Localized Syndemic Assemblages: COVID-19, Substance Use Disorder, and Overdose Risk in Small-Town America

Localizing the Syndemic Assemblage

As mentioned, we adopt a locally situated perspective. In so doing, we join other researchers addressing issues of locality within the larger global impact of COVID-19. For instance, research shows how community-based organizations (CBOs) in the San Francisco Bay Area shifted their services to better address inequality in the social and structural determinants of health amid the COVID-19 pandemic (Cohen et al. 2022, this issue). SUD and overdose rates varied between urban and non-urban places before the COVID-19 pandemic (Monnat and Rigg 2016; Young, Havens, and Leukefeld 2012). This variation, however, shifted in response to the pandemic. For instance, state-mandated stay-at-home orders were associated with a 17.59 percent increase in overall incidence of overdose nationwide and with increases in overdose numbers in 61.84 percent of counties monitored by the Overdose Detection Mapping Application Program (ODMAP) (Alter and Yeager 2020a, 2020b). Notably, ODMAP reports from five U.S. states detailed a shift in the most severe overdose issues from urban to non-urban counties (Alter and Yeager 2020a, 3). Overdose numbers soared in rural areas, suburbs, small-town micropolitans, and the infrastructurally interdependent surrounding micropolitan statistical areas (µSAs) (Alter and Yeager 2020a, 3).

With the shift from rural to urban in mind, we use a localizing view of the global COVID-19 pandemic. Thus we consider how global processes influence conditions within a locality as, in turn, local actors and conditions shape the relevance of global contexts (Long 2003). Addressing syndemics through a localizing perspective offers an opportunity to study the interconnections between diseases and specific local conditions. We therefore conceptualize localized syndemic assemblages as a combination of two or more diseases, as enhanced or attenuated through relevant laws, policies, and practices, and situated within the context of specific local conditions.

Site of the Research

Sandusky, Ohio, is a Rust Belt town with a population of approximately twenty-five thousand residents, situated along the shoreline of Lake Erie (U.S. Census Bureau 2019). Sandusky, and the rest of Erie County, comprise the Sandusky µSA. The main industry is tourism and hospitality. The town’s main tourist attraction, Cedar Point Amusement Park, draws millions of visitors to the area annually (OLESI 2017). Despite the popularity of Cedar Point, Sandusky has had decades of economic uncertainty and has poverty and violent crime rates far above the national average (U.S. Census Bureau 2019; Hackworth 2018). Sandusky also hosts a thriving illicit drug market, as evidenced by a recent seventeen-count indictment in U.S. District Court involving seven Sandusky residents, and by several other court cases in recent years, including State v. Reed,³ State v. Leavell,⁴ and State v. Nettles (Dunn 2019).⁵ The town’s vital tourism industry, perennial economic blight, and active clandestine drug economy establish Sandusky as a dynamic research setting, full of complexity, and contradictions. This dynamism provides a distinct challenge to existing conceptions of small-town life and the potential impact a global pandemic may have on the lives of small-town residents.

Police Data on Substance Use and Overdose

Figure 1 plots the number of drug-related police interactions in Sandusky in recent years, demonstrating the pervasive presence of illicit psychoactive substances. At first glance, the number of drug-related police contacts in Sandusky for 2020 may suggest a decrease in drug availability, as the number represents a seven-year low. In truth, this mirrors the national trend during the early months of the COVID-19 pandemic as policing priorities changed and overall crime rates declined (Abrams 2021; Sisak, Bleiberg, and Dazio 2020). Notably, the decrease in police drug contacts is far less pronounced in Sandusky than in most major metropolitan areas during, and because of, stay-at-home orders (Abrams 2021).

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Figure 1.

Yearly Number of Drug Contacts by Sandusky Police

Source: Authors’ tabulation.

Figure 2 compares the number of overdose calls in each matched month of the studied period. Despite decreased drug contacts overall, overdose calls increased during the COVID-19 period. From April to June 2020, when unemployment was highest in Erie County and tighter restrictions caused social and economic uncertainty, the number of overdose-related calls for service significantly outpaced the prior year. The month with the highest overall calls for service, August 2020, coincided with a significant spike in overdoses in the county (Jackson 2020a). More overdose calls were made for service during the COVID-19 period in eight out of the eleven months relative to the pre-COVID period. The COVID-19 period also had a higher number of overdose calls for service overall.

