Pandemic Has Unanticipated Consequences

The COVID-19 pandemic has placed incredible and truly unprecedented stress on the domestic health care system. The need to shift the focus of our limited resources and the demand that that course correction has placed on our health care colleagues and staff members have been a part of our daily lives for more than a year. Unfortunately, the need to manage the complications and consequences of this devastating viral pandemic has diverted much attention from the many health care needs of communities and patients in ways that are having unanticipated consequences. Although we are cautiously optimistic that the highly effective vaccines we are busily getting into arms are going to bering a return to normalcy, the likelihood is that some aspects of the health care landscape have shifted, and much work will be needed to address these shifts. In addition, the stress of social distancing, unemployment, and other consequences of COVID-19 are amplifying some of the health care needs of communities as we emerge from this pandemic.

The health care community and the media have been sounding the alarm about the mental health impact of the pandemic, and there are significant concerns that an already overtaxed mental health care system may be overwhelmed. For example, the most recent data from the Household Pulse Survey for the first 2 weeks of March 2021 showed that 36.8% of adults surveyed reported symptoms of anxiety or depressive disorders compared with 11.0% from January to June 2019 using a similar methodology.¹

Before the pandemic, the opiate crisis was one of the most widely discussed issues in health care, and the relative silence on this topic during the past year could be mistakenly interpreted. The rate of overdose deaths has in fact accelerated since the start of the pandemic, with 81,000 drug overdose fatalities in the 12 months ending May 2020, the highest number ever in a 12-month period. The primary driver is synthetic opiates (primarily illicitly manufactured fentanyl), with a 38.4% year-over-year increase from 2019 to 2020.² On the other side of this pandemic, the opiate crisis will loom larger than ever. Alcohol consumption and abuse have also increased significantly during the pandemic. One survey-based study reported an overall increase in alcohol consumption of 14% compared with baseline data from 2019.³ In another cross-sectional survey, 60% of respondents reported increased alcohol consumption compared with 13% reporting a decrease pre–COVID-19. Also, 34.1% reported binge drinking and 7.0% reported severe binge drinking episodes.⁴

A recent publication reported a steep increase in hospitalizations due to alcohol-related diseases, including acute liver failure and alcoholic hepatitis. Although national numbers are not yet available, one hospital in Southern California reported a 30% increase in alcohol-related admissions in 2020 compared with 2019.⁵

When speaking about the substance abuse increases during the pandemic, Robert Redfield, MD, former director of the CDC, said, "As we continue the fight to end this pandemic, it's important to not lose sight of different groups being affected in other ways. We need to take care of people suffering from unintended consequences."²

The delays and interruptions in maintenance and preventive health care due to the pandemic also carry the risk of unanticipated consequences. Two examples are reductions in scheduled childhood vaccinations and delays in routine cancer screening. For instance, recent testimony from the CDC to Congress stated that from 1994 to 2016, childhood immunizations prevented an estimated 855,000 child deaths, 281 million child illnesses, and nearly $1.65 trillion in health care costs.⁶ However, early in the pandemic, the number of childhood vaccines decreased significantly across all age cohorts, with children enrolled in Medicaid at greatest risk.^7-9 Although pediatric care providers have been working diligently to catch up during the later portion of the pandemic, millions of missed vaccinations have left children susceptible to epidemics of vaccine-preventable diseases, including measles, meningitis, and pertussis.

Furthermore, the results of multiple studies have shown a pronounced decrease in routine screening for breast, cervical, colon, lung, and other cancers.¹⁰ One report from a single medical center in the Northeast estimated that over a 3-month period during the pandemic, about 1400 cancerous or precancerous diagnoses were missed.¹¹ These delays or missed diagnoses will put patients at risk for presentation at more advanced stages of cancer, different and more aggressive therapeutic interventions, and other serious complications.¹⁰

The unanticipated consequences of both the pandemic and the prioritization of its management are likely to result in continued high demands on the health care system as we emerge from the pandemic. We should be prepared for this shift affecting our return to "normal."

REFERENCES

1. Anxiety and depression. CDC. Updated April 7, 2021. Accessed April 13, 2021. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm

2. Overdose deaths accelerating during COVID-19. News release. CDC. December 18, 2020. Accessed March 31, 2021. https://www.cdc.gov/media/releases/2020/p1218-overdosedeaths-covid-19.html

3. Pollard MS, Tucker JS, Green HD Jr. Changes in adult alcohol use and consequences during the COVID-19 pandemic in the US. JAMA Netw Open. 2020;3(9):e2022942. doi:10.1001/jamanetworkopen.2020.22942

4. Grossman ER, Benjamin-Neelon SE, Sonnenschein S. Alcohol consumption during the COVID-19 pandemic: a cross-sectional survey of US adults. Int J Environ Res Public Health. 2020;17(24):9189. doi:10.3390/ijerph17249189

5. Knopf A. Pandemic linked to rise in alcoholic hepatitis and liver failure. Alcohol Drug Abuse Wkly. 2021:33(9):7. doi:10.1002/adaw.32988

6. U.S. public health response to the measles outbreak. CDC. February 27, 2019. Accessed April 13, 2021. https://www.cdc.gov/washington/testimony/2019/t20190227.htm

7. King K. Pediatricians are concerned with declines in well-child visits and vaccines during COVID-19. Children’s Defense Fund. May 13, 2020. Accessed on March 31, 2021. https://www.childrensdefense.org/blog/pediatricians-are-concerned-with-declines-in-well-child-visits-and-vaccines-during-covid-19/?gclid=EAIaIQobChMIgenZv5nU7wIVFoizCh3R-Ao9EAAYASAAEgKwZ_D_BwE

8. Santoli JM. Lindley MC, DeSilva MB, et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration – United States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(19):591-593. doi:10.15585/mmwr.mm6919e2

9. Bramer CA, Kimmins LM, Swanson R, et al. Decline in child vaccination coverage during the COVID-19 pandemic — Michigan Care Improvement Registry, May 2016–May 2020. MMWR Morb Mortal Wkly Rep. 2020;69(20):630-631. doi:10.15585/mmwr.mm6920e1

10. Mitchell EP. Declines in cancer screening during COVID-19 pandemic. J Natl Med Assoc. 2020;112(6):563-564. doi:10.1016/j.jnma.2020.12.004

11. Bakouny Z, Paciotti M, Schmidt AL, Lipsitz SR, Choueri TK, Trinh QD. Cancer screening tests and cancer diagnoses during the COVID-19 pandemic. JAMA Oncol. 2021;7(3):458-460. doi:10.1001/jamaoncol.2020.7600

ABOUT THE AUTHOR

Curtis E. Haas, PharmD, FCCP is the chief pharmacy officer for the University of Rochester health care system in New York.