Clinical Update
October 2020
COVID-19 and Its Impact on Persons with Mental Illness and Substance Use
The COVID-19 pandemic has brought significant challenges to both healthcare systems and public health. Social distancing, disruption of healthcare services, and unemployment are affecting at-risk populations at a high rate. The pandemic has been recognized as the cause of a wide variety of behavioral health problems and increasing adverse mental health outcomes. According to the Centers for Disease Control (CDC), an increase of up to 40% was seen in Americans who reported struggling with mental health or substance abuse. People with preexisting mental health conditions such as depression, anxiety, posttraumatic stress disorder, bipolar disorder or schizophrenia, and substance use disorders are more vulnerable and susceptible in an emergency not only to COVID-19 infection but also to its behavioral health consequences.1
According to an online survey, people with mental illnesses are concerned about disrupting mental health services, running out of medication, new or worsening symptoms, and social isolation during the pandemic.1 A study conducted by the World Health Organization (WHO) showed that 35% of people worldwide had reported the disruption of essential services for mental, neurological, and substance use (MNA), and up to 30% have experienced a disruption in their supply of medications for MNA. The study also reported that 60% of psychotherapy and counseling services and 50% of overdose prevention and critical harm reduction services had been disrupted due to the implications of COVID-19.2
Impact on Substance Use
Although COVID-19 pandemic measures impact the entire population, they disproportionally affect vulnerable groups, including those who already face discrimination and stigma as persons with substance use disorders (SUD). The social and economic changes due to the pandemic make it more challenging to access recovery programs and medication treatment. As a result this has worsened the adherence in individuals with SUD. Physical distancing or isolation strategies and the pandemic outbreak has been associated with negative emotions such as irritability, anxiety, fear, sadness, anger, or boredom. These conditions are known to trigger a relapse, even in long-term abstainers, or intensify drug consumption.3
Studies have shown that stress predicts relapse to substance use among those who use tobacco, alcohol, cannabis, and cocaine or heroin. Moreover, chronic brain changes and alternated circuitry make SUD persons more susceptible to stress, leading to a potential relapse and increased substance use during the COVID-19 pandemic. Anxiety and low mood due to loss of income or social isolation can increase motivation to consume substances evident by intense cravings and substance preoccupation, culminating in substance relapse in SUD persons.4 There is a surge of addictive behaviors (both new and relapse), including behavioral addiction in this period. Withdrawal emergencies and death are also being increasingly reported. Those with addictions face difficulties accessing healthcare services, making them prone to procure drugs by illegal means.5
Also, factors such as inadequate infection control measures, ongoing substance use, and drug-seeking behaviors among SUD persons make them at increased risk for COVID-19 infection and poorer outcomes. The COVID-19 pandemic and its social and economic consequences build a “perfect stressor” that can lead to recurrence or increase in substance use, causing physical and physiological harm, including death from overdose. COVID-19 and addiction are the two pandemics on the verge of a collision causing significant public health threat.
Impact on Opioid Epidemic
COVID-19 has a profound impact on the co-occurring national crisis, the opioid epidemic, due to challenges in maintaining access to substance use and addiction services during such times, including medications for the treatment for opioid use disorder (OUD), such as buprenorphine and methadone. During this time, seeking emergency care for opioid-related events, such as withdrawal and overdose, may initially be avoided because of overcrowded emergency departments and fear of COVID-19 exposure. Likewise, patients may also avoid care entirely and resort to alleviating symptoms with illicit substances and overdose rescue medications, like naloxone.