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Figure 2.

Overdoses in Sandusky

Note: March 9, 2019, through January 31, 2020, and March 9, 2020, through January 31, 2021.

Source: Authors’ tabulation.

Overdose Reversal and Official Use of Narcan

Glyph reports demonstrate that knowledge of signs of overdose, access to Narcan, and changes in drug policy all factor into the official SPD overdose response, both before and during COVID-19. In their reports, officers regularly explain how they know someone was experiencing an overdose. Common symptoms of overdose noted by officers include pinpoint pupils, skin with a blue or purple hue, trouble breathing, and appearing lifeless. Officers used these observations and any information from witnesses on the scene to justify deploying Narcan before emergency medical services (EMS) arrived. Narcan had a positive effect in most cases, though sometimes it took multiple doses from police officers and other first responders. Officers applied numerous medical techniques to reverse an overdose. For instance, one report stated, “An officer attempted a sternum rub in attempts to wake Bonnie. I administered 2 doses of nasal Narcan with attempts to rouse [her] between them. Bonnie was barely breathing and still unconscious. SFD arrived on scene and administered an additional 8 doses of Narcan.”

Police employed sternum rubs and cardiopulmonary resuscitation (CPR), sometimes in tandem with the deployment of Narcan. In total, Narcan was deployed in 71 percent of overdose calls across both study periods.

Officers relied on prior knowledge of an individual’s substance use history in their decision to deploy Narcan. The data included several such cases, reports referencing as many as five prior overdoses known to the police. One officer explained his decision-making calculus: “I had prior knowledge that Danielle was [a] user of opiates so I administered 1 dose of Narcan and began chest compression to get the oxygen moving through her lungs. I received reaction to the first dose and administered another. I continued the compressions and [she] woke up.”

This excerpt illustrates an essential aspect of small-town police involvement in life-saving medical treatment. The likelihood is greater that police officers in small-town settings might be familiar with prior drug use or overdose among their constituents than their counterparts in larger jurisdictions.

Police capacity to respond to the incidence of overdose relies heavily on the information of bystanders and their capacity to contact authorities. Before COVID-19, this capacity was greatly expanded by Ohio’s Good Samaritan Laws. Friends, acquaintances, or strangers that witnessed an overdose, whether in a private residence or public space, could dial 911 and report the incident, even if they might otherwise fear their own drug charges from such an interaction. As we show later, the social isolation from stay-at-home orders meant to stop the spread of the coronavirus had the unintended consequence of reducing the likelihood that an eyewitness would be present at the time of an overdose. Relatedly, as the next section illustrates, a well-informed citizenry, once able to react immediately to an overdose event, was rendered ineffectual by social distancing guidelines.

Civilian Narcan Use

Before COVID-19, Glyph reports describe bystanders, friends, family, and other witnesses deploying Narcan directly before police arrived at an overdose call. One report reads, “On arrival, I was directed to the kitchen where Otto was unconscious on the floor. Several empty packs of Narcan were laying next to [him]. There were several subjects in the residence who left as soon as I arrived.”

Bystander deployment of Narcan has important implications. First, it illustrates community members’ awareness and the capacity to recognize and reverse an overdose. Lisa told officers that a man had overdosed in front of her in one such incident: “so she ran next door and borrowed Narcan from the neighbors.” Lisa’s actions represent cases where bystanders might not have Narcan on their person but possess knowledge of other community members who do. Witnesses provided detailed information to SPD, local EMS, or Sandusky Fire Department (SFD) regarding Narcan administration.

Second, an unknown number of residents have overdosed and avoided contact with police through peer or bystander intervention. Prior to the COVID-19 pandemic, this meant that someone using substances with overdose potential could rely on a friend or co-user to reverse an overdose if needed. During the COVID-19 period, however, social isolation and long-term stay-at-home orders enhanced this population’s vulnerability, due to a lack of available bystanders to witness and report an overdose.

Law, Policy, and Procedure

The Glyph reports document the enactment of Good Samaritan Laws before the emergence of COVID-19. SPD officers cross-referenced a mobile digital terminal system, called ALERT, to determine whether criminal charges were warranted at the scene of an overdose. In keeping with Ohio law, one officer reported as follows: “I checked ALERT and learned that Richard had no previous overdoses, so Richard will not be charged with Possession of Marijuana or Drug Paraphernalia. Due to this, these items were retained and placed in the Evidence Receiving Room (ERR) for disposal.”

