The COVID-19 pandemic is expected to have large-scale negative impacts on substance use and mental health around the world with increases in anxiety, depression, and substance use disorder (SUD) diagnosis1,2. Fear of contagion, job loss and economic struggles, and the stress of having a loved-one sickened by the virus, have increased stress levels1,2. Becoming severely ill from the virus or working in the health care setting and treating severely ill patients can be traumatic, and the virus may have direct adverse neuropsychiatric effects that predispose to worse mood and cognitive function3,4. Mitigation measures to reduce virus-spread such as quarantining, stay-at-home orders, travel bans, and the shutting down of schools and businesses has resulted in reduced access to treatment and social isolation, compounding these adverse effects1,2.
The Pandemic’s Adverse Effects: What We Know So Far
A large study conducted in multiple emergency rooms showed that emergency department (ED) visit counts and rates per overall ED visits were significantly higher for suicide attempts and opioid overdoses when comparing a period between March 2020 and October 2020 with the same time period in 2019, due likely to increased drug use, more solitary or risky use, or reduced access to naloxone and other treatment1. Other studies have also shown increases: one found that overdose numbers increased by 11% (fatal) and 18% (non-fatal) over January to April 2020 compared to the same time period in 20195, and another that there was a 17% increase in the number of emergency medical services opioid overdose runs with transportation to an emergency department, a 71% increase in runs with refused transportation, and a 50% increase in runs for suspected opioid overdoses with deaths at the scene during the pandemic6.
As demonstrated through alcohol sales7, alcohol use disorder severity measures7, and self-reports2,8-12, alcohol consumption has increased during the pandemic in several countries around the globe. Factors that are associated with increased use of alcohol during the pandemic include depression, anxiety2, high stress levels2, use of social media as a source of information, being personally affected by COVID-19, experiencing child care challenges, not being associated with a religious community13,14, and a tendency to use alcohol to cope with negative mood12,15. Many of these factors are also well known to increase the risk of alcohol-related problems and persistence of alcohol use disorder symptoms over time12,15,16
Other substance use and behavioral addictions
Increased cannabis use9, other substance use17, and gambling and internet addiction behavior8 have also been reported during the pandemic compared to non-pandemic periods.
Nearly 1 in 7 US adults reported psychological distress in April 2020 during the peak of stay-at-home orders, compared with 1 in 25 adults in April 20181,18. A new diagnosis of generalized anxiety disorder and depression was reported by 12% and 29% more people from April to June 2020 compared to recall of a month prior to the outbreak, and in those with premorbid psychiatric diagnoses, there was a worsening in anxiety depression and suicidality compared to pre-outbreak measures9. Increases in ED visit counts and rates per overall ED visits were also observed for suicide attempts in the large emergency room study mentioned previously1 in discussion of opioid overdose risk. Factors associated with mental health struggles during the pandemic include female sex, younger age, lower income, poorer coping skills, multiple psychiatric comorbidities, previous trauma exposure, deteriorating physical health, poorer family relationships, and lower exercising9.
COVID-19 and substance use
Substance use disorders (SUD) are seen at greater rates in the homeless and incarcerated populations, which by nature of their instability and living situations, are at increased risk for disease transmission. More than half of U.S. prisoners have SUD19.
Pathophysiological data indicates an increased risk of serious infections and mortality from COVID-19 for individuals with Substance Use Disorders (SUD)6,20. However, there is also a possible protective role of nicotine use6,20. Population data shows better outcomes for active smokers but worse outcomes for past smokers, although causality is unclear21 and increased rates of COVID hospitalization with CUD (1.78 OR) and AUD 96.68)22.
Effects on treatment
Access to mental health and substance use disorder care initially decreased during the pandemic5,19,23, contributing to increased rates of involuntary opioid withdrawal6 and overdose. But the use of telehealth and other technology is expanding5 and governmental regulations regarding prescribing of medication assisted treatment for opioid use disorder such as buprenorphine were relaxed early on, resulting in an increase in access to care later on in the pandemic4,6,19,24,25. However, it is well-understood that group work and developing connections with other recovering people are an important part of recovery from psychiatric and substance use disorders, and it is unknown whether the care that is currently being provided across the country, much of it remote, will be as effective long term.
Windward Way Recovery Can Help
Windward Way Recovery offers individuals with SUD with or without psychiatric comorbidities evidence-based and efficacious treatment and is equipped to provide detoxification services, residential treatment, partial hospitalization (PHP), sober-living, intensive outpatient treatment (IOP), and standard outpatient treatment (OP). Telehealth options are available for PHP, IOP, and OP programs. In line with current recommendations, staff match services to the needs, preferences, and financial situation of the individual, and both group and individual counseling are provided at the various levels of care. Both SUD and comorbid psychiatric conditions are addressed concurrently. Evidence-based psychotherapies are selected for each patient based on their particular needs and include cognitive behavioral therapy (CBT), dialectical behavior therapy, acceptance and commitment therapy, trauma informed care, motivational interviewing (group and individual) and/or psychodynamic therapy, eye movement desensitization and relaxation therapy and trauma focused CBT. Finally, if interested and it is clinically warranted, patients are offered medication assisted treatment (MAT), usually with naltrexone or injectable buprenorphine. The psychiatrist (addiction specialist) will also provide medication treatment for comorbid disorders.
The majority of the patients who sought treatment at Windward Way (Detox, Residential, Partial Hospitalization Program, Intensive Outpatient) from 2018-2019 (total n=453) from November 2018-2019 cited alcohol as their primary drug of choice (41%) followed by opiates or heroin (33%), methamphetamine (8%), cocaine (5%), and benzodiazepines (4%). The median age was 31 years, 40% were male, and 72% were Caucasian. Sixty-two percent were not married or never married, 26% did not graduate from high school, but 64% were employed and 82% lived in a stable living environment prior to treatment.
