Impact of the COVID-19 Pandemic on Substance Use and Mental Health

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) diagnosis^1,2. Fear of contagion, job loss and economic struggles, and the stress of having a loved-one sickened by the virus, have increased stress levels^1,2. 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 function^3,4. 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 effects^1,2.

The Pandemic’s Adverse Effects: What We Know So Far

Opioid overdoses

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.

Alcohol use

As demonstrated through alcohol sales⁷, alcohol use disorder severity measures⁷, and self-reports^2,8-12, 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 community^13,14, and a tendency to use alcohol to cope with negative mood^12,15. Many of these factors are also well known to increase the risk of alcohol-related problems and persistence of alcohol use disorder symptoms over time^12,15,16

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.

Mental health

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 2018^1,18. 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 use^6,20. 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 pandemic^5,19,23, 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 pandemic^4,6,19,24,25. 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

Treatments offered

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.

Patient characteristics²⁶

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.

Outcomes²⁶

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.)