Richard, an eyewitness who might have otherwise fled the scene without contacting authorities, reported the overdose and stayed onsite long enough to interact with the reporting officer. Examples such as these provide instrumental insight, further illustrating the importance of Good Samaritan Laws. Unfortunately, the need for social distancing necessarily reduced the efficacy of these laws, contributing to the syndemic effect of COVID-19 on overdose prevention.

Drug User-Dealers, Narcan, and the Availability of Narcotics

As confirmed in police Glyph reports, substances such as the highly potent synthetic opioid fentanyl, and its more concentrated analog carfentanil, remained readily available in the local drug supply alongside cannabis, methamphetamine, and other psychoactive substances. Although less readily available than methamphetamine and fentanyl, heroin and cocaine are also present throughout the study period. Frequently, substances sold as heroin or fentanyl may instead contain carfentanil or some other, highly concentrated opioid, making the potency variable and the risk of overdose greater. Our data shows that, for this and several reasons, many local user-dealers, those who both use and sell illicit psychoactive substances, maintain a ready supply of Narcan.

Much of our information on the inner workings of the local drug market comes from Zachary, a one-time user-dealer and frequent user of heroin, fentanyl, and methamphetamine. Zachary has intimate and extensive knowledge of local fentanyl and methamphetamine availability in Sandusky. Zachary informs us that he regularly purchases fentanyl from as many as six user-dealers, many of whom he has known most of his life.

User-dealers often use their residences for illegal drug sales. Most people selling fentanyl expect buyers to use some portion of their product onsite in front of them to prove that they are not working with the police. This, however, creates an additional concern: the potential for a customer to overdose onsite. According to Zachary, the concern, then, is that if an overdose proves fatal, the user-dealer might then “catch a body,” that is, be charged with involuntary manslaughter. These concerns motivate user-dealers to maintain a supply of Narcan in house. Zachary illustrates such a scenario: “My one buddy, I’ve known him forever. He sells dope. So, like I said, somebody went to his house to get some. And he wasn’t letting nobody use at his house because of that reason, but he must have been comfortable letting this kid. I don’t know how long, how much he did, but he f—ing fell out. Luckily, they had Narcan at the house. The Narcanned him and brought him back to, but it’s just too scary, man.”

User-dealers have multiple reasons to maintain a ready supply of Narcan to prevent the death of friends and customers and prevent their overdoses. Zachary’s account mirrors the use of Narcan by ordinary citizens in the Glyph reports but also confirms that, unbeknownst to police and official records, nonfatal overdose events are occurring in the community.

To further supplement official police data on area overdoses, we spoke with Joe, an EMT and 911 dispatcher working in the Sandusky µSA. Joe has extensive and up-to-date knowledge of the local overdose problem. Although police are routinely onsite for overdose calls, EMTs are more intimately acquainted with the outcomes of overdose victims, whether fatal or otherwise. Joe’s experience as a small-town EMT includes responding to overdose calls for friends, neighbors, and relatives. According to Joe, and later corroborated by a few of his fellow EMTs, this was a common occurrence before COVID-19. As stressful and emotionally tasking as his position was before COVID-19, Joe later explains that the pandemic made the local drug problem, and his job more broadly, significantly worse. We next provide an in-depth description of the syndemic impact of COVID-19 on first responders, substance users, and recovery support personnel in the area.

Recovery Services During COVID-19

One major local syndemic effect in the early months of the pandemic was the short-term loss and long-term impediment of community-based and professional addiction services, such as 12-Step groups and intensive outpatient programs (IOPs). The recovery professionals we interviewed implicated social distancing guidelines in an inability to provide official and unofficial addiction and recovery services. The result, according to our interview participants, was a rise in relapses that led to the spike in overdose deaths during the early months of the pandemic.

The lack of available services, along with the implicit need to move in-person services to virtual left several within the local recovery community uneasy. In the early days of statewide and national shutdowns, Howard, a CPRS, began implementing a plan to host virtual meetings through SARCC. As a person in addiction recovery with a 12-Step background, Howard values his anonymity and initially expressed reluctance in virtual meetings, saying, “my confidentiality is shot, I didn’t have any interest in it.” Still, he began the process and became a major proponent for virtual recovery meetings. Additionally, Howard and his partner are both immunocompromised and cite virtual meetings as a significant factor in their continued health and wellness.