On intake, a majority of the sample reported severe levels of anxiety and depression symptoms. Reflecting on the month prior, 30% scored in the severe, and 21% in the moderately severe depression range, 44% scored in the severe and 22% in moderate anxiety range, and 53% scored in the severe and 11% in the probable PTSD range on validated self-report measures (PHQ-9, GAD-7, PCL, respectively). In the month prior, 60% also had had thoughts of killing him or herself or of wishing they were dead or could go to sleep and not wake up.
The sample was also severely addicted. On entry into the program 53% met all 11 of the DSM-V symptom criteria, and 37% scored in the severe substance use disorder range, reporting 6-10 criteria. Almost 80% of the sample reported that the reason they sought treatment was because they were tired of living that way, indicating they were probably quite motivated to change.
Despite the high severity levels, 57% successfully completed all recommended treatment, while another 7% completed at least one level of care (excluding detox), 1% completed their mandated treatment, and 3% transferred elsewhere. This total of 68% surpasses the national average from the 2016 TEDS-D Discharge data for national rates of short-term residential and IOP programs, in which the completion rates were 54% and 32% respectively with a median length of stay of 24 days highlighting the program’s effectiveness.
Impressive reductions in anxiety and depression symptoms over time were also reported by a subsample of Windward Way patients that were available to provide follow-up data (about half the sample). At follow-up in residential, only 17% reported moderate or worse levels of depression, 15% moderate or severe anxiety, and 19% severe or probable PTSD, which reduced further in those who attended IOP (3%, 9%, 7% respectively). Thoughts of SI were only reported by 7% at follow-up. Seventy-three percent were very satisfied with their treatment at Windward Way Recovery, and 90% said treatment goals were met. (Of note – even if dropouts were included in the analyses and assumed no psychiatric symptom improvement, there still would have been clear improvements in all mental health outcomes, important in light of the fact that negative affect and psychiatric comorbidity predict relapse and poor treatment response.)
- Holland KM, Jones C, Vivolo-Kantor AM, et al. Trends in US Emergency Department Visits for Mental Health, Overdose, and Violence Outcomes Before and During the COVID-19 Pandemic. JAMA Psychiatry 2021.
- Capasso A, Jones AM, Ali SH, Foreman J, Tozan Y, DiClemente RJ. Increased alcohol use during the COVID-19 pandemic: The effect of mental health and age in a cross-sectional sample of social media users in the U.S. Prev Med 2021;145:106422.
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- Chandler RK, Villani J, Clarke T, McCance-Katz EF, Volkow ND. Addressing opioid overdose deaths: The vision for the HEALing communities study. Drug Alcohol Depend 2020;217:108329.
- Mallet J, Dubertret C, Le Strat Y. Addictions in the COVID-19 era: Current evidence, future perspectives a comprehensive review. Prog Neuropsychopharmacol Biol Psychiatry 2021;106:110070.
- Naughton F, Ward E, Khondoker M, et al. Health behaviour change during the UK COVID-19 lockdown: Findings from the first wave of the C-19 health behaviour and well-being daily tracker study. Br J Health Psychol 2021.
- Sun Y, Li Y, Bao Y, et al. Brief Report: Increased Addictive Internet and Substance Use Behavior During the COVID-19 Pandemic in China. Am J Addict 2020;29:268-70.
- Robillard R, Daros AR, Phillips JL, et al. Emerging New Psychiatric Symptoms and the Worsening of Pre-existing Mental Disorders during the COVID-19 Pandemic: A Canadian Multisite Study: Nouveaux symptomes psychiatriques emergents et deterioration des troubles mentaux preexistants pendanturant la pandemie de la COVID-19: une etude canadienne multisite. Can J Psychiatry 2021:706743720986786.
- Stanton R, To QG, Khalesi S, et al. Depression, Anxiety and Stress during COVID-19: Associations with Changes in Physical Activity, Sleep, Tobacco and Alcohol Use in Australian Adults. Int J Environ Res Public Health 2020;17.
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- Creswell KG, Bachrach RL. A Commentary on Drinking to Cope During the COVID-19 Pandemic: The Role of External and Internal Factors in Coping Motive Pathways to Alcohol Use, Solitary Drinking, and Alcohol Problems. Alcohol Clin Exp Res 2020;44:2150-3.
- MacMillan T, Corrigan MJ, Coffey K, Tronnier CD, Wang D, Krase K. Exploring Factors Associated with Alcohol and/or Substance Use During the COVID-19 Pandemic. Int J Ment Health Addict 2021:1-10.
- Ambrosetti J, Macheret L, Folliet A, et al. Impact of the COVID-19 Pandemic on Psychiatric Admissions to a Large Swiss Emergency Department: An Observational Study. Int J Environ Res Public Health 2021;18.
- Wardell JD, Kempe T, Rapinda KK, et al. Drinking to Cope During COVID-19 Pandemic: The Role of External and Internal Factors in Coping Motive Pathways to Alcohol Use, Solitary Drinking, and Alcohol Problems. Alcohol Clin Exp Res 2020;44:2073-83.
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- Almandoz JP, Xie L, Schellinger JN, et al. Substance use, mental health and weight-related behaviours during the COVID-19 pandemic in people with obesity. Clin Obes 2021:e12440.
- McGinty EE, Presskreischer R, Han H, Barry CL. Psychological Distress and Loneliness Reported by US Adults in 2018 and April 2020. JAMA 2020;324:93-4.
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- Data obtained from Windward Way Treatment Effectiveness Report, Vista Research Group, Covering Nov12 2018-Nov 30 2019.