During the epidemic, people used a variety of substances
The continuous tension and uncertainty around COVID-19 has resulted in a rise in demand for psychological treatments in the United States—but anxiety and depression aren't the only mental health challenges people are dealing with.
Experts believe that overuse of opiates and stimulants is also on the rise, and that psychologists can assist.
Those with substance use disorders (SUD) are more likely to develop COVID-19 and have worse COVID-19 outcomes, including a higher chance of hospitalization and mortality, in addition to the other concerns associated with substance usage (Wang, Q., et al., Molecular Psychiatry, 2020).
According to the Centers for Disease Control and Prevention, 13% of Americans started or increased substance use as a manner of coping with stress or emotions associated to COVID-19 as of June 2020. Since the start of the pandemic, overdoses have also increased. According to the ODMAP reporting system, the early months of the epidemic saw an 18 percent rise in overdoses nationwide compared to the same months in 2019. According to the American Medical Association, the trend has persisted into 2020, with rises in opioid-related mortality documented in more than 40 U.S. states, as well as significant concerns for persons with substance use disorders.
During the epidemic, Mandy Owens, PhD, a clinical psychologist and researcher at the University of Washington Alcohol and Drug Abuse Institute, has noticed an increase in substance use, including an increase in both quantity and frequency of drug use. If their normal substances were more difficult to obtain, some persons who use substances may have started using new drugs. According to Owens, a shift in drug supply availability has resulted in an increase in the usage of fentanyl, a synthetic opioid that is increasingly produced illicitly. However, according to Wilson Compton, MD, MPE, deputy director of the National Institute on Drug Abuse, precise statistics on use and drug type is difficult to come by.
According to Sharon Walsh, PhD, a professor of behavioral science, pharmacology, pharmaceutical sciences, and psychiatry at the University of Kentucky (UK) and director of the UK Center on Drug and Alcohol Research, health care records are the primary source of data on substance use, and toxicology reports for overdose incidents can take months for medical providers to provide to the CDC. The ability to conduct door-to-door family or school-based surveys, which have been more difficult to undertake during the pandemic, is also critical to correctly tracking substance usage.
State-level figures, on the other hand, according to Walsh, are a little clearer. During the pandemic, Kentucky's emergency department visits for overdose-related occurrences have increased, according to her research. Across contrast, the number of emergency medical care calls for non-opioid-related situations decreased in the state. "When you look at that against a drop in presentation at the hospital for other ailments, it really accentuates the opioid problem," she adds.
The link between the pandemic and the usage of drugs
Compton warns against lumping together any increased drug use with COVID-19. Shifts in drug availability, for example, could be to blame for an increase in illicit opioid use deaths; if heroin isn't readily available, someone might turn to fentanyl, which is far more potent. Experts concur, however, that pandemic-related strains, ranging from economic stress and loneliness to general anxiety about the virus, are a primary driver of the surge, based on study and clinical observation. "There's a perfect storm of characteristics that we know enhance drug use," says William Stoops, PhD, a University of Kentucky professor of behavioral science, psychiatry, and psychology. "Because people are more worried and isolated, they make harmful choices, such as drinking more and abusing drugs." (For more information on drinking behaviors during COVID-19, see the January Monitor.)
People may have less options to cope as their stress levels rise, which Owens believes leads to the rise in substance abuse. For example, resilience-building activities like as physical activity and social contacts haven't always been as safe or accessible, which can contribute to certain people starting to use drugs or using them more frequently or in larger amounts.
Overdoses are also on the rise due to practical pandemic factors. People who use drugs alone are more likely to die, according to Compton, since there is no one nearby to contact 911 or deliver naloxone, an opioid reversal medicine. This seclusion poses a clear risk to those who are alone during the pandemic. In the early stages of the epidemic, it was also more difficult for people to get the medical help they needed for opioid addiction rehabilitation since some clinics and community-based organizations reduced their services.
According to Walsh, Kentucky methadone clinics saw an increase in patients finishing treatment and a reduction in new patients initiating treatment in March and April. "Physicians have been focusing mostly on COVID-19, and medical systems are overburdened, so people don't always get the care they need," Stoops explains. "There's also a stigma associated with substance use disorder that prevents people from seeking treatment, which is exacerbated during a pandemic."