Months after the initial shock of global shutdown and widespread social isolation, most 12-Step and similar recovery meetings switched from an in-person to a virtual meeting format or went to a group telephone system. Despite these resources, many area residents still had no way to access these services. A few CPRS and volunteer peer supporters point out that not all their clients have access to laptops or smartphones. Many vulnerable people became isolated during stay-at-home orders because of this new digital divide.

Gary, a CPRS who personally relies on 12-Step recovery meetings, decided to start an open-air Narcotics Anonymous (NA) meeting in a public park while social distancing guidelines still limited public gatherings. Gary estimates that this weekly NA meeting averages fifteen to twenty people, more than the CDC recommendation for public gatherings at the time. Gary expressed a belief that the need for in-person meetings outweighed the potential risk of COVID-19 transmission: “For a while we didn’t have meetings. I think after like seventy-five or eighty days, and a few phone calls from people I said, well, you know what, let’s get together. You know, I got a lot of people [saying] ‘no, no, no, no.’ I said, well, the disease [of addiction] is running rampant right now. We need to get together. Sometimes, just the fellowship helps you.”

Gary’s assertion that addiction is “running rampant” during the early months of the COVID-19 pandemic, though it does not fully recognize the safety concerns inherent in the spread of SARS-CoV-2, nonetheless points out the concern among those in the recovery community. As we demonstrate, by the time of Gary’s decision to hold an open-air NA meeting, COVID-19 had already become associated with a massive increase in overdose deaths in the local area.

Mental Health During a Syndemic

Mental health challenges are associated with new substance abuse and relapse (Dubey et al. 2020). Area residents we interviewed described emergent mental distress due to social isolation and a pervasive fear of the unknown. Relatedly, medical professionals pointed to a potential mental health crisis in the Sandusky area due to COVID-19. Because trauma, depression, and suicidal ideation are all associated with an enhanced risk of overdose, we highlight how these risk factors increased in prevalence within the area due to COVID-19 (APA 2013).

In our discussion with Howard, he expressed concerns that a severe mental health crisis had developed in the area because of COVID-19. Like Howard, both a CPRS and a paraprofessional working with the Erie County Health Department, many of his colleagues straddle multiple institutional and noninstitutional roles and echoed this concern. Irene, a CPRS who manages a local crisis hotline for a local hospital, is also active in the 12-Step recovery community. Irene expressed concerns over the interrelated health crises of alcohol and other drug abuse (AOD) alongside mental health in the area. Irene explained that, like overdose death rates, area suicide rates were “going through the roof” during the COVID-19 study period. She further described that the local crisis hotline experienced a dramatic increase in calls, especially among adolescents, “because of COVID.” When asked whether these adolescents were calling due to mental health or substance abuse issues, Irene replied, “Both. You know, how it is with adolescents and kids, a lot of them don’t want to admit to AOD issues, because they’re afraid of getting in trouble. But I have had some that do. A huge majority of it is, with the adolescents, is suicidal thoughts. Because I feel like typically, the parents feel like they can handle it until it reaches that level.”

Irene, like Howard, hoped to sound the alarm about widespread declines in mental health in the Sandusky area due to COVID-19. Despite the dire state of mental health locally, Irene sought to maintain a positive overall outlook during our discussion. For Irene, and many of the people we interviewed, any positivity was hard fought, if possible.

Patricia, a former opioid addict turned volunteer recovery advocate, decried the loss of regular in-person contact. She espoused newfound pessimism in explaining that COVID-19 rendered her work, connecting active drug users with recovery services, nearly impossible. Worse still, Patricia described the chaotic uncertainty and recurring tragedy that she experienced as halfway houses and sober living facilities abruptly reduced their capacity or ceased operations entirely in the early weeks of adjusting to COVID-19 restrictions. She explained: “Unfortunately, there’s so many different facets to this nightmare that there is not a solution. It’s not just a financial solution, because I had an eighteen-year-old girl that I had in [a sober living house] for six months. Then when COVID happened; she left, lived in a tent, got her stimulus check, and was dead within twelve hours [in a nearby city].”

