Syndemic: The Opioid Epidemic, COVID-19, and an Epidemic of Firearm Violence

Syndemics are intertwined epidemics, each exacerbating the other. We are all familiar with the syndemic of the opioid epidemic and the COVID-19 pandemic (1, 2), and we have seen this association in our hospital. In her opinion article (2), Dr. Volkow, Director of the National Institute on Drug Abuse at the National Institutes of Health, outlines the increased risks patients with substance use disorders faced from all directions during the early stages of the COVID-19 response. The number of firearm-related injuries is growing contemporaneously. Calls to label the prevalence of firearm injury as an additional epidemic are increasing as well (3). In their recent editorial (3), Drs. Laine and Bornstein connect increasing firearm violence with increasing firearm ownership. They urge us to meet this crisis with the same resolve with which we have faced COVID-19 and the opioid crisis. The spate of firearm-related injuries is compounding the already heavy burden of disease from opioid use disorder and COVID-19, adding additional complexity to the syndemic framework. Several recent patient interactions have prompted the following reflections on these connected crises.

Health system e-mails remind us to ensure that doors close behind us and to review the “active shooter” training modules. Underscoring the necessity of this training, we met a patient admitted under an alias suffering from traumatic injuries from physical and sexual violence at the hands of their partner. Even while we managed their injuries and opioid withdrawal, I wondered about the patient’s AND my team’s safety should the partner learn of the patient’s whereabouts. What would I do if the partner arrived on the unit wielding a handgun? Instead, the patient self-directed their discharge, and we felt an overwhelming sense of failure, fearing for the patient’s well-being outside of our care.   

Another patient had been purchasing methadone illegally before admission. An abdominal gunshot wound piercing their spine changed everything—they required high doses of methadone for acute pain in addition to treating the substance use disorder. Now, the patient is unable to walk. How will they access life-saving, evidence-based treatment requiring daily dosing at an outpatient treatment program? Moreover, in yet another tragic twist, the number of patients in our community seeking care for opioid use disorder with methadone far exceeds the capabilities of the 2 outpatient methadone treatment programs in town—they are no longer accepting new patient referrals. Staffing shortages due to COVID-19 interfere with the ability of patients to receive appropriate care.  

I worried about another patient’s repeated requests for intravenous hydromorphone. Hospitalized for a surgical wound infection, the patient was getting objectively better with antibiotics and supportive care. The patient and I discussed moving to oral opioid pain medications and trialing nonopioid adjunctive medications. These suggestions were met with resistance: "I am allergic to nonsteroidal medications." "I will vomit anything oral because my insides are burning." Using language absorbed at required continuing medical education lectures on opioids, I expressed concern about the potential harms of continuing opioids. We talked a little about my other work—helping people with opioid use disorder. I described my experience with seeing lives and relationships destroyed by addiction, addiction often taking hold after use of prescription opioids. My patient brushed aside my concerns. And on the day on which a physician was murdered in Tulsa, Oklahoma by a patient seeking pain management, I retreated. Although I knew the responsible path, I continued intravenous opioid medication instead.  

Physicians are finding themselves involved in aspects of all of these public health crises because these crises are playing out at the hospital bedside and in the clinic examination room as well as in courtrooms, schools, and grocery stores. As healers, restoring the health of the human in our care is the core tenet of our oath. Thick in the syndemic of fentanyl and violence, exacerbated by the ongoing unknowns and stressors of COVID-19, physicians face crushing grief and emotional strain on behalf of our teams and our patients. However, when violence threatens our ability to do our work, patients will suffer too. Flashing a firearm in an urgent care parking lot or threatening violence in the emergency department does little to engender a therapeutic alliance between physician and patient. Yet these are now commonplace occurrences in health care, and sometimes just a looming notion of violence forces us to rethink medical decisions and change the way we practice medicine. Even at the conclusion of this writing, another violent incident at our sister hospital has reminded us about the current involution of violence and health care.

References 

1. Alexander GC, Stoller KB, Haffajee RL, et al. An epidemic in the midst of a pandemic: opioid use disorder and COVID-19 [Editorial]. Ann Intern Med. 2020;173:57-8. [PMID: 32240283] doi:10.7326/M20-1141
2. Volkow ND. Collision of the COVID-19 and addiction epidemics [Editorial]. Ann Intern Med. 2020;173:61-2. [PMID: 32240293] doi:10.7326/M20-1212 
3. Laine C, Bornstein SS. Firearm injury in the United States: time to confront it as the epidemic it has become [Editorial]. Ann Intern Med. 2022;175:897-8. [PMID: 35377712] doi:10.7326/M22-0865