents a unique set of challenges for those in recovery; treatment centers, and outpatient services operate differently if at all due to social distancing guidelines.
Another major cultural shift results from the lack of a unified response to COVID-19 from the US federal government; American citizens continue to lose their jobs. Preliminary research shows that unemployment is one of the largest contributors to the increase in substance use disorders during COVID-19. Daniel Buccino of the Johns Hopkins Broadway Center for Addiction writes, “At first, some of our patients were resilient and resourceful in staying drug-free. As time went on, it started getting harder for them” (Winer 2020).
Unemployment has increased dramatically due to COVID-19, but the issue has been tied to opioid use before COVID-19. Research conducted in 2017 by economists at the National Bureau of Economic Research found that “As the county unemployment rate increases by one percentage point, the opioid death rate per 100,000 rises by 0.19 (3.6%) and the opioid overdose ED visit rate per 100,000 increases by 0.95 (7.0%)” (Hollingsworth, Ruhm and Simon 2017). Macroeconomic shock affects opioid use in “normal” times making the COVID-19 pandemic a perfect storm as it brings economic downturn and mass unemployment coupled with isolation and uncertainty. Coupled with a lack of access to care due to the stress on the health system from the immediate threat of the virus, those in recovery from a substance use disorder find themselves in an exceptionally challenging position.
The solution is twofold. First, healthcare providers need to innovate in order to reach struggling patients. Solutions like Aspenti’s mobile health unit allow healthcare professionals to reach the most vulnerable population without putting themselves or their patients at risk. Second, economic relief provided by the federal government and an expansion of unemployment benefits are crucial resources for the health of the population in these challenging times. Solutions to the pandemic and opioid epidemic are complex and intersected, but until the economic recession due to COVID-19 subsides, it is more difficult than ever for those with a history of substance use to improve their situation.
Hollingsworth, A., Ruhmn, C., and Simon, K. (2017). MACROECONOMIC CONDITIONS AND OPIOID ABUSE. National Bureau of Economic Research. https://www.nber.org/papers/w23192.pdf
Devivo, A. (2020). Aspenti Health™ launches a Mobile Unit for Urine Drug Testing Collections. https://aspenti.com/aspenti-health-launches-a-mobile-unit-for-urine-drug-testing-collections/
Robezieks, A. (2020). COVID-19 may be worsening opioid crisis, but states can take action. https://www.ama-assn.org/delivering-care/opioids/covid-19-may-be-worsening-opioid-crisis-states-can-take-action
Weiner, S. (2020). COVID-19 and the opioid crisis: When a pandemic and an epidemic collide. https://www.aamc.org/news-insights/covid-19-and-opioid-crisis-when-pandemic-and-epidemic-collide
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