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Arjun V.K. Sharma is a writer and resident physician at the University of Toronto.

In the first six months of life under the virus, between April and September of last year, opioid overdoses claimed the lives of a record 3,351 people. To date, more than 1.1 million people have been infected by the virus, and survived. But in the thick of our campaign to vaccinate our way through this pandemic, with its end inching slowly into sight, we risk simply trading one evil for the other.

A new vernacular is set to define our viral language – that of “long COVID,” a constellation of symptoms that includes the likes of brain fog, fatigue, muscle pain, loss of smell and palpitations, among others, which linger for weeks, even months, in roughly one in eight COVID-19 survivors. An April study in the journal Nature, the largest of its kind in examining the health of COVID survivors, has helped add understanding to these more mysterious symptoms: Heart disease, kidney disease and mental-health conditions, including anxiety and trauma-related disorders, are the most common of the large array of diagnoses newly made in the months after an infection.

For individuals in recovery, the effects of the syndrome can be debilitating. In Britain, clinics for “long-haulers,” as they’re called, are being widely put into place, but for clinicians, the best practices for treatment have been perplexing.

In the weeds of the Nature study, however, lies an all-too-familiar tragedy: Researchers found that nine out of every thousand COVID-19 survivors were given a prescription for an opioid – one that, if not for the virus, they would otherwise not have had.

The number is easy to dismiss. If the pandemic has proven anything – and it has exposed many things – it is that maintaining perspective can be a struggle. But over the past week, Canada has recorded an average of 7,275 cases a day. Assuming the large majority of those beat the infection, that means that 63 survivors may be prescribed an opioid to manage the bodily fallout. To that end, if prescribed for chronic pain – and according to statistics we know – almost 20 of those individuals may misuse them. Six may go on to develop an opioid-use disorder. That’s six too many.

I have firsthand experience with the confusion around post-COVID treatment. After coming down with many of the symptoms of COVID-19 at the beginning of the pandemic, my tinnitus became considerably worse. Thwarting any rest between gruelling shifts – not to mention ringing that was at times so loud that I could barely make out what my patients and colleagues were saying to me – I went to see a doctor from whom I’d long sought advice. He offered me the small dose of a benzodiazepine – a sedative that 22 survivors in the Nature study were prescribed and which are found in nearly a third of opioid-related deaths. I don’t blame him for the suggestion – there is simply not enough clear information around treating survivors – but I gently declined.

Still, on certain sleepless nights, I found myself thinking long and hard about my doctor’s offer. The image of the prescription pad and his pen in hand glowed large in the theatre of my tired mind. But years ago, he’d also arranged for me to see a therapist, who had taught me a form of cognitive behavioural therapy that has, for me, been the most effective treatment for my tinnitus. I reached out to reconnect with her, and her medicine – to be mindful, to think, distract and attenuate the phantom noise – helped.

The Nature study does not make explicit the link between opioids and the specific conditions in “long COVID” they are meant to remedy. Whether or not “long COVID” is driven by a direct effect of the virus, or whether it is the social, behavioural and economic turbulence that it leaves in its wake, is also not clear. And the majority of the study’s participants – registrants at the Veteran Health Administration in St. Louis, Mo. – were older white men, a demographic that has been at the centre of the opioid epidemic. That is in contrast to the ethnic minorities who’ve largely borne the brunt of the pandemic, and among whom overdoses have shown the greatest increase in recent years.

Just like COVID-19, opioid overdose deaths have crashed in waves. The first, in the 1990s, was brought on by the rise of prescription opioids, such as OxyContin and Vicodin. The second came in 2010, for a period when heroin became more readily accessible, was less expensive and offered a greater potency of effect. The arrival of synthetic opioids such as fentanyl marked the third wave, in 2013.

But even as opioid prescriptions have trended down over the past decade in the United States, the incidental offering of opioids for COVID-19 survivors deepens existing concerns for a potential fourth wave of the opioid epidemic, driven by a pandemic that has already buoyed the level of toxic opioids in supply, disrupted crucial public-health services, and worsened personal stresses.

We might soon find ourselves at a break in the path – or rather, when we look back, where two tortuous journeys might converge. As we emerge from the pandemic, we must continue furthering our efforts to improve access to overdose prevention services, harm-reduction sites and safer supplies, and supporting grassroots community organizations that reach those most vulnerable. Yet, we must also devote resources to understanding “long COVID,” both in terms of how it develops and how it is diagnosed. Most importantly, we health care providers must learn how to treat it in ways that avoid an opioid prescription.

Because if we don’t, I fear that we risk asking and re-litigating that very stale question, made even more stale by how often it’s asked: Are we too late?

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