Is opioid use also a risk factor for Covid-19 disease severity?
The pathogenicity of the SARS-Cov 2 virus and the risk factors for disease severity of Covid-19 are still being elucidated amongst different population groups(1). Meanwhile, the Opioid crisis is estimated to cause the deaths of 130 people in the USA per day(2), and opioid prescribing has been rising in many other countries(3). The use of opioids for chronic non-cancer pain is controversial and this has led to the World Health Organization withdrawing its opioid guidelines in 2019(4). As Stannard states, the “US opioid crisis is a story that keeps on giving”(5), and we wonder what effect Covid-19 will have on those members of the population who are using high-dose opioids, especially when the benefits are questionable.
Whilst the benefits may be questionable, the harms are not. The chronic use of high dose of opioids is associated with side effects which may increase disease severity of Covid-19. Opioids definitely interact with the immune system(6) and may decrease immune responses(7). Sleep-disordered breathing is exacerbated by opioids(8) and opioid induced ventilatory impairment is well described in both the post-operative(9) and obese(10) population groups. These opioid effects may point to pathophysiological causes for the increased the risk of pneumonia(7) seen in patients on opioids. Our own anecdotal (non-Covid-19) experience is that patients on high dose opioids are commonly only a severe infection away from opioid toxicity. In addition, opioids and other sedating agents are often weaned and ceased during their intensive care stays.
We acknowledge the importance of patients remaining on opioid agonist treatment in a harm minimisation paradigm(11). However, in some situations (where the patients and their treating clinicians are willing and able) the Covid-19 pandemic may provide further motivation, incentive and opportunity to reflect on opioid prescribing practices given the risks might outweigh the benefits. Opioid use, in our opinion, is modifiable, and by extension a modifiable potential risk factor during the Covid-19 pandemic.
At this point, we must stress that this link between Covid-19 and opioid use is purely speculative, as we were unable to find any published data looking specifically at associations between Covid-19 and opioid use. Given that most early data emerged from China, and given China’s history with opioids, it is unlikely that opioids played a role in disease severity there. However, now that Covid-19 is spreading quickly in Western countries where opioid use is problematic, we feel that collecting this data should be a matter of some urgency. This data may be difficult to collect but it is certainly not impossible in the age of electronic medical records. We therefore call for formal epidemiological studies analysing the relationship between Covid-19 disease severity and opioid use so that we might better stratify patient population risk to guide treatment decisions.
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11. Pearce LA, Min JE, Piske M, Zhou H, Homayra F, Slaunwhite A, et al. Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study. BMJ [Internet]. 2020 Mar 31 [cited 2020 Apr 3];368. Available from: https://www.bmj.com/content/368/bmj.m772
Competing interests: No competing interests