COVID-19, Medication-Assisted Treatment, and Increased Risk for Further Respiratory Depression

To the Editor: The COVID-19 infection is characterized by respiratory distress, which has sparked Herculean efforts to increase the supply of ventilators in the United States. Even as the medical establishment races to cope with this pandemic, clinical authorities continue to emphasize the need for opioid agonist treatment, more commonly known as medication-assisted treatment, which includes methadone and buprenorphine. In fact, longstanding rules are now being relaxed to allow people receiving medication-assisted treatment to receive a full 28-day supply of their medication to decrease the spread of the novel coronavirus at treatment centers. Medication-assisted treatment has been demonstrated to significantly decrease mortality associated with substance use. In their recent epidemiological study, Pearce et al. demonstrated that the relative risk of mortality off of medication-assisted treatment was 2.1 (1).

In considering the overall health of Americans, including those with known respiratory compromise secondary to long-term tobacco use, asthma, and bronchitis, as well as chronic obstructive pulmonary disease in the elderly and the possibility of respiratory compromise related to vaping among the young, it is important to remember that many of these same patients are also taking prescribed opiates and/or may be misusing opiates. Further, it is essential that those prescribing medication-assisted treatment are acutely aware that these opiate agonists and agonist/antagonists are also capable of causing significant respiratory distress (2). Finally, it is important to remember that benzodiazepines (especially when combined with opiates) are associated with respiratory depression in patients with other respiratory challenges (3).

Patients prescribed opiates and benzodiazepines should be advised of these risks and collaborate with their care team to establish the lowest effective dosage of their medications during this pandemic. If nothing else, it is always prudent to periodically review dosages of controlled substances to ensure safety and satisfaction. In cases in which the patient becomes symptomatic and/or has tested positive for COVID-19, clinicians are advised to discuss at least temporarily decreasing the dosage and quantity of prescribed opiates or medication-assisted treatment. In addition, clinicians need to be aware of the availability and value of naltrexone inhalers, which, if prescribed, could prove lifesaving in a patient with respiratory compromise that has been exacerbated by an opiate or opioid agonist treatment.