For those who inject opioids, reduced availability of needle exchange programs heightens the risk for needle sharing and a concomitant increase in HIV and HCV transmission, or infectious endocarditis. Moreover, decreased access to opioid agonist therapy (OAT), and fear of virus transmission may push some persons with SUD to inject illicit high-potency opioids alone, risking opioid overdose and death. Loss of traditional in-person support systems and an increase in stressors may escalate substance use, as a result this can cause adverse health outcomes, including alcohol withdrawal seizures, accidental opioid overdoses, and death.5,6
To mitigate the effect of COVID-19
According to experts, health care systems must continue to serve this vulnerable population to prevent associated morbidity and mortality. The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Agency (DEA) have responded to the pandemic by making unprecedented regulatory changes regarding prescribing OUD medications and telemedicine to lessen some of the challenges providers and addiction service facilities face. To adapt to the pandemic's impact, healthcare providers and mental health services could address these concerns by connecting with persons with mental illness through virtual platforms or the use of technology to minimize disruption of care.1,3,4,5,6
Telepsychiatry has also been found to have equivalent clinical outcomes as regular face-to-face assessment and treatment, including improved adherence and decreases in hospital admissions.7 Not only is it being used to help combat and triage COVID-19, but it has also been beneficial for patients suffering from mental illnesses and substance abuse.8 Since the start of the pandemic, states are lessening their regulations on telemedicine. With the ease of restrictions and increasing access to providers, patients find it easier and more accessible to meet with their providers to receive care.9,10
Medication monitoring is a crucial tool to measure therapy adherence and potential substance misuse. It is imperative to keep this essential tool available to clinicians to assist with care decisions during the COVID-19 pandemic and into the future as telemedicine becomes more widely used. Aegis offers providers the ability to perform remote oral fluid sample collections for continued patient medication adherence monitoring.
NOTICE: The information above is intended as a resource for health care providers. Providers should use their independent medical judgment based on the clinical needs of the patient when making determinations of who to test, what medications to test, testing frequency, and the type of testing to conduct.
References:
1. Costa M, Pavlo A, Reis G, Ponte K, Davidson L. COVID-19 Concerns Among Persons With Mental Illness. Psychiatric services (Washington, DC). September 2020
2. Czeilser ME, Lane RI, Petrosky E, et al. Mental Health, Substance Abuse, and Suicidal Ideation During the COVID-19 Pandemic-United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep 2020; 69: 1049-1057. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a1
3. Ornell F, Moura HF, Scherer JN, Pechansky F, Kessler FHP, von Diemen L. The COVID-19 pandemic and its impact on substance use: Implications for prevention and treatment. Psychiatry research. 2020;289:113096. DOI:10.1016/j.psychres.2020.113096
4. Osnat C. Melamed, Tanya S. Hauck, Leslie Buckley, Peter Selby & Benoit H. Mulsant (2020) COVID-19 and persons with substance use disorders: Inequities and mitigation strategies, Substance Abuse, 41:3, 286-291, DOI: 10.1080/08897077.2020.1784363
5. Dubey MJ, Ghosh R, Chatterjee S, Biswas P, Chatterjee S, Dubey S. COVID-19 and addiction. Diabetes & metabolic syndrome. 2020;14(5):817-823. doi:10.1016/j.dsx.2020.06.008
6. McCann Pineo M, Schwartz RM. Commentary on the coronavirus pandemic: Anticipating a fourth wave in the opioid epidemic. Psychological trauma: theory, research, practice and policy. 2020;12(S1):S108-S110.
7. Chakrabarti S. Usefulness of telepsychiatry: a critical evaluation of videoconferencing-based approaches. World J Psychiatry. 2015;5(3):286-304.
8. Hubley S, Lynch SB, Schneck C, Thomas M, Shore J. Review of key telepsychiatry outcomes. World J Psychiatry. 2016;6(2):269-282.
9. Centers for Disease Control and Prevention. 2020. Coronavirus Disease 2019 (COVID-19). [online] Available at: <https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html>
10. Conrad, MD, R., Rayala, H., Diamond, JD, R., Busch, MD, B. and Kramer, MA, N., 2020. Expanding Telemental Health In Response To The COVID-19 Pandemic. [online] Psychiatric Times. Available at: https://www.psychiatrictimes.com/view/expanding-telemental-health-response-covid-19-pandemic [Accessed 8 October 2020].