key: cord-0722646-n3qx28t5
authors: Murthy, Pratima
title: How will Covid-19 Influence Addictive Behaviours and their Management?
date: 2020-10-22
journal: J Psychosoc Rehabil Ment Health
DOI: 10.1007/s40737-020-00207-3
sha: b041e3bb478595c14fe1e6bbd15c8d9ca0747953
doc_id: 722646
cord_uid: n3qx28t5

nan

The world had witnessed a global surge in substance use and other addictive behaviours even prior to Covid-19. The World Drug Report 2020 estimates that 5.3% of the global population between 15 and 64 years, translating to about 210 million persons used substances in 2018, up 0.5% since an earlier report in 2009 [1] . This trend is also seen in low and middle income countries (LMIC) like India which has witnessed an increase in the use of cannabis, opioids and prescription drugs [2] . The World Health Organization estimates that about 350 million persons globally experience problems related to gambling, with prevalence rates ranging from 0.1 to 6% [3] . Internet addiction shows a global prevalence of 6.0% with moderate heterogeneity across the world [4] .

In the past, a variety of disasters have been known to fuel substance use. Covid-19, forecasted to be a prolonged pandemic, with physical, mental, economic and social health consequences, is likely to produce greater and more enduring adverse impacts with respect to SUDs, fuelling both relapse in persons with pre-existing SUD and contributing to new-onset substance use. It is a sobering fact that the crisis of SUDs is now being described as an 'epidemic in the midst of a pandemic' [5] , as all efforts for the effective management and prevention of SUDs are in a complete state of disarray in many countries. The ripple effects are likely to be even stronger in LMICs, where the treatment gap for substance use disorders was already 86% or higher [6] .

The pandemic has impacted addictive behaviours in a myriad ways. Lockdown and its ensuing isolation and stress have led to increase rates of psychological distress as well as substance use. It is known that individuals preconditioned to use substances for coping relieve anxiety, depression or insomnia through excessive use of tobacco, alcohol or other drugs, all of which lead to relapses or exacerbations of existing conditions [7] . In the case of AUDs, with closure of alcohol vends during lockdown, an increase in the presentation of complicated withdrawal, including delirium and seizures has been reported [8] . While the closure of all alcohol outlets may have led to improved health and reduced violence (including intimate partner violence) on the one hand, on the other, the ensuing social isolation and stress may also heighten domestic tensions, negating or reversing this possible benefit [9] . The pattern of alcohol sales has varied greatly, with a reduction in sale in some countries and stockpiling leading to a jump in sales, including online sales in others. Closure of pubs and other drinking venues may also change the patterns of drinking.

While the risks of substance use have been well established, it is clear that substance use presents clear P. Murthy (&) Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore, India e-mail: pratimamurthy@gmail.com and imminent danger for Covid-19 and complications thereof. The compromising of self-protecting behaviours during intoxication and repeated touching of the nose and face in substance users may increase the risk to Covid-19 infection. Smoking and associated respiratory disease may exacerbate COVID-19 severity. Alcohol is known to reduce immunity and increase risks to respiratory, cardiologic and neurological consequences. Stimulant users may be at the risk of lung disease and cardiovascular morbidity [9] .

An electronic health records (EHRs) evaluation of 73,099,850 unique patients (of whom 12,030 had a diagnosis of Covid-19), showed that those with a recent diagnosis of SUD had a significantly increased risk for Covid-19 (adjusted odds ratio or AOR 8.669). Patients with SUD had significantly higher prevalence of chronic kidney, liver, lung, cardiovascular disease, type 2 diabetes, obesity and cancer. Covid-19 patients with SUD also had a significantly worse outcome (death 9.6%; hospitalization 41%) as compared to general Covid-19 patients (death 6.6%, hospitalisation 30.1%). The study underscores the need to screen and treat individuals with substance use disorder as part of core strategy to control the pandemic [10] .

Covid-19, in turn, has affected the timely diagnosis, treatment and rehabilitation of patients with SUDs. Other difficulties during Covid-19 times are related to socio-economic distress and the difficulty in accessing care, the discontinuation of medications and other follow-up interventions as a result of service disruption, leading to relapse. Patients stabilised on opioid substitution and other maintenance treatments may not be able to receive their treatments [7] .

Covid-19 has brought with it an increased focus on digital technology, to remain connected in the times of physical distancing. For the young population, with online classes replacing face-to-face education, the time spent on digital devices has hugely increased. A limitation on outdoor play and socialisation has also led to the use of digital gadgets for recreational purposes. Thus, gaming and excessive use of the internet, which was an emerging problem among adolescents, is likely to be further aggravated during Covid-19 times. Countries like China which faced the Covid-19 outbreak earlier than others, report excessive internet use among children and adolescents during the outbreak. One third (33.37%) of 6-18 year olds participating in a self-reported survey could be classified as having problematic internet use and 2.68% met the criteria for internet addiction [11] .

In addition, working adults whose work schedules and working spaces have been disrupted may turn to digital platforms for both work and recreation. There are reports of increase in online gambling [12] , with underlying reasons attributed to financial problems, social isolation and stress.

While digital technology was initially seen as a boon for the elderly who needed to be socially connected, it remains to be seen whether problem use will emerge in this population, which is at greatest risk for social isolation.

In the face of this addiction epidemic within the Covid-19 pandemic, there is a need to innovate and adapt to address the problems of SUDs and other addictions.

Clearly, one of the major strategies would be to increase public awareness of the risks of SUDs and minimise the need for substance use by encouraging healthy lifestyles, daily routines, regular sleeping, eating and exercise habits, good communication with family and friends and simple and practical strategies for relaxation and stress coping. Provision of services for detoxification, psychosocial support, relapse prevention and rehabilitation with appropriate Covid-19 precautions are required. Inpatient settings also need to put in such precautions.

Covid-19 has also thrown open the possibility of online treatment support, particularly for follow-up and this approach is likely to gain further popularity if the pandemic extends. Home-based care programmes, programmes for vulnerable groups who are further marginalised due to Covid-19, novel ways of delivering harm reduction and digital group interventions are other options which may become popular. Covid-19 has also underscored the importance of addressing multi-morbidity in patients with addictive disorders.

Ongoing research in the area of addictive disorders has also been compromised with the termination of face-to-face data collection and other restrictions. Covid-19 has brought in its own challenges for research including funding, a shift from face-to-face to online data collection, all of which come with their own unique challenges.

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