Patricia insisted that this story was not unique and that situations had not improved after the initial lockdown period. Patricia reported that, in a rural county adjacent to Erie County, fifty-eight people overdosed between mid-December 2020 and mid-January 2021; about 40 percent were fatal.

Patricia continued to explain that restrictions related to COVID-19 forced her clients to contend with months-long wait times for medically assisted treatment (MAT). State laws require that MAT prescriptions be refilled in person. In addition to long waits for MAT, IOP providers that once served upward of twenty-five people per day capped their enrollment at ten participants to comply with social distancing protocols. Patricia described the precarity of the situation, further aggravated by the death of loved ones due to COVID-19, through the experiences of two of her colleagues: “[My one friend is] heartbroken. There was a two-week period where every other day she was posting one of her girls had overdosed and died, and it just broke my heart because she doesn’t do the job for the money. [My other friend] lost her father to COVID complications, and she’s [only able to serve] half of her IOP class.”

Institutional Disarray

Interviews repeatedly implicate COVID-related restrictions as contributing factors in delays and breakdowns in services and public safety. Likewise, interview participants highlighted the inability of government agencies to address issues posed by COVID-19 restrictions and the impact these failures had on vulnerable populations. For instance, Patricia tells of an issue that she encountered at several county jails in the area: a failure to produce COVID-safe ways for inmates to be reached by anyone outside the county lockup. Before COVID-19, most local county jails maintained a videophone system to communicate with inmates. Ordinarily, videophones are available for public use via a proprietary prepaid phone card and accessible in a public lobby area. During the height of COVID-19 restrictions, videophones were inaccessible. Patricia explained how this restriction affects an already damaged system of justice during the pandemic: “[Attorneys] are struggling with not being able to have communication with their clients prior to hearings that are being postponed beyond belief. They’re postponed six months out! They can’t see their clients. Their clients are sitting in jail without any treatment services, without any religious services, without any visitation.”

This failure to address gaps in existing communications systems placed undue stress on inmates, their families, and legal representation. Patricia adds that other services available to inmates before the pandemic, including addiction treatment, were suspended because of COVID-19.

First responders dealt with long shifts for days or weeks during the early months of the pandemic. These extended hours, coupled with increased health risks, led to career-ending burnout. Joe described working long hours as an EMT and 911 dispatcher and struggling to manage the stress of being on the front lines of an overdose epidemic during a viral pandemic. When we interviewed Joe, his day included a standard twelve-hour shift as a 911 dispatcher: the shortest shift for him in weeks and the first of a scheduled ten-day stretch. COVID-19 outbreaks forced multiple ambulance stations in the area to close due to a lack of available staff. Joe’s station, too, was short staffed for months. This resulted in chronic exhaustion, or burnout, for EMTs and other first responders. In addition to burnout, viral outbreaks, and related first-responder turnover; Joe stated that EMTs were forced to reuse personal protective equipment “until they’re soiled.” This likely contributed to several of Joe’s fellow EMTs contracting COVID-19, resulting in fewer available EMTs and longer work shifts for those who remained. Joe explained: “People are burned out, or tired. My boss, who just left here a few minutes ago, has not seen his house in three days. He’s been hopping from station to station to station because we’re closed. We got people out sick, and we got people quitting because they’re tired. They’re burned out! They’re sick of getting run. You come in on an ambulance and you’re gonna run twenty-three or twenty-four hours, and it’s gonna be nonstop balls-to-the-wall.”

Another aspect of the impossible working situations for EMTs was patient transport logistics. When COVID-19 infection rates were at their peak, hospitals statewide filled up with patients, forcing ambulances in Joe’s company to transport patients upward of a hundred miles to the nearest available facility. This excess travel decreased first-responder capacity to respond to drug overdoses and other life-threatening emergencies. Conversely, until first responders began receiving the new COVID-19 vaccine, toward the end of the study period, every overdose call constituted another chance for an EMT to contract COVID-19. If we consider the decrease in first-responder readiness, as Joe illustrates, alongside the increase in substance use relapses among people in long-term recovery, as Gary suggests, and the widespread mental health struggles that Irene dealt with daily through the local crisis hotline—the syndemic effects of COVID-19 on the health of the local population in general, and elevated overdose mortality risk, becomes evident. Likewise, Joe points out that the increase in overdose calls diminished EMT readiness, leading to longer wait times for COVID-19 patients needing transportation to hospitals and other emergency care necessities.