Telemedicine is becoming more popular
Fortunately, because to the improved availability of telemedicine for behavioral health concerns, patients have been able to receive care for substance use disorders more easily during the pandemic. While the epidemic forced many clinics and community-based groups to close their doors, as insurance carriers and organizations recognized the need, telemedicine options for physical and mental health concerns have become increasingly available. Furthermore, community-based groups such as Narcotics Anonymous and Alcoholics Anonymous are increasingly meeting remotely. In addition, most insurers, including Medicaid, have relaxed past telemedicine limits on behavioral health therapy, such as substance use disorder treatment.
Compton claims that clinicians may now use telehealth to initiate patients on buprenorphine, an opioid recovery treatment, without having to conduct an in-person evaluation. During the epidemic, practitioners of the Opioid Treatment Program (at so-called "methadone clinics") have started offering patients take-home methadone for maintenance more frequently. "Normally, you have to be really stable to take 30 pills at a time home," Compton explains, "but they've reduced some of those [requirements] so patients don't have to show up every day to an opioid treatment program."
People with drug use disorders can now seek remote mental health care because to improved telehealth availability. While Owens claims that persons without stable internet or phone service may have difficulty getting treatment, Compton claims that physicians are reporting more patients showing up for psychotherapy appointments as a result of the increased usage of telehealth. "One evident benefit of improvements in treatment infrastructure throughout the pandemic has been the availability of telehealth," says Justin Strickland, PhD, a postdoctoral fellow in behavioral pharmacology at Johns Hopkins University School of Medicine.
What can psychologists do to assist?
Psychologists are in a good position to help patients who are battling with substance abuse issues. However, the type of medicine they use determines how they assist their patients. Medications like buprenorphine are an important part of treating opioid use disorder. According to Owens, the first step in reducing the long-term effects of opiate usage, such as overdose, is to encourage individuals to seek medical treatment. Concurrent psychological treatment can help people stick to their medication schedules, identify and respond to stressors in healthier ways that led to opiate addiction, and address linked disorders like pain, PTSD, anxiety, and depression.
According to Paul Christo, MD, an associate professor in the Division of Pain Medicine at Johns Hopkins University School of Medicine, psychologists should also advocate for increased access to naloxone, which, in some states, anyone can request from a pharmacy to have on hand in an emergency to treat narcotic overdose. "There has to be more awareness around the country that this is something that can save a life," Christo says.
There is no FDA-approved drug that doctors can use to assist patients recover from stimulant use, such as cocaine or methamphetamine, but Stoops says there are a number of behavior-based strategies that psychologists can employ, such as cognitive behavioral therapy (CBT). Some physicians combine CBT with a technique known as contingency management, which encourages abstinence by rewarding patients with alternative reinforcers such as gift cards or vouchers if they don't use drugs.
Psychologists should make it a routine to question all of their patients if they take any substances. Owens cautions physicians against assuming that patients without an SUD diagnosis aren't abusing substances or are at danger of abusing them in the future. "As stressors persist and appropriate coping strategies become scarce, people are more prone to turn to substances," she says.
If a patient admits to using, Owens advises doctors to show compassion, with the objective of assisting patients in understanding how compounding stressors may be influencing their substance use and identifying better coping mechanisms. "Rather than presuming that people desire to stop using, psychologists should assist patients in performing a functional analysis of the substance's role in their life," she advises.
It's also critical, according to Owens, to acknowledge that weekly outpatient appointments may not be enough for many patients, particularly those who have more free time during the pandemic. Psychologists should collaborate with other healthcare practitioners as appropriate, focusing on providing as much structure and support as possible to their patients' daily routines. Owens, for example, sees a patient with an SUD once a week in an outpatient environment, but the patient also receives intense outpatient therapy from another nearby clinician. Owens adds that psychologists should consider encouraging patients to join virtual community support groups. She claims that there is no black-and-white approach to assisting those who are battling with substance abuse. "It's all about adapting to the specific demands of each patient."